Maarten van Egmond

107 The effectiveness of physiotherapy with telerehabilitation 5 DISCUSSION This systematic review shows that physiotherapy with telerehabilitation is feasible and improves QoL in surgical populations, although the overall effectiveness on functional outcomes could not be determined. The risk of bias assessment of the included studies was often high or unclear, which is a potential limitation of this review. Standards of reporting were not optimal across all included studies, with incomplete outcome reporting in seven studies. These methodological shortcomings are one of the reasons why a comparison of effectiveness between studies was not possible. The majority of included studies (78%) investigated the effectiveness of telerehabilitation on more than one functional outcome measure, and reported a significant positive effect on at least one measure. However, none of the studies detected a significant positive effect on all outcome measures in favor of telerehabilitation. This is in line with the results of previously published systematic reviews focusing on the effectiveness of telerehabilitation in non-surgical populations. Kairy et al. 48 reported that most of the clinical outcomes in their included studies improved after telerehabilitation, but stated that there is still a need for more methodologically sound research to confirm its effectiveness. Wide variation was noted between the included studies in terms of type of intervention, duration, frequency and outcome measures. This heterogeneity made it inappropriate to pool data from different studies and investigate the overall pooled estimate of effect. 23 The lack of overall significant evidence in favor of telerehabilitation could also be due to the fact that many studies used questionnaires to quantify outcome. In a review on the effectiveness of telerehabilitation in stroke patients, Laver et al. 10 stated that questionnaires often contain subscales with significant differences between the intervention and control groups, whereas the overall score does not differ. This is the first systematic literature review to demonstrate that interventions with telerehabilitation have the potential to increase QoL in surgical populations. Van den Brink et al. 16 reported that despite the rarity of studies investigating telerehabilitation with QoL as an outcome measure, the results looked promising. Despite the high heterogeneity between studies leading to effects with large variation, a meta-analysis was still considered to be appropriate because QoL was measured with the same questionnaire in the different studies, and is not directly related to the type of patients or intervention provided.