Comparative effectiveness of telerehabilitation vs. face-to-face rehabilitation in adults with chronic low back pain: a systematic review and meta-analysis of randomized controlled trials

Background Chronic low back pain (CLBP) is a major cause of disability worldwide and creates substantial rehabilitation demand. When core rehabilitation content is similar, the comparative effectiveness of telerehabilitation (TR) and face-to-face rehabilitation as delivery modes remains unclear. Methods Methods: This meta-analysis used strict eligibility criteria to distinguish the two delivery pathways and better isolate delivery-mode effects. PubMed, Web of Science, the Cochrane Library, and Embase were searched for randomized controlled trials in adults with CLBP. Paper-based home exercise programs, continuous hybrid delivery, and remote-assessment-only designs were excluded. Random-effects meta-analyses used standardized mean differences (SMDs) with 95% confidence intervals (CIs). RoB 2 and GRADE assessed risk of bias and evidence certainty. Sensitivity and subgroup analyses were conducted. Results Ten trials involving 562 participants were included. Content-matched primary analyses found no significant difference between TR and face-to-face rehabilitation in pain intensity (7 trials; SMD = −0.05, 95% CI − 0.34 to 0.24; very low certainty) or functional disability (8 trials; SMD = 0.22, 95% CI − 0.07 to 0.52; low certainty). In secondary analyses including two trials that provided manual therapy only to the face-to-face group, pain intensity did not differ significantly (9 trials; SMD = −0.01, 95% CI − 0.26 to 0.24), whereas functional disability favored face-to-face rehabilitation (10 trials; SMD = 0.26, 95% CI 0.01 to 0.52). Subgroup interaction tests were nonsignificant for intervention duration, weekly treatment frequency, and supervision status. Conclusion When rehabilitation content was similar, TR and face-to-face rehabilitation showed no statistically significant differences in pain intensity or functional disability. However, these findings should not be interpreted as evidence of equivalent effectiveness between TR and face-to-face rehabilitation, because the certainty of evidence was low for functional disability and very low for pain intensity, and the functional disability estimate was sensitive to the exclusion of one study. Future high-quality trials with comparable interventions and longer follow-up are needed, particularly direct comparisons of supervised and unsupervised TR. Systematic review registration PROSPERO, CRD420261467122.