EFFECTIVENESS OF PHYSICAL THERAPY SERVICES THROUGH TELEMEDICINE DURING THE COVID-19 PANDEMIC: SYSTEMATIC REVIEW

The Covid-19 pandemic has greatly impacted physiotherapy services. In the context of the physical distancing strategy, physiotherapy services at health care centers are very limited. Telemedicine or telerehabilitation offers a way out to solve this problem. Despite its popularity, it turns out that this method is still becoming associated with its effectiveness. Therefore, this systematic review aims to update current evidence on the effectiveness of physiotherapy via telemedicine or telerehabilitation during the Covid-19 pandemic. The method used is a systematic review using Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA). Article searches were conducted from the Science Direct, Scopus, and Proquest databases with the keywords “Effective AND Physical Therapy AND Telemedicine OR Telerehabilitation AND Coronavirus”. The literature is then analyzed based on the results of existing research. All studies show that physiotherapy services through telemedicine or telerehabilitation?n have a good impact on the recovery process of motion and body functions of patients, Cost-effectiveness, as well as outreach to patients, are also added values of this telemedicine or telerehabilitation method. Telemedicine or telerehabilitation is the answer to the cause of the occurrence of physiotherapy services during this pandemic. This method of providing remote health services allows patients with impaired movement and bodily functions of patients with cardiorespiratory, musculoskeletal, and neuromuscular disorders to carry out an exercise program at home under the supervision of a physiotherapist and can reduce the risk of being infected with the


INTRODUCTION
Since its first outbreak report on December 31, 2019, the Coronavirus disease (Covid-19) has infected hundreds of millions of people worldwide. Meanwhile, new cases and deaths continue to emerge non-stop, as vaccines are still under development and distribution. The whole world must not only face the direct health impacts of this virus, but also the enormous indirect impacts on both the economic and social sectors (Kim & Katelyn Kim, 2021).
In Indonesia alone, as of August 2021, there were 3,760,497 confirmed cases of Covid-19 (Covid-19 Handling Task Force, 2021). Indonesia has the most active cases of Covid-19 among countries in Southeast Asia, (Dong et al., 2020). Until now, with more than 1000 new cases per day, the Covid-19 daily confirmed cases are still relatively high in Indonesia (Cucunawangsih et al., 2021).
The rate of spread of infection indicates that transmission occurs from human to human (Sitorus et al., 2021). Therefore, in order to protect their citizens from the virus and reduce the burden on their healthcare systems, many governments from different countries have used a variety of measures to maintain physical distancing including bans crowd puller events, and travel restrictions (Connor, 2020). The Covid-19 pandemic has also dramatically changed the way outpatient services are practiced in healthcare. Many outpatients avoid visiting health facilities because they do not want to leave their homes and are exposed to the risk of getting a Covid-19 virus infection. The existence of government regulations related to restrictions on mobilization also affects patient behavior where patients tend to reduce or even avoid visits to health care facilities to check their health conditions (Mehrotra et al., 2020).
The direct effects of the Covid-19 infection and the indirect consequences of government policies have a severe impact on the subgroups of the population with the greatest health needs, such as people with disabilities or at risk for disability due to chronic conditions. Several international bodies have established health policies that focus not only on the acute management of the Covid-19 disease but also on prevention, intervention, and care in chronically ill patients living at home or in health care facilities, as well as patients suffering from recent functional limitations that require rehabilitation (or treatment in a rehabilitation facility) (Ceravolo et al., 2020).
This situation is a challenge for the medical rehabilitation team, especially physical therapy services to be able to adapt to the conditions of the Covid-19 pandemic (Nugraha et al., 2020). The question is what should the patient do at home to recover his condition? Telemedicine is an alternative approach that can ease some of these obstacles (Batalik et al., 2021). There are several types of telemedicine such as telerehabilitation, telemonitoring, and teleconsultation. Telerehabilitation can be the solution to the state of physical rehabilitation during the Covid-19 pandemic (Prabawa et al., 2021). Telerehabilitation can be defined as the use of telecommunications, either with live video or audio, to provide rehabilitative interventions (Appleby et al., 2019). In a previous study with physical therapy intervention through telerehabilitation services to reduce pain and disability in patients with Patellofemoral Pain Syndrome (PFPS), it was proven successful in 12 physical therapy sessions over 4 weeks (Albornoz-Cabello et al., 2021). Other studies have shown that telerehabilitation services carried out at home, based on the 200 meters Fast Walk Test can effectively improve cardiorespiratory fitness in patients with coronary heart disease with low to moderate cardiovascular risk (Batalik et al., 2021). However, in other studies, it was found that the results of evaluating the effectiveness of telerehabilitation were contradictory. Where Piotrowicz et al. who conducted a study in patients with heart disease found that administering a 9-week Hybrid Comprehensive Telerehabilitation (HCTR) program did not increase the percentage of days alive and hospital discharge and did not reduce mortality and hospitalizations during a 14-to-26-month follow-up period (Piotrowicz et al., 2020). Therefore, the purpose of this review is to update the literature on the effectiveness of physiotherapy services through telerehabilitation, especially during this Covid-19 pandemic.

METHODS
This study is a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). Data were acquired from research articles by accessing 3 electronic databases, namely Science Direct, Scopus, and Proquest on the lib.ui.ac.id page.
The search for research articles was conducted using the keywords "Effective AND Physical Therapy AND Telemedicine OR Telerehabilitation AND Coronavirus". The articles found are read carefully to see if they meet the author's inclusion criteria. The inclusion criteria used are articles published from April 2020 to April 2021 which can be accessed in full text and English. Meanwhile, the exclusion criteria in this study are research journals that have topics outside of physical therapy services through telemedicine or telerehabilitation during the Covid-19 pandemic.
In the initial search, 1,129 articles were found from 3 databases. Then articles with similar content are removed from the list of articles. These results were then selected based on the title, abstract, and content of the article to produce 8 complete articles relevant to this research and included in a systematic review.

RESULTS
A total of 1,129 potentially relevant articles were found by searching from 3 databases. After the deletion of duplicate articles, as well as the screening of titles and abstracts, a total of 30 articles were reviewed in full text. A total of 8 articles met the eligibility criteria and were included in the analysis. The PRISMA flowchart is illustrated in Figure 1. The articles that were included in the systematic review were then analyzed based on the title, year, author's name, location, study design, results, and research conclusions. These data are then listed in Table 1.
The eight articles that meet these criteria are studies conducted in the continents of Asia, Europe, North America, and South America. The continent of Asia is represented by China. The European continent is represented by the Czech Republic, Spain, England, and Italy. The continent of North America is represented by the United States of America. The continent of South America is represented by Chile. From the eight articles reviewed, it is known that physical therapy services through telemedicine or telerehabilitation have produced good results for their users during the Covid-19 pandemic. This method has been successfully applied to patients with cardiorespiratory disorders, patients with musculoskeletal disorders (Patellofemoral Pain Syndrome and breast cancer), as well as patients with neurological disorders (

DISCUSSION
Several studies have been conducted to find out about the effectiveness of physical therapy services through telemedicine or telerehabilitation. One of them is a study conducted by Albornoz-Cabello et al. in 54 patients with musculoskeletal disorders, namely patellofemoral pain syndrome (PFPS). In this study, patients were given an exercise program at home supervised by a physical therapist via telephone and email, 3 times a week (4 weeks duration, 12 therapy sessions). The results obtained were a significant improvement in pain intensity, joint range of motion, and level of disability. This study concluded that therapeutic exercises supervised by a physical therapist via telematics channels showed greater effectiveness in reducing pain and disability rates in patients suffering from PFPS than simply providing patient education brochures (Albornoz-Cabello et al., 2021).
Other studies related to physical therapy services through telemedicine or telerehabilitation have also been carried out in patients with cardiorespiratory disorders, where the sample used was 19 patients with coronary heart disease (CHD). This patient did a regular exercise program 3-5 times a week, with a minimum duration of 30 minutes, for 8 weeks.
The physical therapist acts as a remote trainer, examining patients and providing feedback or feedback over the phone every two weeks. The effectiveness of similar telerehabilitation approaches in people with CHD has also been confirmed, and this approach is highly recommended as a promising alternative (Scherrenberg et al., 2020;Scott-Sheldon et al., 2020).
Likewise in neuromuscular cases, such as Amyotrophic Lateral Sclerosis (ALS). In a study conducted by De Marchi et al. On 19 ALS patients, the physical therapist provided advice aimed at managing the main problems felt by the patients through demonstration videos and explained how to perform the exercises. As a result, the local pain felt by the patient was stable, not getting worse (De Marchi et al., 2021).
From the studies that have been reviewed above, it is very clear that the provision of physical therapy services through telemedicine or telerehabilitation is effective in restoring or maintaining the function and movement of the patient's body. In addition, it turns out that this method has other advantages. One of them is cost-effective (Batalik et al., 2021;Miao et al., 2021). Telerehabilitation showed to be at least as cost-effective as traditional cardiac rehabilitation programs (Kraal et al., 2014). This cost-effectiveness can occur because it requires fewer clinic-based facilities and less contact with physical therapists for treatment (Fatoye et al., 2020).
In addition to the advantages mentioned above, telerehabilitation may have advantages that far exceed the current limitations of the government's policy of social distancing related to the Covid-19 pandemic.
The effectiveness of telerehabilitation can be strengthened by several currently available technologies, such as virtual reality which can recreate a realistic environment in which patients can physically move, and wearable sensors that allow physical therapists to quantitatively monitor patient achievements (Nuara et al., 2021).

CONCLUSIONS
The use of telemedicine or telerehabilitation methods allows the provision of physical therapy services through long-distance communication media, whether in the form of audio or video. This method can be a way out for patients with impaired movement and body function during the Covid-19 pandemic because it allows patients to carry out an exercise program at home, thereby reducing the risk of being infected with Covid-19.