Effects of Home-Based Pulmonary Rehabilitation on Dyspnea, Exercise Capacity, Quality of Life and Impact of the Disease in COPD Patients: A Systematic Review

Figures & data

Figure 1. Flow chart of study selection.

Table 1. Main methodological characteristics of the included studies.

Year, Author	Country	Randomized (Y/N)	Follow-up	Inclusion criteria	Exclusion criteria
1996, BAULDOFF; ZULLO; HOFFMAM	USA	Y	8 weeks	Diagnosis of COPD (FEV1 / FVC <60% of predicted) Clinically stable Not having been hospitalized for 6 weeks or more before data collection Never having received training with arm exercises Without unstable heart disease (eg: recent myocardial infarction, uncontrolled hypertension, severe congestive heart failure) Not having musculoskeletal disability	NR
1996, STRIJBOS; ALTENA; KOETER	Netherlands	Y	6, 12 and 18 months	COPD, diagnosed by history, physical examination, radiography and results of pulmonary function tests; Dyspnea on exertion, which limits activities of daily living; PaCO2 at rest <6.5 kpa, and Pa02 at rest> 7.5 kpa; Post-bronchodilation FEV 1 between 600 and 1800 ml and <65% of predicted	Ischemic heart disease, musculoskeletal disorders, or other disabling diseases that may restrict therapy rehabilitation.
1996, WIJKSTRA et al	Netherlands	Y	3 months	FEV1 < 60% predicted; FEV1 / vital inspiratory capacity (VCI) <50%, both after two inhalations of 40 μg of ipratropium bromide; Severe airway obstruction (mean FEV1 44% pred, mean FEV1 / CVI 38%) Reversibility less than 10% (mean increase in FEV1 of 0.15 L, 5% predicted)	Patients with evidence of myocardial ischemia, intermittent claudication, musculoskeletal disorders or other disabling diseases.
2000, HERNANDEZ et al	Spain	Y	3 months	Diagnosis of COPD Stable disease with drug optimization FEV1 < 60% of predicted time Being a former smoker or having previously been included in a smoking cessation program that resulted in abstinence	Patients with evidence of severe or uncontrolled ischemic heart disease, systemic arterial hypertension, changes in the rib cage, neuromuscular disorders or intermittent claudication or osteoarticular lesions in the lower extremity that could affect normality Patients with acute exacerbation during the program
2003, SINGH et al	India	Y	1 month	Stable COPD Dyspnea in three or more daily activities been Never involved in a pulmonary rehabilitation program Had given up smoking for at least two months	Patients with right ventricular failure, unstable ischemic heart disease, oxygen saturation less than 88% at rest, musculoskeletal diseases, acute exacerbation and pneumothorax
2003, OH	Korea	Y	2 months	Diagnosis COPD Less than 85% of predicted FEV1 No exacerbation evidenced by physician No evidence of ischemic heart disease, musculoskeletal disorders, or other disabling diseases that could restrict the rehabilitation therapy	NR
2005, BOXALL et al	Australia	Y	3 months	Diagnosed with COPD Age> 60 years, Dyspnea on exertion Having no worsening of the symptoms of the disease during the last 2 weeks Motivated to run the program daily without supervision. Patients functionally confined at home	Patients who are already part of an outpatient program Patients with restricted shoulder movement Nursing home residents Patients with previous lung volume reduction surgery Patients with pain limiting mobility
2005, MURPHY; BELL; COSTELLO	USA	Y	6 weeks	Moderate to severe COPD (FEV1 < 60%) Long-standing smoking	Congestive heart failure, pneumonia, pneumothorax, pleural effusion, pulmonary embolism and arrhythmia
2006, KOPPERS et al	Netherlands	Y	5 weeks	Chronic airflow obstruction, defined as FEV1/FVC ratio ≤70%, FEV1 of 30 to 80% predicted, after bronchodilatation Stable clinical condition for at least 6 weeks	hypoxemia at rest or during exercise cardiac or orthopedic disease body mass index (BMI)≥30 kg/m2
2007, RESQUETI et al	Spain	Y	2 months–6 months	Age <80 years Dyspnea: MRC> 3 Difficulty going to the hospital due to severe shortness of breath or problems related to the place of residence	Heart disease or any other type of disease that limits exercise tolerance Mental disability that prevents participation
2007, SHEA; TAYLOR; PARATZ	Australia	Y	3 months	Diagnosis of COPD Written consent Not having participated in pulmonary rehabilitation in the last 12 months	Breathing problems other than COPD, or unstable medical conditions that limit the performance of progressive resistance exercise
2008, MOULIN et al	Spain	Y	3 weeks	Diagnosis of COPD Not having participated in pulmonary rehabilitation in the last 12 months	Patients unable to perform physical training due to heart problems, lung or orthopedic problems
2008, MALTAIS et al	Canada	Y	3 months	Stable COPD, that is, no change in medication and symptoms (dyspnea, volume, or color of sputum) for at least 4 weeks before the study; were 40 years or older; were current or former smokers of at least 10 pack-years (20 cigarettes per pack); had an FEV1 less than 70% of the predicted value and FEV1–FVC ratio less than 0.70; and had a Medical Research Council dyspnea score of at least 2.	A previous diagnosis of asthma, congestive left heart failure as the primary disease, a terminal disease, dementia, or an uncontrolled psychiatric illness. We sought to study a broad COPD population and did not exclude patients with oxygen dependence or other comorbid conditions.
2009, FERNANDEZ et al	Spain	Y	12 months	Diagnosis of very severe COPD Younger than 80 years of age Stable COPD The correct administration of pharmacological treatment according to the recommendations of the Global Initiative for Chronic Obstructive Lung Disease Guide2 Home treatment with oxygen for at least 6 months prior to the commencement of the study absence of severe cardiovascular pathology, unstable angina or acute myocardial infarction, cerebral vascular accident, or physical or psychological disorder that impedes the practice of physical exercise	NR
2010, OLIVEIRA et al	Brazil	Y	2 months	COPD based on the GOLD classification Clinical stability in the eight weeks prior to the study	Hospitalization COPD instability Presence of neuromuscular disease, other associated respiratory disease, orthopedic or neurological disease that affects gait Recent impairment due to comorbidities, such as myocardial infarction, heart failure, stroke or neoplasia Previous pneumonectomy or other thoracic surgery
2010, GHANEM et al	Egypt	Y	2 months	Arabic as the first language Age> 40 years Local district resident Ability to complete the CRQ in one session	Patients unable to read or write; Patients with locomotor problems Cognitive impairment, ischemic heart disease, aortic valve disease, cancer or lung diseases other than COPD
2012, AKINCI, OLGUM	Turkey	Y	3 months	COPD GOLD 3 or 4 Clinically stable No history of infections or exacerbation of respiratory symptoms No change in medication during the 2 months prior to the study	Myocardial infarctions in the previous 4 months Unstable angina, severe congestive heart disease, severe hypertension problems, diabetes mellitus with complications and muscle and joint problems Cancer and asthma patients
2013, DIAS et al	Brazil	Y	2 months	Both sexes Age> 40 years COPD diagnosed by GOLD guidelines Clinically stable No signs of disease exacerbation in the past 30 days Do not participate in any program that involves simultaneous physical activity	Patients with severe comorbidities, such as previous heart disease, orthopedic diseases in the upper and lower limbs, motor sequelae of neurological or visual disorders that could interfere with physical exercise, Uncontrolled SAH Other respiratory diseases Patients who did not agree to participate in the study
2014, PINTO et al	Spain	Y	12 weeks	Patients with severe or very severe COPD with or without the use of oxygen Age <80 years of age Ex-smokers; Never having participated in any rehabilitation	Long period of exacerbation Cognitive problems, musculoskeletal disorders, heart disease or other disabling diseases that could restrict exercise Communication problems
2014, TABAK et al	Netherlands	Y	9 months	No exacerbation in the month prior to enrolling the program Three or more exacerbations or hospitalization for respiratory problems in the 2 years prior to entering the study Clinical diagnosis of COPD according to GOLD. No exacerbation in the month prior to enrollment > 3 exacerbations, defined as respiratory problems that required a course of oral corticosteroids and / or antibiotics, or> 1 hospitalization for respiratory problems in the 2 years prior to the start of the study Ex-smoker Age 40 to 75 years Post-bronchodilator forced expiratory volume in 1 s (FEV 1) 25 to 80% of predicted Able to understand and read Dutch Written informed consent of the subject before participation Having a computer with Internet access at home	Another serious illness with a low survival rate; Diseases with respiratory symptoms or that compromise lung function (for example, heart failure or sarcoidosis); erious psychiatric illness Uncontrolled diabetes mellitus during a past COPD exacerbation or hospitalization for diabetes mellitus in the 2 years preceding the study; Need for regular oxygen therapy (> 16 h / day or oxygen tension <7.2 kpa); Maintenance therapy with antibiotics; Deficiency of α −1 antitrypsin, disorders or progressive diseases that seriously influence the ability to walk (eg, amputation, paralysis, progressive muscle disease)
2016, HOLLAND et al	Australia	Y	8 weeks–12 months	Diagnosis of COPD Smoking history ≥ 10 pack-years No exacerbations in four weeks Comorbidities that prevented physical training Not having undergone pulmonary rehabilitation within 2 years	NR
2016, TSAI et al	Australia	Y	2 months	Primary medical diagnosis of stable COPD (forced expiratory volume in 1 s (FEV1) / forced vital capacity (FVC) <70% and FEV1 < 80% post-bronchodilator predicted)	Not being interested in physical training; Not having access to a computer; Prefer to attend outpatient pulmonary rehabilitation; Mini mental status exam <24, poor hearing; Vision problems; Do not speak English
2017, HORTON et al	England	Y	7 weeks	Dyspnea (MRC) 2–5 Proficient level of English	Any condition that prohibits rehabilitation such as inability to use the lower limbs and other unstable comorbid conditions Participants who have completed another rehabilitation program in the past 12 months
2017, VASILOPOULOU et al	USA	Y	12 months	Written informed consent obtained before any assessment is carried out; Male and female patients ≥ 40 years’ old; Diagnosis of COPD [forced expiratory volume post-bronchodilator in the first second (FEV1) <80% of predicted and FEV1 / forced vital capacity (FVC) <75% without significant reversibility of the post-bronchodilator (<10% of FEV1% of normal foreseen); Ideal medical treatment according to GOLD, without regular use of systemic corticosteroids; Smokers or ex-smokers with a smoking history equivalent to at least 10 packs years (1 pack year = 20 cigarettes smoked per day for 1 year); Absence of other significant illnesses that may contribute to exercise limitation and at least 2 exacerbations of COPD in the year prior to entry time; No exacerbation of COPD in the year prior to the time of entry	Orthopedic, neurological or other complaints that significantly compromise normal biomechanical movement patterns, as judged by the investigator; Specifically, if the patient’s condition / comorbidities are such that physical activity cannot be increased, respiratory diseases other than COPD (for example, asthma), cognitive impairment of reading and / or difficulties in managing electronic devices, preventing interaction with the tablet, as judged by the investigator; Patients who do not use ideal pharmacotherapy
2018, COULTAS et al	USA	Y	5 months	Medical diagnosis of COPD confirmed by spirometry (FEV 1 / FVC <70% and FEV 1 < 70% predicted) Did not participate in pulmonary rehabilitation	NR
2019, LAHHAM et al	Australia	Y	2 months	Smokers or ex-smokers of at least 10 pack-years; Age> 40 years COPD diagnosis confirmed by spirometry	Previous diagnosis of asthma; Participated in a pulmonary rehabilitation program in the past two years; COPD exacerbation in the past four weeks; Has comorbidities that prevent participation in a physical training program
2019, BURGE et al	Australia	Y	8 weeks 12 months	NR	NR
2020, LAHHAM et al	Australia	Y	2 months	Potential participants were people diagnosed with spirometrically defined mild COPD (forced expiratory volume in one second (FEV1)/forced vial capacity (FVC) < 70%; FEV1 > 80%predicted), aged 40 years old or older, had a smoking history of at least 10 packet years and had no reported hospitalizations or exacerbations during the month before recruitment.	formal diagnosis of asthma or co-morbidities that precluded exercise participation
2020, JIANG et al	China	Y	6 months	aged 60 years and older, confirmed diagnosis of COPD according to the diagnosis and treatment guidelines for chronic obstructive pulmonary disease, forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio of <0.7, FEV1 < 80% predicted, and use of WeChat for effective communication	patients with mental disorders, cognitive disorders, and limb dysfunction; patients with unstable heart disease or arrhythmia requiring drug intervention; patients with a history of myocardial infarction or cerebral infarction in the previous year; patients too weak to perform the muscle strength test; patients with hypertension that could not be controlled with drugs; and patients with a history of syncope after exercise
2020, HANSEN et al	Denmark	Y	10 weeks	Adults with a clinical diagnosis of COPD defined as FEV1/FVC <0.70, FEV1 < 50%, Medical Research Council ≥2 and no participation in rehabilitation within 6 months of the start of intervention	NR
2021, KO et al	Hong Kong	Y	12 months	NR	NR

NR: Not reported; NA: Not available; ^†Data extracted from abstracts; MRC: Medical Research Council; MMRC: modified Medical Research Council; COPD: chronic obstructive pulmonary diseases; GOLD: Global Initiative for Chronic Obstructive Lung Disease; USA: United States of America.

Table 2. Characteristic of the interventions and the population enrolled in included studies.

Year, Author	Age (mean, years)	Age (range)	Gender male/female	Smoker (Y/N)	Heart rate	Breathing frequency	Peripheral capillary oxygen saturation (SpO2%)	VO2	Carbon dioxide production (VCO2)	Concentration of blood lactate	COPD Gold classification	Symptoms: secretion (Y/N)	Symptoms: Cough (Y/N)	Symptoms: Wheezing (Y/N)	Description of Home-based rehabilitation programme intervention	Description of conventional supervised pulmonary rehabilitation
1996, BAULDOFF; ZULLO; HOFFMAM	62	47 − 76	9/11	NR	NR	NR	NR	NR	NR	NR	Grave	NR	NR	NR	Training program: upper extremity training 5 days a week for 8 weeks with the training level increased during weekly visits	standard medical treatment
1996, STRIJBOS; ALTENA; KOETER	61.4	53 − 67	38/7	Y: 17 N: 28	NR	NR	B: G1: 95.1 G2: 93.8 G3: 93.7 Post G1: 94.1 G2: 93.2 G3: 94.4 6 G1: 94.6 G2: 93.4 G3: 93.8 12 G1: 94.3 G2: 92.9 G3: 93.5 18 G1: 94.0 G2: 92.9 G3: 92.7		NR	NR	Moderate – severe - Very severe	NR	NR	NR	Training program: 24 sessions of 30 min in 12 consecutive weeks with 30 min on exercise days and at least 15 minutes on other days. monitoring three times a week for monitoring and motivation	standard medical treatment
1996, WIJKSTRA et al	63	57 − 69	37/6	NR	B G1: 120 G2: 126 P G1: 122 G3: 121	B G1:30 G2: 29 P G1: 29 G3:28	NR	B G1:1.0 (0.3) G2:1.1 (0.3) P G1:1.1 (0.4) G2: 1.0 (0.3)	B G1: 0.9 (0.4) G2: 1,0 (0.4) P G1: 1.0 (0.4) G2: 0.9 (0.3)	B G1:3,7 (1.7) G2:4,1 (1.9) P G1:3,1 (1.3) G2:3.4 (1.7)	Moderate– severe	NR	NR	NR	Training program: relaxation exercises, breathing techniques, UL training, target flow inspiratory muscle training (IMT) and physical training at home.	Did not participate in the rehabilitation program and received a diary to record the time spent on daily activities
2000, HERNANDEZ et al	64.3	56 − 72	NR	NR	NR	NR	NR	NR	NR	NR	Moderate – severe - Very severe	NR	NR	NR	Training Program: exercises for LL, through walking. With intensity set at 70% of the maximum speed reached in the swt. Sessions lasting 1 h, 6 days / week, at home, with checkup every 2 weeks	standard medical treatment
2003, SINGH et al	59.37	48–75	32/8	NR	NR	NR	NR	NR	NR	NR	Severe	NR	NR	NR	Training program: in removal of secretions, lower extremity exercise, breathing strategies, energy conservation and work simplification. Duration: 30 minutes twice a day Follow-up: supervised weekly	No intervention
2003, OH	65.80	54–79	14/9	Y: 2 N: 21	NR	NR	NR	NR	NR	NR	Moderate - severe –	NR	NR	NR	Training program: education, inspiratory muscle training, exercise training, and psychosocial components that include relaxation and telephone calls.	received only educational advice at the initial interview.
2005, BOXALL et al	76.7	67 − 85	26/20	NR	NR	NR	NR	NR	NR	NR	Severe – very severe	NR	NR	NR	Multidisciplinary education on COPD and its management UL training program: from level 1 (6 repetitions of each weightless exercise) to 18 (3 sets of 6 repetitions of each exercise, 1.5 kg weights in both hands) Walking program from level 1 (walking on level ground for 1-minute, maximum rest, 2 minutes and walking again for 1 min) to 10 (walking for 15 min, rest and then walk for 15 min	standard medical treatment and orientations
2005, MURPHY; BELL; COSTELLO	66	54 − 76	17/9	Y:9 N: 19	NR	NR	NR	NR	NR	NR	Moderate – severe	NR	NR	NR	Training program: follow-up for 6 consecutive weeks, with 12 exercise sessions lasting 30 to 40 min, including rest. Aerobic exercises: climbing up and down a ladder and sitting up in a chair. UL training: Thera-Band. Exercise for at least 15 min on other days according to received diary	standard medical treatment
2006, KOPPERS et al	55.7	38–73	17/19	NR	B G1: 150 (17) G3: 144 (17) P G1:135 (16) G3:142 (17)	NR	NR	B G1: 1.52 (0.41) G3: 1,52 (0.42) P G1: 1.42 (0.41) G3: 1.50 (0.40)	NR	NR	Moderate – grave	NR	NR	NR	Respiratory muscle endurance training (RMET) by means of normocapnic hyperpnea. trained twice daily for 15 min, 7 days per week, for 5 weeks	Standard medical treatment sham training
2007, RESQUETI et al	68	61 − 75	35/3	NR	NR	NR	NR	NR	NR	NR	Severe – very severe	NR	NR	NR	Training for 9 weeks. • 1st week: 1 hour of patient education and 30 min of physical therapy • 2nd week: 3 sessions at the clinic to learn how to do the exercises that they should continue doing at home. 3rd to 9th week: program at home 5x per week for a period of 1.5 hours performing exercises for lower limbs, upper limbs and inspiratory	Training for 9 weeks. • 1st week: 1 hour of patient education and 30 min of physical therapy 2nd week: perform respiratory physiotherapy exercises at home and walk, without any supervision
2007, SHEA; TAYLOR; PARATZ	67.65	59 − 78	NR	NR	NR	NR	NR	NR	NR	NR	Moderate- severe	NR	NR	NR	Training program: 6 exercises with progressive load for 3x per week for 12 weeks, being 1x per week at the clinic and 2x at home. Exercises: standing hip abduction, sitting and standing, with 3 sets of 8 to 12 repetitions, with Theraband.	Did not receive intervention
2008, MOULIN et al	67	63 − 77	14/6	Y:2 N: 18	NR	NR	NR	NR	NR	NR	Moderate	NR	NR	NR	Training program: walking distance equivalent to 125% of your last 6MWT, 3x / day for 15 min. Daily and telephone follow-up every 4 weeks	Perform your daily life activities
2008, MALTAIS et al	66	NR	140/100	Y: 126 N: 114	NR	NR	NR	NR	NR	NR	Moderate – severe	NR	NR	NR	The self-management educational program “Living Well with COPD” consisted of an educational flipchart and 6 skill-oriented, self-help, patient workbook modules. The program was provided in the hospital on an outpatient basis. A qualified exercise trainer presented the exercise module.	The training program combined aerobic and strength exercises. Briefly, the aerobic training consisted of stationary leg cycling for 25 to 30 minutes in each session. The target training intensity was 80% of peak work capacity during incremental exercise.
2009, FERNANDEZ et al	66	51–79	41/0	NR	NR	NR	NR	NR	NR	NR	Moderate- severe – very severe	NR	NR	NR	Training program: 2 one-hour sessions in the Hospital: respiratory reeducation, taught the exercises at home with educational materials. Muscular training of the UL, initially through isotonic exercises without weights and subsequently a progressive weight increases 30 min. Muscular training of the LL, initially through isotonic exercises and subsequently resistance exercises	standard medical treatment and orientations
2010, OLIVEIRA et al	69.5	56 − 79	65/20	NR	NR	NR	NR	NR	NR	NR	Moderate – severe – very severe	NR	NR	NR	Exercises to strengthen the UL and LL. Aerobic exercise was performed by walking on flat ground, from 60 to 80% of the maximum heart rate achieved on the 6MWT.	Control group: standard medical treatment; Outpatient group: received the same training program as home rehabilitation
2010, GHANEM et al	56.69	45 − 68	NR	NR	NR	NR	NR	NR	NR	NR	severe – very severe	NR	NR	NR	Education of Patient: 4 days for 1 hour Exercise program: Respiratory muscle training, aerobic training (walking and cycling), UL strength training and hamstring, quadriceps, calf, shoulder, neck and lower back stretching	standard medical treatment
2012, AKINCI, OLGUM	71.8	55 − 79	NR	NR	NR	NR	B: G1: 93.5 (3.7) G3: 94.8 (3.4) P: G1: 94.8 (3.4) G3: 94.3 (3.3)	NR	NR	NR	severe - very severe	NR	NR	NR	Patient education: 2 to 3x at home for 2 to 3 hours. Training program: mmii aerobic exercise (walking) and UL and breathing exercises (lips and diaphragmatic breathing)	standard medical treatment
2013, DIAS et al	65.25	58 − 72	8/15	NR	NR	NR	NR	NR	NR	NR	Mild - Moderate - severe	NR	NR	NR	Education program Training program: stretching, respiratory reeducation exercises and aerobic exercises for the UL (with individual load determined at 50% of the load obtained after the evaluation)	Instructions for performing breathing and stretching exercises
2014, PINTO et al	70.2	61 − 78	39/2	NR	NR	NR	NR	NR	NR	NR	Severe - very severe	NR	NR	NR	Weekly visits and monitoring by phone Training program: breathing exercises, resistance (UL and LL) resistance (walking for 30 minutes, climbing stairs, cycling and walking on a treadmill or stationary bicycle from 5 to 30 min) and stretching. Exercises coordinated with breathing patterns and rest time. Patients on long-term oxygen treatment were instructed to exercise using flow to maintain saturation above 90%	standard medical treatment
2014, TABAK et al	63.45	55 − 73	12/12	Y:8 N: 16	NR	NR	NR	NR	NR	NR	mild -moderate – severe- very severe	31	77	61	4 modules: 1st: training in real time using the activities present in the activity diary 2nd: web exercise program for home exercises 3rd: self-management of exacerbations of COPD through a screening diary 4th: teleconsultation	standard medical treatment
2016, HOLLAND et al	69	56 − 82	99/67	Y: 28 N: 138	NR	R	NR	NR	NR	NR	Moderate – severe	NR	NR	NR	Training program: 30 min aerobic activity, resistance training (functional activities). Motivational follow-up 1x per week.	Outpatient group: received the same training program as home rehabilitation.
2016, TSAI et al	74 (8)	66 − 82	NR	Y: 2 N: 34	NR	NR	NR	NR	NR	NR	mild -moderate – severe	NR	NR	NR	Training program: 3x a week, for 8 weeks, with LL ergometry, walking and strengthening exercises Remote monitoring by videoconference	standard medical treatment
2017, HORTON et al	68 (8.86)	59 − 77	100/187	Y: 73 N: 214	NR	NR	G1: 94.54 G2: 93.91	NR	NR	NR	Moderate – severe	NR	NR	NR	Training program: walking every day of the week and resistance exercises 3x a week. Motivational follow-up	Outpatient group: supervised exercise and twice a week for 7 weeks
2017, VASILOPOULOU et al	66.9 (9.6)	57 − 76	119/28	Y: 14 N:147	NR	NR	NR	NR	NR	NR	Moderate – severe – very severe	NR	NR	NR	12-Month training program: • Individualized action plan • Educational session on self-management of the disease; • Physical exercise sessions • Access to the call center; remote monitoring	Outpatient group: visit to the hospital twice a week for 12 months where he received the same home rehabilitation training program
2018, COULTAS et al	70.3 (9.5)	60–79	151/154	Y: 282 N: 23	NR	NR	NR	NR	NR	NR	Moderate – severe	NR	NR	NR	Training program: 30 min of moderate intensity physical activity Motivational follow-up	Education advice on self-management and usual care
2019, LAHHAM et al	68 (8)	59–77	23/22	Y:7 N: 45	NR	NR	NR	NR	NR	NR	Moderate – severe	NR	NR	NR	Training program: resistance and strengthening exercises for at least 30 min a day, starting at an intensity of 80% of the 6MWT Motivational follow-up	Outpatient group: received the same training program as home rehabilitation
2019, BURGE et al	70	60 − 80	63/96	NR	NR	NR	NR	NR	NR	NR	Moderate – severe – very severe		NR	NR	Training program: aerobic exercises for 30 min, exercises to strengthen the lower limbs and upper limbs; Patient education on self-management; Motivational follow-up	Outpatient group: received the same training program as home rehabilitation
2020, LAHHAM et al	68 (9)	57–77	34/24	NR	NR	NR	NR	NR	NR	NR	Mild	NR	NR	NR	endurance training programme calculated at 80% of initial walking speed from the baseline (6MWT) Resistance training comprised upper and lower limb exercises using equipment available at home (home stairs for step ups and sealed water bottles as weights)	advised to keep active and to follow their medication
2020, JIANG et al	71.83 (7.60)	64–79	87/19	Y: 12 N: 94	NR	NR	NR	NR	NR	NR	Moderate – severe – very severe	NR	NR	NR	Exercise training included upper extremity training, lower extremity training, and balance training; Respiratory training included lip contraction breathing and abdominal breathing	other activities, but in a clinic
2020, HANSEN et al	68.3 (9)	NR	60/74	Y: 30 N: 104	NR	NR	NR	NR	NR	NR	Moderate – severe	NR	NR	NR	It was a group-based, supervised and standardized programme performed by the patients in their homes three times weekly for 10 weeks via a videoconference software system installed on a single touch screen. The exercise sessions lasted 35 min with incorporated warm-up and high repetitive time-based muscle endurance training followed by 5 min’ rest before beginning a patient education session of 20 min.	The exercise sessions lasted 60 min and incorporated warm-up, endurance and resistance training and a cool-down period
2021, KO et al	75 (6.70)	68–82	132/0	NR	NR	NR	NR	NR	NR	NR	Moderate – severe	NR	NR	NR	Our case manager provided support and reinforcement via telephone to the subject every fortnight on continuing exercise at home for1 year	received neither physiotherapy training nor phone calls from the case manager for reinforcement of home exercise

NR: Not reported B: Baseline; P: Post-intervention; LL: lower limb; UL: upper limb; 6MWT: 6-minute walk test; SWT: Shuttle Walk Test; COPD: chronic obstructive pulmonary disease; Min: minutes; G1: home rehabilitation; G2: conventional outpatient rehabilitation; G3: no rehabilitation/ control group.

Table 3. Clinical characteristics of the population enrolled in included studies.

Year, author	Level of dyspneia	Forced expiratory volume in 1 s (FV1)	Forced vital capacity (FVC)	Inspiratory capacity (IC)	Residual volume (RV)	Inspiratory and expiratory maximal pressure (MIP and MEP)	Total lung capacity	Distance walked on six-minute walk test (6mwt)	Bode index	Health related quality of life	Impact of the disease (CAT)
1996, BAULDOFF; ZULLO; HOFFMAM	NR	G1: 27 (16) G2: 37 (18)	G1: 40 (20) G2: 55 (24)	NR	NR	NR	NR	NR	NR	NR	NR
1996, STRIJBOS; ALTENA; KOETER	NR	G1: 40.40 (19.60) G2: 45.50 (6.90) G3: 42.60 (8.80)	NR	NR	NR	NR	G1: 103.50 (19.60) G2: 99.20 (13.70) G3: 98.70 (17.80)	NR	NR	NR	NR
1996, WIJKSTRA et al	NR	G1: 44 (11) G3: 45 (9)	NR	NR	NR	NR	G1: 118 (14) G3: 114 (11)	NR	NR	NR	NR
2000, HERNANDEZ et al	MRC G1: 3.20 (0.90) G3: 3.40 (0.90)	G1: 41.70 (15.60) G3: 40 (16.40)	G1: 71.10 (18.90) G3: 74.70 (14.70)	NR	NR	NR	NR	NR	NR	CRQ G1: 82.60 (18.90) G3: 91.20 (21.40)	NR
2003, SINGH	CRDQ G1: 4.12 (0.88) G3: 3.58 (0.84)	G1: 29.10 (10.40) G3: 26.90 (9.20)	NR	NR	NR	NR	NR	G1: 315 (118) G3: 264 (157)	NR	CRDQ G1: Dyspnea: 4.12 (0.88) Fatigue: 3.70 (0.90) Emotion: 3.90 (1,10) Mastery: 3.78 (0.90) G3: Dyspnea: 3.58 (0.84) Fatigue: 3.04 (0.80) Emotion: 3.20 (0.90) Mastery: 3.15 (0.80)	NR
2003, OH	BORG G1: 4.67 (2.91) G3: 3.43 (1.13)	G1: 42.12 (15.07) G3: 44.91 (17.75)	NR	NR	NR	NR	NR	G1: 350.70 (59.42) G3: 360.10 (59.46)	NR	CRDQ G1: 82.00 (22.53) G3: 89.75 (10.38) G1: Dyspnea: 14.44 (8.14) Fatigue: 16.20 (5.28) Emotion: 29.93 (8.61) Mastery: 19.20 (3.35) G3: Dyspnea: 16.38 (7.65) Fatigue: 15.88 (3.91) Emotion: 34.00 (6.72) Mastery: 23.50 (3.89)	NR
2005, BOXALL et al	NR	G1: 40.5 (15.9) G3: 37.7 (15.0)	G1: 1.39 (0.61) G3: 1.61 (0.58)	NR	NR	NR	NR	G1: 163.0 (60.1) G3: 147.5 (62.3)	NR	CRDQ G1: 56.50 (11.0) G3: 61.0 (10.70)	NR
2005, MURPHY; BELL; COSTELLO	MRC G1: 3.10 (1.10) G3: 2.80 (1.13)	G1:38 (12) G3: 42 (12)	NR	NR	NR	NR	NR	NR	NR	SGRQ G1: 70.20 (14.20) G3: 65.30 (17)	NR
2006, KOPPERS et al	BORG G1: 8.40 (1.90) G3: 8.30 (1.70)	G1: 1.50 (0.40) G3: 1.70 (0.50)	NR	NR	NRN	NR	NR	G1: 512 (86) G3: 549 (75)	NR	CRQ G1: 78.70 (20.60) G2: 82.40 (14.70)	NR
2007, RESQUETI et al	MRC G1: 3.40 (0.80) G2: 3.60 (0.80)	G1: 27.50 (9) G2: 29.60 (8)	G1: 60.10 (15) G2: 62.20 (18)	NR	NR	NR	NR	NR	NR	CRQ G1: 15.40 G2: 16.90	NR
2007, SHEA; TAYLOR; PARATZ	CRDQ G1: 3.20 (0.80) G3: 3.70 (0.90)	G1: 49 (25) G3: 52 (22)	NR	NR	NR	NR	NR	G1: 376 (114) G3: 337 (83)	NR	CRDQ G1: 16.20 G3: 17.50	NR
2008, MOULIN et al	CRQ G1: 5.30 (4.50–6.10) G3: 4.80 (4–5.60)	G1: 58.60 (53.80–63.40) G3: 58.40 (50–66.90)	NR	NR	NR	NR	NR	G1: 511.20 (461.70–560.70) G3: 465.20 (415.70–514.70)	NR	CRQ G1: 5.40 (4.90–6) G3: 5 (4.40–5.50)	NR
2008, MALTAIS et al	NR	G1: 46 (13) G2: 43 (13)	G1: 2.55 (0.76) G2: 2.58 (0.84)	NR	NR	NR	NR	G1: 370 (89) G2: 368 (85)	NR	G1: 46 (16) G2: 46 (16)	NR
2009, FERNANDEZ et al	MRC G1: 2.60 (0.80) G3: 2.30 (0.80)	G1: 34 (10) G3: 38 (12)	G1: 56 (10) G3: 67 (19)	NR	B: G1: 131 (36) G3: 130 (20) P:	MIP B: G1: 59 (16) G3: 60 (20) MEP G1: 75 (18) G3: 86 (30) P: MIP G1: 66 (17) G3: 67 (16) MEP: G1: 77 (21) G3: 77 (25)	G1: 89 (14) G3: 98 (15)	G1: 313 (72) G3: 348 (85)	NR	SGRQ G1: 40.60 (13.80) G3: 50.00 (12.70) G1: Symptoms: 36.30 (20.40) Activity: 59.90 (13.90) Impact: 30.90 (16.30) G3: Symptoms: 36.60 (17.30) Activity: 70.00 (12.10) Impact: 42.90 (16.90)	NR
2010, OLIVEIRA et al	MRC G1: 0 = 8 1 = 9 2 = 10 3 = 6 4 = 0 G2: 0 = 6 1 = 8 2 = 5 3 = 4 4 = 0 G3: 0 = 8 1 = 8 2 = 10 3 = 2 4 = 1	G1: 47.50 (23.30) G2: 51.50 (23.90) G3: 41.40 (18.40)	G1:68.70 (30.20) G2: 79.10 (30) G3: 69.90 (28)	NR	NR	NR	NR	NR	G1:4 (0-7) G2: 4 (0-8) G3: 4 (1-9)	NR	NR
2010, GHANEM et al	CRQ G1: 11.80 (5) G3: 12.40 (4.40)	G1:29.44 (13.14) G3: 23.21 (7.70)	G1: 36.24 (14.17) G3: 29.00 (10.91)	NR	NR	NR	NR	G1: 88.79 (19.14) G3: 83.79 (15.9)	NR	SF-36 Physical component: G1: 30.60 (14.20) G2: 40.60 (21.9) Mental component G1: 26.30 (14.60) G2: 30.4 (19.90)	NR
2012, AKINCI, OLGUM	BDI G1: 5.20 (1.60) G3:6.10 (2.10)	G1: 36.10 (10.80) G3: 39.20 (11)	NR	NR	NR	NR	NR	G1: 157.90 (64.50) G3: 176.30 (54.90)	NR	SGRQ G1:55 (16) G3: 45 (18)	NR
2013, DIAS et al	NR	G1: 55.14 (24.80) G3: 60 (20)	NR	NR	NR	B MIP G1: 65.10 (11) G3: 71.10 (16.70) MEP: G1: 77.90 (38.80) G3: 51.60 (21.70) P MIP G1: 74.2 (19.3) G3: 70.2 (13.9) MEP G1: 82.7 (38.3) G3: 53.7 (22.9)	NR	NR	NR	AQ-20 G1: 12 (3–18) G3: 10 (4–20)	NR
2014, PINTO et al	MRC G1: 3,.0 (0.70) G3: 3.50 (0.70)	G1: 33.50 (7.30) G3: 34.50 (9.50)	G1: 2.50 (0.80) G3: 2.30 (0.50)	NR	NR	NR	NR	G1: 197 (106) G3: 190 (120)	NR	SGRQ G1: 56.30 (13.10) G3: 62.30 (11.60)	NR
2014, TABAK et al	G1: 3.0 (2.0–3.30) G3: 4.0 (3.0–4.0)	G1: 50.0 (33.30–61.50) G3: 36.0 (26.0–53.50)	NR	NR	NR	NR	NR	G1: 409.5 (111.60) G3: 313.0 (79.40)	NR	NR	NR
2016, HOLLAND et al	MMRC G1: 0 = 2 1 = 33 2 = 22 3 = 21 4 = 2 G2: 0 = 0 1 = 36 2 = 28 3 = 19 4 = 3	G1: 52 (19) G2: 49 (19)	G1: 78 (17) G2: 79 (22)	NR	NR	NR	NR	NR	NR	NR	NR
2016, TSAI et al	MMRC G1: 2 G3:2	G1: 60 G3: 68	G1: 2.60 (0.70) G3: 2.60 (0.60)	NR	NR	NR	NR	G1: 363 (66) G3: 383 (93)	G1: 6 G3: 6	CRDQ G1: 90 (18) G3: 88 (23)	G1: 16 (7) G3: 15 (6)
2017, HORTON et al	MRC G1: 2: (n:28) 3: (n:52) 4: (n: 47) 5: (n: 18) G2: MRC 2: (n:20) 3: (n:57) 4: (n: 39) 5: (n: 26)	G1:47.89 (18.67) G2:48.79 (17.19)	G1: 2.73 (0.84) G2: 2.67 (0.90)	NR	NR	NR	NR	NR	NR	CRQ-RS G1: Dyspnea (2.58) Fatigue (3.42) Emotion (4.41) Mastery (4.50) G2: Dyspnea (2.42) Fatigue (3.36) Emotion (4.37) Mastery (4.36)	NR
2017, VASILOPOULOU et al	MRC G1:2.30 (1.00) G2:2.50 (1.00) G3:2.20 (1.10)	G1:49.60 (21.90) G2:51.80 (17.30) G3:51.70 (21.00)	G1: 3.07 (0.90) G2: 2.70 (0.65) G3: 2.77 (0.81)	G1:81.70 (33.00) G2:77.30 (30.00) G3:76.90 (31.00)	G1:184.6 (80.6) G2:180.2 (59.9) G3:182.0 (70.9)	NR	G1:118.8 (30.3) G2:120.7 (25.7) G3:19.9 (28.8)	G1: 389.10 (91.30) G2: 385.10 (80.30) G3: 384.80 (80.20)	G1:3.50 (2.70) G2: 3.20 (2.10) G3: 3.30 (2.30)	SGRQ G1:46.2(19.7) G2: 43.5 (16.7) G3: 44.1 (16.6)	G1:17.6 (8.1) G2:15.7 (5.6) G3: 15.8 (4.9)
2018, COULTAS et al	CRDQ G1:4.48 (1.30) G2:4.33 (1.35)	G1:45.50 G2:47.30	NR	NR	NR	NR	NR	G1:342.80 G2:337.50	B:G1:4.40(1.90) G2:4.40 (2.00) P: G1: 4.10(1.80) G2:4.40 (2.10)	NR	NR
2019, LAHHAM et al	NR	G1: 54 (19) G2: 52 (19)	G1: 2.70 (0.60) G2: 2.9 (0.60)	NR	NR	NR	NR	NR	NR	NR	NR
2019, BURGE et al	NR	G1: 53 (18) G2: 49 (20)	NR	NR	NR	NR	NR	NR	NR	G1: 0.671 (0.429 − 0.912) G2: 0.643 (0.405 − 0.882)	NR
2020, LAHHAM et al	CRDQ G1: 19 (7) G3: 19 (5)	G1: 90 (8) G3: 92 (7)	G1: 104 (8) G3: 104 (24)	NR	NR	NR	NR	G1: 504 (123) G3: 488 (88)	NR	CRDQ G1: 93 (21) G3: 95 (17)	NR
2020, JIANG et al	mMRC G1: 2.79 (0.66) G2: 2.75 (0.71)	NR	NR	NR	NR	NR	NR	NR	NR	SGRQ G1: 50.24 (20.95) G2: 49.57 (17.52)	G1: 21.79 (6.85) G2: 25.55 (6.48)
2020, HANSEN et al	NR	G1: 32.6 (10.3) G2: 33.7 (8.4)	NR	NR	NR	NR	NR	NR	NR	G1: 2.7 (0.9) G2: 2.9 (1.0)	G1: 19.8 (7.3) G2: 20.4 (6.6)
2021, KO et al	mMRC G1: 2.1 (0.7) G3: 2.1(0.5)	G1: 49 (17) G3: 46 (15)	NR	NR	NR	NR	NR	G1: 249.10 (96.07) G3: 246.12 (88.38)	NR	G1: 38.15 (20.64) G3: 36.03 (15.25)	G1:12.85 (6.88) G3: 13.99 (7.84)

NR: Not reported; NA: Not available; † Data extracted from abstracts; MRC: Medical Research Council; MMRC: modified Medical Research Council; G1: home rehabilitation; G2: conventional outpatient rehabilitation; G3: no rehabilitation/control group; SGRQ: St. George’s Respiratory Questionnaire; CRQ/CRDQ: Chronic Respiratory Questionnaire/Chronic Respiratory Disease Questionnaire; AQ-20: Airways Questionnaire 20; SF-36: Short Form-36; MIP: inspiratory maximal pressure; MEP: expiratory maximal pressure.

Table 4. Characteristics of the intervention.

Year, Author	Type of activity HBPR	Type of activity CPR	Percentage of service (minimum 70%) (Y / NR)	Number of sessions per week
1996, BAULDOFF; ZULLO; HOFFMAM	Charge progression every week	NA	NR	5
1996, STRIJBOS; ALTENA; KOETER	After the third and fourth week, the workload was gradually increased up to 70% of stationary bicycles. When this exercise level was attained without any problems, exercise time was gradually increased	After the third and fourth week, the workload was gradually increased up to 70% of stationary bicycles. When this exercise level was attained without any problems, exercise time was gradually increased	Y	2
1996, WIJKSTRA et al	Charge progression every week	Charge progression every week	Y	2
2000, HERNANDEZ et al	The training intensity was set at 70% of the maximum speed reached in SWT	NA	Y	6
2003, SINGH et al	Continuous training	NA	Y	3
2003, OH	Load is gradually increased according to their condition	NA	Y	5
2005, BOXALL et al	Charge progression every week	Charge progression every week	NR	7
2005, MURPHY; BELL; COSTELLO	Continuous training	NA	Y	2
2006, KOPPERS et al	Continuous training	NA	NR	7
2007, RESQUETI et al	Load is gradually increased according to their condition	Load is gradually increased according to their condition	Y	5
2007, SHEA; TAYLOR; PARATZ	Progressive resistance exercises	NA	NR	3
2008, MOULIN et al	Continuous training	NA	Y	5
2008, MALTAIS et al	Continuous training	NA	Y	2
2009, FERNANDEZ et al	Continuous training	NA	NR	5
2010, OLIVEIRA et al	Load is gradually increased according to their condition	Load is gradually increased according to their condition	Y	5
2010, GHANEM et al	Continuous training	NA	Y	4
2012, AKINCI, OLGUM	Continuous training	NA	Y	3
2013, DIAS et al	Load is gradually increased according to their condition	NA	Y	5
2014, PINTO et al	Charge progression every week	NA	Y	7
2014, TABAK et al	Continuous training	NA	Y	7
2016, HOLLAND et al	Continuous training	Continuous training	Y	3
2016, TSAI et al	Load is gradually increased according to their condition	NA	Y	3
2017, HORTON et al	Continuous training	Continuous training	Y	2
2017, VASILOPOULOU et al	Load is gradually increased according to their condition	Load is gradually increased according to their condition	Y	5
2018, COULTAS et al	Continuous training	Continuous training	Y	7
2019, LAHHAM et al	Load is gradually increased according to their condition	Load is gradually increased according to their condition	NR	3
2019, BURGE et al	Load is gradually increased according to their condition	Load is gradually increased according to their condition	Y	5
2020, LAHHAM et al	Continuous training	NA	Y	7
2020, JIANG et al	Continuous training	NA	Y	3
2020, HANSEN et al	Continuous training	Continuous training	Y	3
2021, KO et al	Continuous training	NA	Y	2

NR: Not reported; NA: Not available; Y: yes; SWT: Shuttle Walking Test ^†Data extracted from abstracts.

Figure 2. Mean difference (and 95% confidence interval) of dyspnea levels by CRQ/CRDQ between groups of HBPR (Home pulmonary rehabilitation) versus CG (Control group).

Figure 3. Mean difference (and 95% confidence interval) of dyspnea levels by MRC/mMRC between groups of HBPR (Home pulmonary rehabilitation) versus CG (Control group).

Figure 4. Mean difference (and 95% confidence interval) regarding the results of SPO2 between groups of HBPR (Home pulmonary rehabilitation) versus CG (Control group).

Figure 5. Mean difference (and 95% confidence interval) regarding the results of 6MWT between groups of HBPR (Home pulmonary rehabilitation) versus CG (Control group).

Figure 6. Mean difference (and 95% confidence interval) regarding the results of HRQoL by SGRQ between groups of HBPR (Home pulmonary rehabilitation) versus CG (Control group).

Figure 7. Mean difference (and 95% confidence interval) regarding the results of impact of the disease by CAT between groups of HBPR (Home pulmonary rehabilitation) versus CG (Control group).