The Application of Telerehabilitation for Pain Reduction and Improving Quality of Life in Workers with Work-Related Musculoskeletal Disorders: Systematic Review ^†

Abstract

Disorders of the musculoskeletal system, which includes muscles, tendons, ligaments, joints, peripheral nerves, and blood vessels, due to workload and unsupportive work conditions are referred to as work-related musculoskeletal disorders (WMSDs). In a pandemic situation, virtual activities are the main alternative allowing people to remain active. One approach that can be applied in this situation is telerehabilitation. The purpose of this study was to determine the effectiveness of the application of telerehabilitation in reducing pain and increasing the quality of life in workers with WMSDs. Based on the search results of 5 databases, 14 articles were found, which then underwent a critical appraisal, resulting in 6 articles to be reviewed. The results of this systematic review indicate that the application of telerehabilitation 2–3 times per week with a duration of 20–40 min for more than 6 weeks may be effective for individuals with neck, shoulder, and low back pain complaints due to an increase in the level of adherence to the physiotherapy program. It can be concluded that the application of telerehabilitation for workers provides benefits that can significantly reduce pain levels and have a positive impact on their quality of life, which affects work productivity and can be seen with the parameters VAS, QVAS, SF-12 HS, SF-36 HS, Work Ability Index, and EQ5D.

1. Introduction

The health of workers must begin to become a priority for every company. The health quality of human resources can affect the productivity of the company’s performance. Working more than 8 h every day in a static or non-ergonomic body position can cause many health problems [1]. Musculoskeletal disorders are one of the most frequent complaints by every type of worker [2]. Disorders of the musculoskeletal system, which includes muscles, tendons, ligaments, joints, peripheral nerves, and blood vessels, due to workload and unsupportive work environment conditions are called work-related musculoskeletal disorders (WMSDs) [3]. The risk factors for WMSDs are static and non-ergonomic postures, repetitive movements, excessive use of body strength, vibration, mechanical compression, and temperature. In addition, psychosocial conditions also affect the occurrence of WMSDs, such as stress related to work assignments or problems adapting to the work environment [2].

According to data released by the Indonesian Basic Health Research (2018), muscu-loskeletal complaints that occur in Indonesia reach 37.2% in productive age with a per-centage difference of 6.1% in men and 8.5% in women [4]. Based on data from the Great Britain Labor Force Survey (2021), as many as 470,000 workers were recorded as suffering from work-related musculoskeletal disorders. The majority of the complaints felt by the workers were in the neck (45%), back (39%), and lower extremities (16%). Of the total cases, 85,000 cases were recorded to have worsened during the COVID-19 pandemic [5].

Since December 2019, the whole world has experienced a pandemic due to the out-break of the COVID-19 virus. COVID-19 is an infectious disease caused by the SARS-CoV-2 virus. WHO has recorded 364,191,494 confirmed cases as of January 2022, including 5,631,457 deaths in the world [6]. The presence of the COVID-19 pandemic in the midst of dense human activities has had a negative impact on the world, causing all human activ-ities to be limited to prevent higher transmission of the COVID-19 virus.

Telerehabilitation is a method of implementing remote rehabilitation carried out by health services using telecommunication devices such as computers, laptops, or smartphones. Telerehabilitation applied using videoconferencing as a medium of com-munication between patients and health services. The implementation of telerehabilita-tion in the rehabilitation of workers is expected to be a solution to prevent the spread of the virus from getting higher and to support the government’s program to limit the impact of the pandemic [7]. Based on the above background, the authors raised the title of the re-search in the form of the application of telerehabilitation to reduce pain and increase qual-ity of life in workers with work-related musculoskeletal disorders.

2. Clinical Statements

The many problems caused by work-related musculoskeletal disorders make physiotherapy an important effort in solving these problems. In a pandemic situation, technology plays an important role in the sustainability of community activities. Virtual activities are the main alternative for individuals to stay active. One approach that can be applied to rehabilitation care in this pandemic situation is telerehabilitation. Based on the above, the formulation of the problem raised in this study is “How does the application of telerehabilitation affect pain reduction and increase quality of life in workers with work-related musculoskeletal disorders?”.

3. Material and Methods

The method used in this study is a systematic review with a search period from 2021 to 2022. The authors searched for articles using keywords and Boolean operators (AND, OR NOT, or AND NOT) in 5 databases (Google Scholar, Medline, Proquest, Pubmed, and Scopus). To filter the results of the articles, inclusion criteria and exclusion criteria were used as filters.

The inclusion criteria in this study were (1) workers; (2) never had or have experienced a work-related musculoskeletal disorder; (3) telerehabilitation; (4) measuring pain intensity and quality of life; (5) study design: mix methods study, experimental study, survey study, cross-sectional, comparative, or qualitative study; (6) published after 2017; (7) article in English or Indonesian. The exclusion criteria included (1) non-employees, (2) interventions other than telerehabilitation, (3) not measuring pain intensity and quality of life, (4) systematic review study design, (5) published before 2017, (6) articles in languages other than English and Indonesian. The keywords used to search for articles were mapped using the PICO framework, with the following details:

• Population: WMSD;
• Intervention: telerehabilitation;
• Comparison: none;
• Outcomes: pain and quality of life.

4. Results

Based on the results of a literature search in Google Scholar, Medline, ProQuest, PUBMED, and Scopus databases using the keywords “Work-Related Musculoskeletal Disorder OR Musculoskeletal Disorder OR Worker AND Telerehabilitation OR Telecare OR Telehealth OR Videoconferencing OR Internet-based AND Pain OR Functional Ability OR Quality of life”, the researchers found 1.677 articles that matched these keywords. The research articles were then screened by title and abstract, and the researcher found 61 articles met the inclusion criteria, with 1.616 articles in the exclusion criteria. Then, a critical appraisal was carried out on 14 published articles, obtaining 6 articles for which data synthesis would be carried out. The data collection process used the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) method. The PRISMA Chart can be seen in Figure 1.

5. Outcome Measures

In assessing the quality of the intervention given to improve pain and quality of life, various parameters were used, such as the VAS, SF-12 HS, SF-36 HS, Work Ability Index, and EQ5D. The demographics and outcomes reported in each article can be seen in Table 1.

The VAS is a pain measurement scale depicted by a 10 cm line that describes the conditions from “no pain” to “severe pain” at both ends of the line. Patients were in-structed to mark numbers on a line that describes the intensity of the pain felt. The ad-vantage of using the VAS is that this scale is more sensitive to see changes in pain, so it is easy to understand and is often used in various clinical conditions [8]. While the weak-ness of this scale is that it is difficult to use in the elderly or individuals with cognitive deficits and children [9].

The Short Form 36 Health Survey is one of the measurement instruments that assesses the quality of life of individuals [10]. This questionnaire consists of 36 questions that have been classified into 8 domains in the form of physical aspects, social aspects, emotional aspects, physical health aspects, emotional health aspects, pain aspects, vital aspects, and general health aspects [11]. Each question is given a score of 0–100. The higher the score for each domain, the better the quality-of-life score. The weakness of this parameter is that too many questions are asked so that it is more complicated and takes longer [12].

The Short Form 12 Health Survey is a measurement parameter that assesses quality of life. The SF-12 contains 12 short questions drawn from all aspects of the SF-36. This pa-rameter is considered more effective and does not take much time because the number of questionnaire questions is only small. According to the research of Shou, et al. the param-eters SF-12 and SF-36 are considered valid and reliable in measuring quality of life status [12].

The WAI is a measurement instrument used to assess workability. WAI contains seven items of questions related to job demands, health status of workers, and resources. The achievement score of this index ranges from 7–49 [13].

The EQ-5D is the most frequently used parameter in assessing an individual’s quality of life. These parameters can be applied to patients with various diagnoses of different dis-eases. The EQ-5D consists of 5 domains which include aspects of mobility, aspects of self-care, aspects of daily activities, aspects of pain, and aspects of depression [14].

Table 1. Demographics and outcomes.

Study	Study Design	Level of Evidence	Age (Years)	Diagnosis	Outcomes
					Pain	QoL
Maliaras, et al. [15]	RCT	1c	41–65	Shoulder pain	VAS	EuroQol 5D-5L
Yaghoubitajani, et al. [16]	RCT	1c	21–42	Neck pain and shoulder pain	VAS	Work ability
Moreira, et al. [17]	Quasi-experimental	2d	29–44	Low back pain and neck pain	SF-36 HS	SF-36 HS
Blanquero, et al. [18]	RCT	1c	31–56	Wrist, hand, or finger injuries	VAS	Return to work
Mbada, et al. [19]	RCT	1c	36–61	Chronic low back pain	QVAS	SF-12 HS
Lee, et al. [20]	RCT	1c	25–35	Chronic neck pain	VAS	SF-36 HS

QoL (quality of life); RCT (Randomized Controlled Trial); VAS (Visual Analog Scale); QVAS (Quadruple Visual Analog Scale); SF-36 HS (Short Form 36 Health Survey).

Table 1. Demographics and outcomes.

Study	Study Design	Level of Evidence	Age (Years)	Diagnosis	Outcomes
					Pain	QoL
Maliaras, et al. [15]	RCT	1c	41–65	Shoulder pain	VAS	EuroQol 5D-5L
Yaghoubitajani, et al. [16]	RCT	1c	21–42	Neck pain and shoulder pain	VAS	Work ability
Moreira, et al. [17]	Quasi-experimental	2d	29–44	Low back pain and neck pain	SF-36 HS	SF-36 HS
Blanquero, et al. [18]	RCT	1c	31–56	Wrist, hand, or finger injuries	VAS	Return to work
Mbada, et al. [19]	RCT	1c	36–61	Chronic low back pain	QVAS	SF-12 HS
Lee, et al. [20]	RCT	1c	25–35	Chronic neck pain	VAS	SF-36 HS

QoL (quality of life); RCT (Randomized Controlled Trial); VAS (Visual Analog Scale); QVAS (Quadruple Visual Analog Scale); SF-36 HS (Short Form 36 Health Survey).

6. Intervention

Telerehabilitation is a remote health rehabilitation service provided through the medium of technology and communication. These services include assessment, diagnosis, prognosis, intervention, consultation, and counseling through patient and family education [21]. The intervention was given through telerehabilitation in the form of physical exercise that was adapted to the patient’s condition and complaints. Physical exercise can reduce pain, which will indirectly increase work productivity [22]. The forms of interventions carried out in the six studies in the intervention group and control group can be seen in

Table 2. Interventions.

Study	Intervention Group	Control Group	Follow-Up
Maliaras, et al. [15]	External rotation exercises in the sleeping position and shoulder elevation in the standing position. The study was conducted for 12 weeks, with the intervention given 3 times/week. Telerehabilitation was carried out via the Zoom application for 30 min per session, where there were 2 sessions in each meeting. Each exercise was performed with 15 repetitions and 3 sets of 4 s for isotonic exercise and 6 sets of 30 s per set for isometric exercise with 2 min rest between each set.	Education related to rotator cuff muscles, risk factors, and suggestions for modifying work-related activities.	None
Yaghoubitajani, et al. [16]	Corrective exercise. The intervention was given 3 times/week for 8 weeks. Each session lasted 50–60 min with 5 min warm-up and cool-down via videoconferencing software (https://meet.jit.si/ accessed on 9 April 2022).	No intervention	Week 8 of the initial intervention
Moreira, et al. [17]	Online workplace exercise (7 mobility, 8 flexibility, and 7 strengthening exercises) through face-to-face applications (Microsoft Teams). The study was conducted for 17 weeks, with the intervention given 3 times/week. Each session was 15 min long via the Microsoft Teams app.	No intervention	None
Blanquero, et al. [18]	Sensorimotor exercise using an application on a tablet device (ReHand). The intervention was presented to participants for 4 weeks on more than 3 days per week for 30–60 min per session plus a home exercise program for 20–30 min with 10 min demonstrations that were given by the physiotherapist via video.	Home exercise programs. In the control, exercise was carried out 2 times/day for a duration of 20–30 min, and demonstrations were given during face-to-face meetings.	3 months after the initial intervention
Mbada, et al. [19]	McKenzie Exercise and back care education via the application. The study provided the intervention 3 times a week for 8 weeks via a smartphone application.	McKenzie Exercise and back care education	None
Lee, et al. [20]	Providing McKenzie via a smartphone and education on neck pain care via SMS. The intervention was given 2 times a week for 10–15 min per session via a smartphone for 8 weeks and pain care education for 1 week.	Posture correction education and education on neck pain treatment via SMS	None

.

7. Discussion

7.1. Effect of Telerehabilitation on Reducing Pain

Based on the six articles reviewed, telerehabilitation can reduce pain in workers with work-related musculoskeletal disorders. In research by Maliaras et al., 36 participants were divided into 3 groups, namely, the advice group (N = 12), the recommended care group (internet-delivered exercise and education) (N = 12), and the recommended care and telerehabilitation group (N = 12), and the measurement parameter used to assess pain was the VAS. The intervention was carried out for 12 weeks. The results showed that there was a significant decrease in group 3, which was given an additional intervention with telerehabilitation, from 59.7 (21.1) to 28.1 (25.6) [15]. This is similar to the results of research by Yaghoubitajani et al., where there was a decrease in pain felt by participants in the intervention group with the provision of online-supervised corrective exercise; participants in this group experienced a significant reduction in pain of 3.25 ± 1.95 [16].

This study is in line with research conducted by Moreira et al. on 39 participants who were divided into two groups, namely, the intervention group (N = 13) and the control group (N = 26). The results showed that providing an exercise program to the intervention group in the form of mobility, flexibility, and strengthening exercises for 17 weeks with 3 meetings a week for 15 min had a major effect on pain, with an increase from 79 (17.1) to 87.4 (12.7), which means there was a decrease in the pain felt by the participants. Meanwhile, in the control group, the pain worsened from 79.2 (19) to 71.1 (20.1) [17].

This study is comparable to research conducted by Lee et al., who provided a measuring tool for pain assessment. The results indicated that there was a significant change in pain reduction before and after the intervention was given, decreasing from 5.20 (2.19) to 2.73 (1.99) [20].

Based on the six articles, it can be concluded that the application of telerehabilitation to workers is able to provide benefits that can significantly reduce the level of pain felt by workers during their daily work. Apart from the six articles above, this is supported by other studies conducted by Cottrell et al., who showed that telerehabilitation is able to provide an alternative for patients so that they can continue to receive proper care with limited environmental conditions that occur at the time [23]. According to Chang et al., the application of telerehabilitation to workers with musculoskeletal disorders can significantly reduce pain that limits work productivity [24]. Telerehabilitation helps patients to maintain an exercise program under the remote supervision of a physiotherapist so that the prescribed exercises can achieve significant results [23].

In the study by Anan et al., it was shown that one of the benefits of telerehabilitation is the level of patient compliance with the given exercise program. Telerehabilitation facilitates exercise reminder services so that patients will be more obedient in implementing exercises at home and at work. In addition, telerehabilitation that is implemented through the application will make patients more motivated to complete the exercises so that patients are encouraged to be more diligent in following the exercise program that has been prescribed [25]. In a study conducted by Smith et al., it was explained that exercise carried out regularly with the supervision of a physiotherapist will reduce pain significantly because physical exercise is able to stimulate the production of analgesics, which will contribute to pain reduction. Physical exercise performed at a certain dose is able to stimulate the release of endorphins, which will activate opioid receptors in the peripheral and central nervous systems, thereby triggering the endogenous opioid system to produce an analgesic effect that will reduce pain sensitivity [26].

7.2. Effect of Telerehabilitation on Improving the Quality of Life and Work Productivity

According to the six studies above, the provision of telerehabilitation to workers is able to improve the quality of life and help improve work abilities. A decrease in the quality of life is caused by the discomfort felt by workers, such as pain. This decline in the quality of life will have an impact on the level of worker productivity, which will disrupt the company’s performance, as described in research by Maliaras et al., in which the intervention group that received recommended care and telerehabilitation showed an increase in quality of life using the EQ5D parameter. The parameter results in the intervention group showed a value of 0.74 (0.12) at the beginning and increased to 0.78 (0.07) [15].

Similar results were shown in a study conducted by Yaghoubitajani et al. In the intervention group with online supervision, there was an increase in work ability, as measured using the Work Ability Index Questionnaire, to 8.00 ± 1.34, while in the control group, it was only 8.27 ± 90 [16]. Another study conducted by Moreira et al. shows comparable results. In this study, there was an increase in physical function and physical performance, as measured using the SF-36 parameter. Although the increase from 93.8 (6.8) to 95.0 (7.4) was not significant, this result was better than the control group, which decreased from 94.4 to 88.1 [17].

This study is in line with research conducted by Blanquero et al. on 74 participants who were divided into 2 groups, namely, the intervention group (N = 40) and the control group (N = 34). The results showed that the intervention group required an average return to work of 76 days in cases of wrist, hand, and finger injuries, and 94 days was the average time required by the control group (MD −18 days, 95% CI −33 to −3). With a fairly large difference in days, telerehabilitation can be said to be able to accelerate worker productivity [18].

The same thing happened in the study by Mbada et al., who used the SF-12 HS parameter for the assessment of physical function. The results showed that the intervention group who exercised through telerehabilitation had a more significant improvement compared to the control group [19]. The study also had comparable results to the study by Lee et al., in which 20 participants received a McKenzie exercise treatment and education through the application, and the control group was only given posture correction education. The results of the study by Lee et al. showed that there was a significant increase in the quality of life in the intervention group compared to the control group, as examined with the SF-36 HS parameter [20].

The pain felt by workers with WMSDs is correlated with their quality of life, which will have an impact on job satisfaction and productivity. An MSD affects attendance and sick leave. Research conducted by Chhabra et al. suggested that physical exercise will improve physical abilities as well as psychological health, which usually occurs as a side effect in individuals with poor health [27]. This is supported by research by Kim et al., who state that nurses who experience pain will have difficulty providing quality services to clients, so it has an impact on the level of client satisfaction [28]. Another study by Nguyen et al. showed the same thing, namely, when physical exercise is carried out regularly, it will have an impact on psychosocial health, where there is an increase in mood and decreased levels of depression and anxiety, so it affects work productivity [28]. Adhikari et al. reported that more than a third of workers experience back and neck pain after sitting for 2 h in front of the computer, which affects their work performance and productivity. With the implementation of telerehabilitation, there is an increase in the quality of life because physical exercise will help increase patient activation [22]. Based on the six articles above, it can be concluded that the application of telerehabilitation to workers has a positive impact on improving the quality of life, which affects work productivity.

7.3. Effective Telerehabilitation Dose

The telerehabilitation dose applied in patients with musculoskeletal pain recommended by Alsobayel et al. was 2–3 times per week with a duration of 20–40 min for 6 weeks. It is proven that telerehabilitation has positive therapeutic impacts in the form of pain reduction and improvements in physical function [29]. The telerehabilitation doses in the study by Blanquero et al., more than 3 days a week for 4 weeks, may be effective in reducing pain and increasing work productivity [18]. This is supported by research conducted by Vega et al., who reported that the intervention carried out with application-based telerehabilitation 5 days a week for at least 4 weeks may be effective in reducing pain and improving the quality of life [30].

8. Limitation

A limitation of this systematic review is that it does not discuss all complaints felt by workers with work-related musculoskeletal disorders; this study only discusses neck pain, low back pain, and upper extremity injuries.

9. Conclusions

Based on the six articles that have been reviewed, it can be concluded that the application of telerehabilitation to workers is able to provide benefits that can significantly reduce pain levels and have a positive impact on the quality of life, which affects work productivity and can be seen with the parameters VAS, QVAS, SF-12 HS, SF-36 HS, Work Ability Index, and EQ5D.