key: cord-0702727-xjni95ws authors: Seron, P; Oliveros, M J; Gutierrez-Arias, R; Fuentes-Aspe, R; Torres-Castro, R; Merino-Osorio, C; Nahuelhual, P; Inostroza, J; Jalil, Y; Solano, R; Marzuca- Nassr, G; Aguilera, R; Lavados-Romo, P; Soto, F; Sabelle, C; Villarroel, G; Gomolán, P; Huaiquilaf, S; Sanchez, P title: Effectiveness of telerehabilitation in physical therapy: A rapid overview date: 2021-02-09 journal: Phys Ther DOI: 10.1093/ptj/pzab053 sha: 8cdd3b8c03cc869b774cc91a01a2e81e2d5b2c9b doc_id: 702727 cord_uid: xjni95ws OBJECTIVE: The purpose of this article was to summarize the available evidence from systematic reviews on telerehabilitation in physical therapy. METHODS: Medline/Pubmed, EMBASE and Cochrane Library databases. In addition, the records in PROSPERO and Epistemonikos and PEDro were consulted. Systematic reviews of different conditions, populations and contexts, where the intervention to be evaluated is telerehabilitation by physical therapy were included. The outcomes were clinical effectiveness depending on specific condition, functionality, quality of life, satisfaction, adherence and safety. Data extraction and risk of bias assessment were carried out by a reviewer with non-independent verification by a second reviewer. The findings are reported qualitatively by tables and figures. RESULTS: Fifty-three systematic reviews were included of which 17 were assessed as having low risk of bias. Fifteen reviews were on cardiorespiratory rehabilitation, 14 on musculoskeletal conditions and 13 on neurorehabilitation. Other 11 reviews addressed other types of conditions and rehabilitation. Thirteen reviews evaluated with low risk of bias showed results in favor of telerehabilitation versus in-person rehabilitation or no-rehabilitation, while 17 reported no differences between the groups. Thirty-five reviews with unclear or high risk of bias showed mixed results. CONCLUSIONS: Despite the contradictory results, telerehabilitation in physical therapy could be comparable to in-person rehabilitation or better than no-rehabilitation for conditions such as osteoarthritis, low back pain, hip and knee replacement, multiple sclerosis, and also in the context of cardiac and pulmonary rehabilitation. It is imperative to conduct better quality clinical trials and systematic reviews. IMPACT: Providing with the best available evidence on the effectiveness of telerehabilitation to professionals, mainly physical therapists, will impact the decision-making process and therefore better clinical outcomes for patients, both in these times of covid-19 pandemic and in the future. The identification of research gaps will also contribute to the generation of relevant and novel research questions. Results. Fifty-three systematic reviews were included of which 17 were assessed as having low risk of bias. Fifteen reviews were on cardiorespiratory rehabilitation, 14 on musculoskeletal conditions and 13 on neurorehabilitation. Other 11 reviews addressed other types of conditions and rehabilitation. Thirteen reviews evaluated with low risk of bias showed results in favor of telerehabilitation versus in-person rehabilitation or norehabilitation, while 17 reported no differences between the groups. Thirty-five reviews with unclear or high risk of bias showed mixed results. Conclusions. Despite the contradictory results, telerehabilitation in physical therapy could be comparable to in-person rehabilitation or better than no-rehabilitation for conditions such as osteoarthritis, low back pain, hip and knee replacement, multiple sclerosis, and also in the context of cardiac and pulmonary rehabilitation. It is imperative to conduct better quality clinical trials and systematic reviews. Impact. Providing with the best available evidence on the effectiveness of telerehabilitation to professionals, mainly physical therapists, will impact the decisionmaking process and therefore better clinical outcomes for patients, both in these times of covid-19 pandemic and in the future. The identification of research gaps will also contribute to the generation of relevant and novel research questions. Rehabilitation is necessary to improve people's ability to live, work and learn as much as possible, maximize their functionality and quality of life. The impact extends to the community, society and the economy. 1,2 While rehabilitation is a comprehensive, multicomponent and multidisciplinary intervention, the specific health condition and other conditioners of the health system or resources available determine the minimum components required, which often include physical therapy. Physical therapy interventions are required when movement and function are threatened in order to develop, maintain and re-establish movement and functional capacity under the consideration that functional movement is fundamental to health and an optimal quality of life. 3 Despite the knowledge of the benefits of rehabilitation and physical therapy, these services are under-used. 4 If to this is added, on the one hand that services or patients' resources are scarce, 5 and on the other that high demand leads to the saturation of services and the generation of waiting lists, 6 the limitation of access becomes a reality. In this scenario, where rehabilitation is necessary but insufficiently implemented, alternative rehabilitation models have been created using new resources such as digital practice to improve coverage. Thus, telerehabilitation, considered a branch of telehealth, is set up as a system for the control or monitoring of remote rehabilitation using telecommunications technologies, the purpose of which is to increase accessibility and improve continuity of care in vulnerable, geographically remote populations with disabilities, with the potential for saving time and resources in health care. 7, 8 In the context of infection by SARS-CoV-2 and the spread of the COVID-19 pandemic, health services have had to adapt and prioritize safe delivery of care, limiting outpatient care. Thus, in addition to finding a way to address patients affected by COVID-19, an innovative method had to be found to provide rehabilitation or physical therapy. 9, 10 Although the main task is to contain the spread of the infection and treat patients affected by COVID-19, health systems cannot ignore other health problems that will inevitably require attention in the future. This crisis will undoubtedly impact the way health services work, and telerehabilitation could become a standard way of working since the previously identified barriers have had to be quickly overcome. 11, 12 There are several telerehabilitation models implemented globally. 13, 14 There are also many studies that have examined its effectiveness. To date, so many telerehabilitation trials are available that many systematic reviews have summarised the scattered and contradictory findings. [15] [16] [17] [18] [19] [20] [21] [22] [23] In order to provide support to rehabilitation professionals, mainly physical therapists, with the best evidence available, this study aims to summarize the available information, from systematic reviews, on telerehabilitation in physical therapy in terms of clinical effectiveness, functionality and quality of life. Additionally, adherence, satisfaction and safety outcomes are evaluated. An overview was conducted in a rapid review format adhering to the PRISMA declaration for systematic reviews. 24 The protocol is registered in PROSPERO under number CRD42020185640 and the methodology has already been extensively described elsewhere. 25 Likewise, the critical methods aspects of the overview are described below. [H2] Data Sources and Searches. Reviews were excluded if they focused on physical activity without consider clinical outcomes (eg, blood pressure control) and on self-management of health conditions (eg, hypertension) where exercise and its effect on a clinical outcome were not included. Similarly, reviews were excluded that considered mobile applications and monitors (eg, pedometer) without involving the active action of a physical therapist. Finally, systematic reviews assessing virtual reality, without remote supervision by a therapist and not performed outside the health center were also excluded. With regard to comparisons, reviews were included if the telerehabilitation was compared with usual rehabilitation (in-person rehabilitation or center-based rehabilitation) or norehabilitation (including usual care and waiting list). Primary outcomes that had to be included in the reviews were clinical effectiveness for each condition (eg, decreasing low-back pain), functionality was defined as the physical abilities which enable functional independence and enhance health-related quality of life (HRQL). Secondary outcomes were satisfaction with the care, adherence and adverse effects. The selection process was performed in the Rayyan software 26 by two investigators, first screening by title and abstract and then by reviewing full texts of the relevant records. The discrepancies were resolved by a third reviewer with more than ten years of experience. The relevant information from each eligible document was extracted through the REDCap© platform (Research Electronic Data Capture software). 27 The risk of bias of the included reviews was assessed with the ROBIS (Risk of Bias in Systematic Reviews) tool. 28 ROBIS was applied in three consecutive phases. First, the relevance of the review for the research question was assessed. Then, concerns with the review process were identified for four domains: study eligibility criteria, identification and selection of the studies, data collection and study appraisal, and synthesis and findings. Finally, a judgment of overall bias in the review was generated. Both the data extraction and the appraisal with ROBIS were performed by one investigator, and a non-independent verification was carried out by a second experienced investigator. Additionally, information related to the methodological quality or risk of bias of the primary studies contained in the reviews assessed as having a low risk of bias was extracted in order to consider this aspect in formulating the conclusions of the overview. A qualitative report of the characteristics and effectiveness findings is summarized in figure and tables by clinical area of rehabilitation or physical therapy interventions. In the design and presentation of the tables and figures, the risk of bias of the included reviews is considered. [H2] Role of the Funding Source [H1] RESULTS In the initial search of electronic databases, 3298 potential studies were identified. Table 2 . Twenty-one reviews were performed in Europe, 12 in Oceania, 11 in North America, 7 in Asia, one in Africa and another one in South America. All 53 reviews included 754 studies, of which 425 were included because they were clinical trials and considered outcomes of interest. About the synthesis, 26 were systematic reviews with qualitative synthesis only and 27 included a meta-analysis. The most common areas of physical therapy included were: 15 on cardiorespiratory rehabilitation, 14 studies on musculoskeletal rehabilitation and 13 on neurorehabilitation. The other 11 reviews addressed other or mixed types of conditions and rehabilitation. Most of the studies included adults (n = 41), older people (n = 2), infant population (n = 2) and others (n = 8). In addition to physical therapists, other professionals participated, including psychologist (24 reviews), nurse (15 reviews), physician (13 reviews), occupational therapist (8 reviews), and a speech therapist (4 reviews). The most common interventions were: therapeutic exercises (48), functional training (27) and education (25). Three reviews included only synchronous interventions, and 1 included solely asynchronous interventions. Most of the reviews (49) included mixed interventions. The majority of the platforms implemented to deliver the rehabilitation were webpages in 43 reviews, phone calls in 37 reviews, teleconference software in 31 reviews and messaging services in 14 reviews. Virtual reality, understood as its use with remote assistance by the therapist, was also used and reported in 9 reviews. The comparisons evaluated were telerehabilitation versus in-person rehabilitation (or usual rehabilitation) in 24 reviews, telerehabilitation versus no-rehabilitation (or usual care or waiting list) in 27 reviews, and mixed comparisons (eg, telerehabilitation plus inperson intervention versus in-person intervention alone) in 22 reviews. The most-reported outcomes were clinical effectiveness in 48 reviews, functionality in 35 reviews, quality of life in 32 reviews, user satisfaction and adherence in 15 reviews each, and adverse events in 13 reviews. Specific characteristics of included reviews are presented in Table 1 for musculoskeletal, neurological, cardiopulmonary and other health conditions. The musculoskeletal rehabilitation was reported in 14 systematic reviews, 16,22,37-40,29-36 including 6 reviews that reported meta-analyses. The majority of conditions included were low back pain, hip arthroplasty, total knee arthroplasty and osteoarthritis, and the most common outcomes reported were pain intensity as an expression of clinical effectiveness, functionality, mostly measured by the WOMAC tool, and health-related quality of life. The neurorehabilitation was reported in 13 systematic reviews, 17,20,49-51,41-48 including 7 reviews that reported meta-analyses. The majority of conditions included were stroke, multiple sclerosis, and physical impairment in children. The most common outcomes reported were motor function, mobility, balance, activities of daily living, and HRQL. The cardiorespiratory rehabilitation was reported in 15 systematic reviews, 15 ,19,59-63,21,52-58 including 9 reviews that reported meta-analyses. The majority of conditions included were coronary artery disease, heart failure, and chronic obstructive pulmonary disease. The most common outcomes reported were related to clinical effectiveness as exercise capacity and HRQL. Other types of rehabilitation were reported in 11 reviews, 18,64,73,65-72 of which 5 included meta-analyses. The majority of conditions covered were associated with metabolic disorders (such as obesity or diabetes), and cancer. The most common outcome reported was physical or exercise capacity. The domain with the greatest concerns was synthesis and findings, with 22 (42%) reviews assessing it as being at high risk of bias, and 12 (23%) reviews as being at an unclear risk of bias. Meanwhile, the domain with the best rating was that of data collection and study appraisal with 37 (70%) reviews being evaluated as at low risk of bias. The ratings for each of the 4 domains in the ROBIS tool and the overall evaluation for the included reviews by clinical area are presented in Table 2 . Complementarily, Supplementary Table 3 shows the reported assessment of the methodological quality or risk of bias of the primary studies included, specifically in the systematic reviews evaluated as having a low risk of bias. Supplementary Tables 4-7 show specific findings for several comparisons in each review included with the specification of outcomes and their measurements, source of results, conclusion of the review authors and risk of bias overall evaluation. A summary of results is presented in Figure 1 . Only one low risk of bias review compared telerehabilitation with in-person rehabilitation. This review reported the effectiveness of telerehabilitation for clinical (pain intensity) and functionality outcomes and no difference between groups for HRQL in unspecified musculoskeletal conditions. 29 Seven low risk of bias reviews compared telerehabilitation with a control group without rehabilitation. Of these, 6, 4, and 1 reviews reported no difference between groups for clinical effectiveness evaluated as pain intensity, A summary of results is presented in Figure 2 . Three low risk of bias reviews compared telerehabilitation with in-person rehabilitation. One, 2 and 1 reviews reported no difference between groups for clinical effectiveness evaluated as balance, 42 functionality 42,51 and HRQL, 42 respectively. Two reviews showed better results in telerehabilitation groups for balance 41 and physical activity 51 in patients with multiple sclerosis. Two reviews considered other outcomes showing no adverse effects 41 and no differences for satisfaction 42 in the telerehabilitation group. Two low risk of bias reviews compared telerehabilitation with a control group without rehabilitation. Of these, 1, 2 and 1 reviews reported no difference between groups for clinical effectiveness evaluated as balance, 42 showed better motor function in children with disabilities in the telerehabilitation group and also reported better effectiveness for functionality in some of the primary studies included. 47 Finally, of 4 high risk of bias reviews, one about multiple sclerosis reported better results for motor disability in the telerehabilitation group compared with the in-person group, and no differences for functionality. 50 The other 3 reviews reported no differences between groups for clinical effectiveness in stroke survivors 17,20,51 in the same comparison. Additionally, one review at high risk of bias showed no differences between telerehabilitation and no-rehabilitation groups for activities of daily living in stroke A summary of results is presented in Figure 3 . Four reviews were evaluated as having a low risk of bias. Only one review with patients with coronary heart disease found better results for telerehabilitation group compared with in-person rehabilitation in clinical effectiveness measured as all-cause mortality. 52 On the other hand, 1 review with patients with chronic obstructive pulmonary disease (COPD) 53 and 2 reviews with coronary heart disease patients 54, 55 reported no differences in clinical effectiveness between groups, regardless of the comparison group. One review included the HRQL outcome, reporting no differences between cardiac telerehabilitation and in-person cardiac rehabilitation, 52 and another review also about cardiac rehabilitation showed mixed results for HRQL for both, telerehabilitation versus in-person and telerehabilitation versus no-rehabilitation comparisons. 55 Finally, one review showed better adherence for telerehabilitation when compared with usual care. 54 Another 4 reviews were evaluated as having an unclear risk of bias. Two of them, comparing telerehabilitation and in-person rehabilitation in patients with coronary heart disease, reported contradictory results. One review found a better HRQL in the telerehabilitation group and no differences for clinical effectiveness measured as exercise capacity. 56 In contrast, the other review reported no differences between groups for HRQL in most of the primary studies included, but better clinical effectiveness measured as prevention of all-cause mortality. 57 On the other hand, for the telerehabilitation versus no-rehabilitation comparison, 2 and 1 unclear risk of bias reviews showed better clinical effectiveness 56, 59 with telerehabilitation and no difference between groups, 58 respectively. Two reviews reported better results for HRQL 56, 59 in some primary studies included. Seven reviews were evaluated as having a high risk of bias. Of these, 2 reviews 60, 61 presented no differences between groups for exercise capacity when telerehabilitation was compared with in-person rehabilitation. One review 15 A summary of results is presented in Figure 4 . Three low risk of bias reviews evaluated telerehabilitation (more extensive than telemedicine) versus usual care. One reported clinical effectiveness to decrease body mass index, 65 another found that an eHealth intervention was effective at managing fatigue in cancer survivors, 64 Three reviews evaluated as having unclear risk of bias and comparing telerehabilitation versus in-person intervention reported no difference between groups for clinical effectiveness 8,66,67 and HRQL. 66 The same reviews also compared telerehabilitation with no intervention, and while one found no difference for pain and HRQL, 66 the other two reported mixed results for clinical effectiveness. 8, 67 Three and 1 reviews with a high risk of bias compared telerehabilitation with an in-person intervention and no intervention, respectively. From the first comparison, one reported a better result for clinical effectiveness measured as body mass index with telerehabilitation 70 and the other reported mixed results. 69 A third review showed better functionality in patients undergoing surgery and mixed results for HRQL in primary studies. 73 For the second comparison, one review found better glycated hemoglobin control in adults with type 2 diabetes with telerehabilitation. 71 Finally, one review with no comparison identified reported mixed results for physical activity in cancer survivors. 72 Fifty-three systematic reviews on telerehabilitation in physical therapy were included in this overview, 27 of which also included meta-analyses. These reviews covered different areas of the practice of physical therapy, mainly in the musculoskeletal, neurological and cardiopulmonary areas. Although there are global reviews and overviews that assess the effectiveness of telerehabilitation in some specific conditions, 7 The population for which there is effectiveness data is mainly adult, with few studies on children or adolescents. In the musculoskeletal area, the conditions they address include chronic musculoskeletal pain, arthroplasties, osteoarthritis and low-back pain, in addition to surgically treated orthopedic conditions. On the other hand, in the area of neurorehabilitation, the evidence focuses on stroke and multiple sclerosis. In the cardiopulmonary area, the conditions are those typically included in cardiac rehabilitation, such as coronary disease, or pulmonary rehabilitation, such as COPD. In other health conditions, the most frequently addressed were cancer and ageing, with these being observed as emerging areas. With respect to the means by which telerehabilitation is implemented, the most frequently studied is the use of the mobile telephone with its messaging services and telephone calls, with knowledge emerging of the effectiveness of the applications available on smartphones as a digital practice tool. Then the Internet, including web pages mainly with educational content, videos or interactive gaming, is also frequently studied. There is Information on electronic devices that are basically used as remote monitors with physical therapy interventions. Also studied were specialized platforms (eg, for videoconferencing), especially when synchronous communication is required. Finally, and above all in the neurological area, virtual reality has been positioned as an intervention tool, also within telerehabilitation, including in this work only those reviews that explicitly said that virtual reality was used outside a health center. Other factors must be considered in the extrapolation of the results. One is the fact that the reviews generally include studies from last the two decades, during which there has been great technological growth at the same time as the widespread use of these media by the population, which makes the first studies in the area very different from the most recent. The other factor is that most of the reviews and their primary studies are concentrated in Europe, North America and Oceania with little information originating from low-resource settings, which could affect the feasibility of using the technologies on a more global scale, exactly when these may be the places that have the least access as and the information in the text and the references of the studies, which only left a couple of reviews with a mixed comparison in results. Another aspect of relevance in the interpretation of the findings was the lack of consideration of the risk of bias of the primary studies in establishing the conclusions of some of the reviews included, which may confuse readers, especially because the tendency in these cases is to overestimate the effects of telerehabilitation on physical therapy. One way to be able to draw valid conclusions in systematic reviews is to associate the results of the reviews or meta-analyses, ie, the estimator of the effect, their magnitude and accuracy, with the risk of bias. This is called certainty of evidence, which can be addressed in the process of interpreting the findings with the GRADE tool, 81 which was used in no more than a third of the reviews included. Consideration must be given to interpreting the results of no differences between groups, a finding presents in more than half of the reviews. This may be due to there being effectively no differences between the groups or to statistical power achieved with the sum of patients in the studies included in the reviews being insufficient to find differences. The importance here is that -although assuming that telerehabilitation is not inferior to in-person rehabilitation or, on the other hand, that telerehabilitation produces the same effects as not doing rehabilitation -caution should be taken in interpreting this finding in light of the accuracy of the results, ie, the size of the sample reached. This overview has some limitations related basically to having been conducted as a rapid review, and within these limitations it should be recognized that the grey literature was 25 not searched and that the data extraction process and evaluation of the risk of bias were not performed in duplicate, in addition to having been conducted by a large group of reviewers, which could have affected the reliability of the data. To minimize this bias, a second reviewer with experience in systematic reviews extracted data and assessed the risk of bias. Another limitation to consider in the extrapolation of the results is the fact that physical therapy can be delivered alone or within a more comprehensive rehabilitation program. Although this distinction was not specifically considered in the selection criteria of most reviews or in the description of interventions, it could be observed that physical therapy was often provided with other rehabilitation interventions. Although the aim of this overview was broad, it was possible to cover, but it must be clearly understood that the scope of the interventions included are about physical therapy and, among them, related with therapeutic or secondary prevention and not those of assessment or primary prevention. The available evidence shows that telerehabilitation could be comparable or better than the conventional methods of rehabilitation to reduce pain and improve physical function in musculoskeletal conditions generally. Additionally, telerehabilitation could improve functionality in patients with osteoarthritis in the knee and non-specific low-back pain, in addition to improving quality of life in patients with non-specific low-back pain, osteoarthritis in the knee, and total arthroplasty in the knee and hip. In the area of neurorehabilitation, telerehabilitation seems to contribute to balance and to increasing the levels of physical activity in patients with multiple sclerosis, but its contribution in terms of balance, functionality and quality of life in patients with stroke is unclear. On the other hand, cardiac rehabilitation via telematic means is possibly better than inperson cardiac rehabilitation at reducing mortality by any cause, and also seems to contribute to a better ability to exercise and HRQL. On the other hand, pulmonary telerehabilitation could have results similar to conventional rehabilitation in terms of reducing dyspnea in patients with COPD. Finally, the interventions performed by physical therapists using technological media could be effective at reducing overweight and obesity as well as improving the physical capacity and quality of life in cancer survivors. Clinicians must bear in mind that these conclusions come from 17 low risk of bias reviews, there being another 36 reviews with methodological issues and contradictory results. Regardless of this, and in a context where it is not possible to perform center-based or inperson rehabilitation because patients cannot access a health center, the health centers cannot provide services to all those who need it or, as in the present times of the Covid-19 pandemic, where outpatient or in-person services have been reduced or suspended in many health centers, telerehabilitation seems to be a suitable and feasible strategy to implement. On this point it must be recognized that the previously identified barriers had to be circumvented quickly, making it increasingly more likely that this form of rehabilitation service will become a new standard during and after this pandemic. This rapid overview provides evidence that it is necessary to continue research in the area of telerehabilitation. On the one hand, systematic reviews must improve their processes This protocol is registered in PROSPERO (CRD42020185640). World Health Organization. Rehabilitation in Health Systems Policy statement: Description of physical therapy Home Health Rehabilitation Utilization Among Medicare Beneficiaries Following Critical Illness Prevalence and factors associated with utilization of rehabilitation services among people with physical disabilities in Kampala, Uganda. A descriptive cross sectional study Effects of waiting for outpatient physiotherapy services in persons with musculoskeletal disorders: a systematic review Ten years of telerehabilitation: A literature overview of technologies and clinical applications A systematic review of clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation Telerehabilitation in the Age of COVID-19: An Opportunity for Learning Health System Research Musculoskeletal Physical Therapy During the COVID-19 Pandemic: Is Telerehabilitation the Answer? Transforming the Provision of Physiotherapy in the Time of COVID-19: A Call to Action for Telerehabilitation Impact of COVID-19 on physical therapist practice in Portugal Telerehabilitation: Review of the State-of-the-Art and Areas of Application Evidence of benefit from telerehabilitation in routine care: A systematic review Patient focused internet-based approaches to cardiovascular rehabilitation -a systematic review Telerehabilitation Approaches for Stroke Patients: Systematic Review and Meta-analysis of Randomized Controlled Trials Combining the benefits of tele-rehabilitation and virtual reality-based balance training: a systematic review on feasibility and effectiveness Diversity of practices in telerehabilitation for children with disabilities and effective intervention characteristics: results from a systematic review Telerehabilitation for stroke survivors: Systematic review and meta-analysis Home-based telerehabilitation for stroke survivors: a systematic review Integrated telerehabilitation approach in multiple sclerosis: A systematic review and meta-analysis Effectiveness of Technology-Based Distance Physical Rehabilitation Interventions for Improving Physical Functioning in Stroke: A Systematic Review and Meta-analysis of Randomized Controlled Trials Telehealth interventions versus center-based cardiac rehabilitation of coronary artery disease: A systematic review and meta-analysis Telehealthcare in COPD: A systematic review and meta-analysis on physical outcomes and dyspnea Telehealth exercise-based cardiac rehabilitation: a systematic review and meta-analysis Effect of eHealth cardiac rehabilitation on health outcomes of coronary heart disease patients: A systematic review and meta-analysis Modes of e-Health delivery in secondary prevention programmes for patients with coronary artery disease: A systematic review Telehealth interventions for the secondary prevention of coronary heart disease: A systematic review and meta-analysis AM. management in chronic obstructive pulmonary disease ( Review ) Smartphones in the secondary prevention of cardiovascular disease: A systematic review A systematic review of the effects of telerehabilitation in patients with cardiopulmonary diseases Exercise telemonitoring and telerehabilitation compared with traditional cardiac and pulmonary rehabilitation: A systematic review and meta-analysis A review of telerehabilitation for cardiac patients eHealth and mHealth interventions in the treatment of fatigued cancer survivors: A systematic review and meta-analysis The effectiveness of telemedicine on body mass index: A systematic review and meta-analysis The effectiveness of exercise-based telemedicine on pain, physical activity and quality of life in the treatment of chronic pain: A systematic review Effects of remote feedback in home-based physical activity interventions for older adults: A systematic review A systematic review of clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation Telerehabilitation and recovery of motor function: a systematic review and meta-analysis Web-based weight management programs for children and adolescents: A systematic review of randomized controlled trial studies The use of technology to promote physical activity in Type 2 diabetes management: A systematic review Lifestyle behavior interventions delivered using technology in childhood, adolescent, and young adult cancer survivors: A systematic review Effectiveness of physiotherapy with telerehabilitation in surgical patients: a systematic review and meta-analysis The role of tele-medicine in patients with respiratory diseases Rehabilitation for people with multiple sclerosis: An overview of Cochrane Reviews A systematic review of recent cardiac rehabilitation metaanalyses in patients with coronary heart disease or heart failure Up to 2.2 million people experiencing disability suffer collateral damage each day of COVID-19 lockdown in Europe Instant paper from the field" on rehabilitation answers to the COVID-19 emergency Feasibility and Acceptability of Telemedicine to Substitute Outpatient Rehabilitation Services in the COVID-19 Emergency in Italy: An Observational Everyday Clinical-Life Study Exercise, physical activity or training prescription Mixed (Synchronous and asynchronous). Phone, internet The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.