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1. Introduction
The Coronavirus Disease 2019 (COVID-19) pandemic not only affected the financial and social life aspects of individuals but also changes the conventional method of managing patients [1]. To prevent COVID-19 spread, some preventive measures should be taken, such as wearing masks and gloves, adopting careful personal hygiene, as well as applying the so-called ‘social distancing’ [2]. Telerehabilitation (TR) is a reliable approach to provide rehabilitation programs, remotely. In the past few years, it has been supported that significant clinical improvements can be achieved by applying TR; thus, that they are equal to the conventional clinical rehabilitation treatment. Implementing TR has especially become more crucial in the COVID-19 pandemic; the clinical face-to-face treatment is at odds with preventive measures and it is dangerous. Currently, remote communication between healthcare professionals and patients is significantly facilitated due to progress in communication and information technologies [3]. This method can provide various rehabilitation services, such as monitoring, assessment, intervention, prevention, supervision, education, consultation, and counseling [4]. Furthermore, applying TR is becoming more viable as the speed and quality of communication technologies enhance [3]. However, the efficiency of this model of delivery remains unclear, compared with face‐to‐face delivered rehabilitation [5].
TR has numerous advantages. It can enhance the standard of services by monitoring patients at their place of residence, particularly for individuals who live far from urban centers [6]. TR can also adapt long-lasting rehabilitation programs with a social and productive life. The term TR stands for any home-based interventions, regardless of which technology is used [7]. Its programs can overcome numerous practical barriers to rehabilitation participation and support long-term adherence to a healthy lifestyle [8]. TR is mainly applied for patients with spinal cord and brain injury, stroke, or joint replacement; it usually involves audio and video technologies [4]. There exist multiple rehabilitation therapy methods and programs based on TR. Besides, they commonly require the clinical professionals to check the patient’s condition; they present rehabilitation therapy examples to the patient or their guardian and use photos or videos to instruct how rehabilitation therapy should be performed [9]. However, no evidence demonstrated the TR capability to improve participation rates. Another valuable benefit of TR is providing efficient feedback that allows patients to follow their improvement process. This could improve patients’ self-management skills; subsequently, it supports more sustainable behavioral change [8]. Some benefits of TR include the following: greater privacy; presented at one’s pace; minimal travel/ transportation barriers; higher patient independence; combination with telemonitoring; protection from virus infections; providing core components at home; possible tailoring, and cost-effectiveness [1, 8].
 Over the recent decade, various TR methods have been employed. However, our healthcare systems have implemented TR in clinical practice disappointingly low. Furthermore, most TR trials have only focused on the physical activity component and exercise training; however, TR ideally involves addressing all core components of rehabilitation tailored to the risk profile of the individual patient [8]. TR has some challenges concerning implementation. The present study reviewed the articles that addressed these challenges and barriers. 

2. Methods
We performed a global systematic review through various national and international electronic databases to identify studies that addressed the barriers and challenges of implementing TR. In this article, we used items for reporting a literature review to present the obtained results.

Study design and data extraction
We conducted a systematic review to explore the barriers of TR. The related articles published in English and Persian languages from 2011 to February 2021 were searched in popular scientific databases (Scopus, MEDLINE/ PubMed, & Google Scholar) as well as domestic databases (Magiran & SID). Google Scholar browser was also used to find relevant resources and complete the search coverage.
The first step of our search consisted of the following keywords: (‘barriers’ OR ‘obstacles’ OR ‘challenges’) AND (‘telerehabilitation’ OR ‘telemedicine’). In this study, we surveyed various published papers. The statistics of searched papers and abstracts are presented in Figure 1.

This diagram illustrates the most recent search. This review required no Institutional Review Board (IRB) approval or consent, as it assessed articles without individually identifiable human subject information. Unfortunately, no Persian study was found in the domestic databases.
Two researchers independently decided whether to submit articles, and disputes were resolved in consultation with each other. Additionally, a list of sources of searched articles was used to find the related articles. Accordingly, 598 articles were identified. 

Inclusion and exclusion criteria
In this study, to select the relevant articles, the following criteria were used: published papers; published articles included only if the focus of the article was to explore barriers of TR; if the papers were published in English and Persian, and their free full texts were available. The exclusion criteria included studies outside the field of rehabilitation; articles in languages other than English and Persian, and letter to editor articles. 

3. Results
Preliminary search results in all databases provided a total of 598 articles. After searching various databases, all identified articles were imported into EndNote, and duplicated titles were removed. Of these, 24 articles were included. Accordingly, we removed duplicates by only examining the titles. Then, the abstracts of the 24 articles met the inclusion criteria of this review. The full-texts of 24 articles were reviewed; eventually, 11 articles remained for further examination and no new relevant studies were identified.
Figure 2 and Table 1 summarize the features of the 11 articles extracted. Most of the extracted articles were published in 2020 (n=4).


The remaining articles disturbed between 2013 and 2021. The selected articles were mostly review, qualitative, case reports/series, and survey studies. Geographically, 27% of the final selected papers were performed in the USA, 46% in Asia, and 27% in Europe.

4. Discussion
Several barriers and obstacles need to be considered in implementing TR. Despite the theoretical advantages of TR over conventional rehabilitation, few studies have evaluated patient satisfaction or acceptance of this rehabilitation method. Furthermore, those studies have found conflicting results for this variable. Further studies are required to evaluate the cost-effectiveness of this rehabilitation model, the barriers encountered by patients when performing TR, and the patients’ acceptance of the model [21]. According to studies, numerous factors can help TR to develop at a slower pace and require further time to be able to convince the patient of its effectiveness as conventional approaches. The current study reviewed the challenges and barriers to the implementation of TR and the evaluation of the published articles points as per the following: 
Jongbae Kim et al. in 2021 highlighted a lack of standardization of reported neurological levels of injury throughout the study. Besides, they outlined inconsistencies in using generalized terms with increased errors and increased skepticism about service delivery. They also highlighted potential biases that obscured the facts. Other challenges mentioned in providing TR for individuals with spinal cord injury in this study included a tendency to conventional rehabilitation methods due to the ease of informing the therapist of their sexual problems; in providing TR, the lack of technological advancement for it remained an obstacle despite advances in telemedicine [10]
Sometimes, devices and technologies used in TR (tactile feedback technology for motor impairments) have limitations that may lead to poor patient satisfaction and complicate performing TR. These disadvantages include the unpleasant feeling, the different perceptions, and the unpleasant sensation of different patients from the vibration of the device on their body [11]. Providing proper equipment was another challenge to TR implementation. Notably, we cannot optimize TR just by integrating a camera into an existing workstation. For TR, a one-size-fits-all method does not suit all therapy approaches. It involves setting different options depending on the type of therapy. Additionally, TR equipment should be adaptable to various scenarios [12]. Furthermore, some user interface issues, including a screen reader, captions, magnification, color, sign language, and contrast must also be managed. Besides, bio peripherals, including instruments that measure blood glucose level and pressure, and other vital signs should be modified for use in the tele-evaluation of individuals with disabilities. The design of new bio peripherals involves improving clinicians’ capability to tele-examine individuals with problems, such as manual dexterity or physical mobility disorders that affect the ability to interact with such bio peripherals [14].
Other barriers were technical issues, the lack of information, the lack of involvement in planning, the shortage of exposure to e-healthcare information, resistance to change, the lack of using hardware and software, low connectivity, staff skill problems, and high-cost provider’s willingness, and the location of the healthcare institute. In addition to these limitations, the attitudes of policymakers impact the use of TR services [13, 16].
Thira M. Anna Swamy et al. reported the challenges and barriers of TR for individuals with a disability, as follows: infrastructure and access; operational conflicts and systems; logistical; regulatory; communication, and unique challenges [14]. The barriers and challenges of TR can also be categorized as follows: 
Respecting human factors, the lack of general acceptance of telehealth, the deficits of knowledge and skills, and anxieties related to private data security. Concerning the various mentioned organizational factors in the literature as the main identified barriers of TR implementation, the most frequent characteristics were no appropriate health information systems framework, the lack of national e-health policies or laws, data privacy measures, and governance measures. Among all individual factors across categories, the lack of access to the internet was the main barrier to telehealth [15].
Another factor was that numerous elderly patients that require continuous rehabilitation have inadequate information about how to use smart devices, while these individuals with limited performance, need the help of technological devices. Fast and reliable internet connections and the need for secondary equipment with the knowledge of their performance are tangible barriers to establish stability and ensure perfect interventions for the optimal clinical care of this population. Eventually, protecting personal data against unintended leakage and securing remains a serious challenge in TR [10, 17]. 
In summary, despite studies on the barriers and challenges of TR, few relevant solutions have been extracted. Obstacles in the technologies required for this approach, whether in the hardware sector or the software sector and infrastructures have been found in most studies [11, 12, 13, 15, 19, 20]; accordingly, further research on the approaches to overcome these barriers is necessary.

5. Conclusion
Studies signified numerous challenges for TR implementation. The main challenges in the technologies used in TR are the awareness and culture of the individuals and the TR infrastructure. Despite these barriers, TR could be a better treatment option for some patients. Furthermore, it has considerable advantages, although further study is required to investigate its effectiveness in other conditions [21, 22]. With the development of technology, and in some conditions that individuals with a disability cannot travel for face-to-face interventions, for example in the COVID-19 pandemic, the need for TR has increased and simultaneously has sped up the adoption of digital culture, worldwide. Therefore, it is necessary for the governments, health policymakers, and especially rehabilitation managers, technology developers, scientists, and clinicians, to cooperatively make serious effort to remove these barriers respecting engineering, technology, the internet, and community culture; thus, they could assist individuals with disabilities to improve their quality of life.

Ethical Considerations
Compliance with ethical guidelines
There were no ethical considerations to be considered in this research.

Funding
No funding was provided for this research. 

Authors' contributions
All authors made considerable contributions to all the conception and design of the study, analysis, and interpretation of the result, writing of the manuscript, and revising it. All authors read and approved the final version of the submitted manuscript. 

Conflict of interest
The authors declared no conflicts of interest.


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