All analyses were based on data from previously published studies. Thus, no ethical approval or patient consent was required. The review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement (see PRISMA checklist in Multimedia Appendix 1) [10]. The a priori protocol for the review is published in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42024564141).

A search for RCTs was conducted across the databases PubMed, PEDro, Cochrane, and Scopus. A total of 207 studies were identified: 83 papers from PubMed, 10 from PEDro, 1 from Cochrane, and 113 from Scopus. The primary keywords used were telerehabilitation, pain management, strength, balance, and physical therapy. Only articles published in English were selected.

A systematic search was conducted across multiple databases, including PubMed (n=83), PEDro (n=10), Cochrane (n=1), and Scopus (n=113), identifying a total of 207 records (Figure 1). After removing duplicates, 120 records remained for screening, where 2 independent reviewers (TP and MI) assessed titles and abstracts using the “RAYYAN” platform. Following this process, 81 records were excluded, and 39 reports were assessed for eligibility. Of these, 33 reports were further excluded due to reasons such as the absence of full text (n=4), irrelevance to the outcome (n=10), noninternet technology support (n=4), or participants having undergone knee arthroplasty (n=15). Ultimately, 6 studies met the predefined inclusion criteria, involving a total of 581 patients with KOA who received telerehabilitation intervention. The inclusion criteria required participants to be at least 18 years old, diagnosed with KOA, and undergoing telerehabilitation intervention.

The interventions in the 6 included RCTs were as follows: (1) telerehabilitation compared with electrotherapy and home exercise [9], (2) telerehabilitation through Zoom (Zoom Video Communications) compared with individual home rehabilitation with the help of a booklet [13], (3) telerehabilitation combined with a web-based PCST (pain coping skills training) rehabilitation program compared with usual care [14], (4) telerehabilitation compared with clinic-based rehabilitation [6], (5) telerehabilitation compared with home rehabilitation [15], and (6) telerehabilitation with an 8-week PAINCOACH (pain management coaching) program compared with rehabilitation without PAINCOACH [16]. In most cases, both groups in all the studies followed the same rehabilitation program, with the main difference being that the intervention group was always guided by a physiotherapist through telecommunication.

For the PEDro scale, the reviewers applied the 11 criteria included in the tool and categorized the studies based on their total scores: 0-3 were considered “POOR,” 4-5 “FAIR,” 6-8 “GOOD,” and 9-10 “EXCELLENT.” The PEDro scale criteria are outlined in Table 1.

The above RCTs were evaluated using the PEDro scale [17]. The average score across the 6 studies was 6.3/10, indicating good quality. More specifically, 1 study scored 8/10 [16], 2 studies scored 7/10 [13,15], and 2 studies scored 6/10 [6,9], all of which are considered good quality according to the scale. However, 1 study scored only 4/10, which classifies it as a fair-quality study (Table 2) [14].

Based on the Downs and Black checklist [18], 4 studies were classified as “FAIR” quality [6,9,14,15], and the remaining 2 studies were classified as “GOOD” quality [13,16].

Although the initial objective of this systematic review was to conduct a meta-analysis, significant heterogeneity among the included studies prevented a reliable quantitative synthesis. Variability in intervention protocols (eg, therapist-guided video calls, self-directed web-based programs, and mobile apps), diverse outcome measures (eg, Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], Visual Analog Scale [VAS], timed up and go test [TUG], and 30-second chair stand test [30-CST]), and differences in comparison groups (eg, traditional physiotherapy, no intervention, home-based exercises) introduced methodological inconsistencies. In addition, high statistical heterogeneity (I²>50%) further undermined the validity of a meta-analysis. As a result, a narrative synthesis was conducted to provide a qualitative comparison of findings.

The baseline descriptive characteristics (country, sample size, age, and gender) of the 6 studies included in the systematic review are summarized in Table 3. A total of 2 studies were from Australia, 1 from the United States, 1 from Brazil and Iran, 1 from Turkey, and 1 from Nigeria. The mean age of patients with KOA ranged from 37 to 72 years, and all studies included both men and women.

In this systematic review, the outcomes of interest were pain, strength, and balance in patients with KOA undergoing telerehabilitation. Pain was assessed in all studies using a variety of tools. The WOMAC was one of the most used tools for pain measurement, especially in studies like those by Bennell et al [19], where significant improvements were observed at the 6th- and 12th-month follow-ups. Other pain measurement tools included the VAS and the Numeric Pain Rating Scale (NPRS). Both tools were used in studies by Lawford et al [14] and Azma et al [9], showing that telerehabilitation interventions led to significant pain reduction compared with traditional physiotherapy. In some cases, such as in the study by Rini et al [16], it was found that women in the telerehabilitation group experienced a greater reduction in pain compared with men.

In terms of strength and balance, fewer studies evaluated these outcomes, and the tools used were less consistent. The 30-CST and the TUG tests were used to assess lower body strength and balance. In particular, the study by Tore et al [13] found significant improvements in both strength and balance in the telerehabilitation group compared with the control group. This study was one of the few that specifically measured these outcomes. The improvements in strength and balance in this study highlight the potential benefits of telerehabilitation for enhancing these physical capacities, though such outcomes were not consistently reported across other studies.

This systematic review examined 6 RCTs assessing the effectiveness of telerehabilitation for KOA. The findings indicate that telerehabilitation can serve as an effective alternative to conventional rehabilitation, demonstrating improvements in pain management, strength, and balance. However, the extent of these benefits varied across studies, with some showing significant clinical improvements while others reported comparable outcomes between telerehabilitation and in-person rehabilitation.

For instance, Azma et al [9] and Odole et al [6] reported significant pain reduction in both intervention and control groups, suggesting that while telerehabilitation is beneficial, it may not always be superior to conventional rehabilitation. On the other hand, Tore et al [13] found substantial improvements in strength and balance among telerehabilitation participants, highlighting its potential to address key functional limitations in patients with KOA. This aligns with the broader understanding that while telerehabilitation effectively delivers structured rehabilitation, its impact may depend on factors such as intervention format, patient adherence, and baseline severity of KOA.

Compared with previous systematic reviews, such as Xie et al [1], which primarily focused on pain and physical function, our study expands the scope by incorporating strength and balance—2 critical components of functional ability and fall prevention that were previously overlooked. In addition, Xie et al [1] included studies up to April 2020, covering 6 RCTs with 791 patients, whereas this review extends the search to May 2024, adding 6 more RCTs. This expanded dataset strengthens the generalizability of our findings and provides a more comprehensive evaluation of telerehabilitation’s role in KOA management.

The included studies exhibited substantial heterogeneity regarding intervention modalities, outcome measures, and patient populations, which limited direct comparisons with a very high homogeneity index (I²=95%). Some trials, such as Bennell et al [15] and Rini et al [16], incorporated therapist-led coaching, whereas others, like Lawford et al [14], relied on self-guided programs with minimal professional interaction. Pain was assessed using different tools (eg, WOMAC and VAS), strength was measured through varied functional tests (eg, 30-second chair stand test), and balance assessments included diverse protocols (eg, timed up and go test). Such methodological variability complicates the pooling of results, necessitating a narrative synthesis rather than a meta-analysis.

Furthermore, differences in study populations introduced additional variability. Odole et al [6] included relatively younger participants, while Azma et al [9] focused on older adults with advanced KOA. Given that older patients often have greater physical limitations combined with cognitive impairments and reduced exercise adherence, the effectiveness of telerehabilitation may differ across age groups. Future research should conduct subgroup analyses comparing intervention effectiveness across different demographic and disease severity levels to clarify which patients benefit most from telerehabilitation.

Unlike previous systematic reviews, which primarily examined general digital rehabilitation interventions, this review categorizes telerehabilitation strategies based on their mode of delivery, distinguishing between real-time therapist-guided interventions and self-managed programs. This distinction is crucial, as previous findings have been inconsistent due to a lack of differentiation in rehabilitation modalities.

Furthermore, while Xie et al [1] relied solely on the PEDro scale for risk-of-bias assessment, this review uses both the PEDro scale and the Downs and Black checklist, offering a more rigorous evaluation of methodological quality. In addition, a sensitivity analysis was conducted to assess the robustness of findings, an approach not included in previous reviews. These methodological enhancements provide a stronger foundation for evaluating telerehabilitation's effectiveness and guide recommendations for its integration into clinical practice.

Several methodological limitations were identified across the included RCTs. Selection bias was evident in studies such as Lawford et al [14], where randomization procedures were not fully detailed, raising concerns about allocation concealment. Performance bias was also a common issue, as blinding of participants and therapists is inherently difficult in telerehabilitation studies. This could have influenced subjective outcomes such as pain perception. In addition, high attrition rates were noted in studies like that of Rini et al [16], potentially affecting the validity of long-term conclusions.

Despite these limitations, most included studies were classified as fair to good quality. Future research should prioritize strategies to mitigate bias, such as using more robust randomization methods, improving participant retention, and using objective outcome measures where possible.

Telerehabilitation offers multiple advantages, particularly for patients with mobility limitations or geographic barriers to health care access. Its flexibility allows for continuity of care, reducing dependence on in-person visits. However, several challenges remain for its widespread implementation.

One major issue is adherence, as engagement tends to decline in self-managed programs. Bennell et al [15] found that interventions with therapist-guided coaching led to higher adherence rates than fully self-directed programs. This suggests that maintaining patient interaction with health care professionals—even remotely—may be key to optimizing outcomes.

In addition, regulatory and reimbursement barriers limit the accessibility of telerehabilitation in many health care systems. Standardizing reimbursement policies and integrating telerehabilitation into clinical guidelines could enhance adoption. Furthermore, technological barriers, such as digital literacy challenges among older adults, must be addressed through user-friendly platforms and comprehensive patient education programs.

A key strength of this review is its inclusion of a broader range of outcome measures beyond pain reduction, allowing for a more holistic assessment of telerehabilitation’s benefits. The extensive literature search across multiple databases minimized selection bias and ensured a thorough synthesis of available evidence. The use of validated quality assessment tools further strengthened methodological rigor.

However, several limitations should be acknowledged. Heterogeneity in intervention protocols and outcome measures limited direct comparisons and precluded meta-analysis. Language bias may also be present, as only English-language studies were included. In addition, most studies had short follow-up periods, making it difficult to determine the long-term sustainability of telerehabilitation outcomes. Future trials should incorporate extended follow-up periods to assess whether improvements in pain, strength, and balance persist over time.

To refine the evidence for telerehabilitation, future research should focus on the following:

This systematic review highlights the potential of telerehabilitation as a viable alternative to conventional rehabilitation for KOA, demonstrating benefits in pain reduction, strength, and balance. However, its effectiveness varies depending on intervention type, patient engagement, and delivery method. In comparison to previous reviews, this study broadens the scope of analysis, incorporates 6 additional RCTs, applies a dual-method risk-of-bias assessment, and differentiates telerehabilitation modalities.

By distinguishing therapist-guided interventions from self-managed programs, this review provides novel insights into how telerehabilitation can be optimized for KOA management. Addressing current methodological limitations and refining intervention strategies will be crucial in ensuring its long-term success. With further research and policy support, telerehabilitation has the potential to become an integral component of rehabilitation care, improving accessibility and patient outcomes in KOA treatment.