Abstract
BACKGROUND: Parkinson disease (PD) presents motor and nonmotor challenges that significantly affect quality of life. Telemedicine has emerged as a promising approach to deliver interventions, including exercise performed through remote equipment (e-Exercise), cognitive behavioral training sessions conducted remotely (e-Cognitive), and consultations conducted through remote devices (e-Visits), yet their comparative effectiveness remains unclear. OBJECTIVE: This paper aimed to evaluate the effectiveness of telemedicine interventions on motor and nonmotor outcomes in PD and compare the efficacy of e-Exercise, e-Cognitive, and e-Visits. METHODS: A systematic review and network meta-analysis were conducted by searching PubMed, MEDLINE, Embase, Cochrane CENTRAL, and Web of Science through November 2024. Randomized controlled trials comparing telemedicine interventions with usual care were included. Outcomes assessed included total motor symptoms, quality of life, cognitive function, depressive and anxiety symptoms, fear of falling, 6-minute walk test, walking velocity, balance ability, and timed up and go. Two investigators independently performed study selection, data extraction, and risk-of-bias assessment using the Cochrane risk of bias 2 tool. Data synthesis included (1) pairwise meta-analyses using random-effects models to calculate standardized mean differences (SMDs) and mean differences; and (2) Bayesian network meta-analysis integrating direct and indirect comparisons to rank intervention efficacy, with transitivity and inconsistency evaluated. Evidence quality was graded using GRADE (Grading of Recommendations, Assessment, Development and Evaluation), incorporating risk of bias, heterogeneity (I²>50% indicating substantial heterogeneity), precision, and publication bias (Egger test). Statistical heterogeneity was quantified by τ² and I². RESULTS: A total of 23 studies involving 1330 participants were included. Pairwise meta-analyses demonstrated that telemedicine significantly improved total motor symptoms (SMD=-0.61, 95% CI -1.19 to -0.4), cognitive function (SMD=0.58, 95% CI 0.15-1.01), depressive symptoms (SMD=-0.46, 95% CI -0.88 to -0.04), anxiety symptoms (SMD=-0.57, 95% CI -1.10 to -0.03), fear of falling (SMD=-0.48, 95% CI -0.77 to -0.19), and 6-minute walk test performance (mean difference=18.98, 95% CI 16.06-21.90 meters). The network meta-analysis revealed that e-Exercise was most effective for improving total motor symptoms (SMD=-1.01, 95% credible interval [CrI] -1.96 to -0.05) and 6-minute walk test performance. e-Cognitive was most effective for enhancing quality of life (SMD=0.39, 95% CrI 0.06-0.73) and cognitive function (SMD=1.02, 95% CrI 0.38-1.66), and reducing depressive (SMD=-1.28, 95% CrI -1.61 to -0.96) and anxiety symptoms (SMD=-1.07, 95% CrI -1.40 to -0.75). e-Visits had a limited impact across outcomes. Evidence quality was moderate or high for motor symptoms, quality of life, and depression, but low or very low for other outcomes. CONCLUSIONS: Telemedicine is effective for improving motor and nonmotor outcomes in PD. e-Exercise is optimal for motor function and physical performance, while e-Cognitive is most effective for psychological and cognitive challenges. These findings highlight the importance of tailoring telemedicine programs to address specific therapeutic needs in PD management. TRIAL REGISTRATION: PROSPERO CRD42024628687; https://www.crd.york.ac.uk/PROSPERO/view/CRD42024628687.