Pulmonary Rehabilitation in a Post-COVID-19 World: Telerehabilitation as a New Standard in Patients with COPD

Figures & data

Figure 1 Various components of telerehabilitation. Telerehabilitation is delivered to patients via information technology (IT) infrastructure. The various components of the rehabilitation program are similar to those of conventional rehabilitation programs which have been demonstrated to improve health status of patients with COPD.

Table 1 Relevant Studies of Telerehabilitation in COPD Patients

Reference (Year) Country	Study Design	Participants	Intervention	Control	Duration	Primary Outcome Parameter	Outcomes
Tabak et al^Citation67 (2014) Netherlands	Pilot RCT	34	Activity coach (3D-accelerometer with smartphone) for ambulant activity registration and real-time feedback, complemented by a web portal with a symptom diary for self-treatment of exacerbations.	Usual care (Details unknown)	4 weeks	Activity level	The activity coach was used more than prescribed (108%) and compliance was related to the increase in activity level for the first 2 feedback weeks (r=0.62, p=0.03). Health status significantly improved within the intervention group (p=0.05). No significant difference in health status improvement.
Tabak et al^Citation68 (2014) Netherlands	Pilot RCT	29	Program consisted of 4 modules. 1) activity coach for ambulant activity monitoring and real-time coaching of daily activity behavior 2) web-based exercise program for home exercising 3) self-management of COPD exacerbations via a triage diary on the web portal, including self-treatment of exacerbations 4) teleconsultation	Regular physiotherapy sessions, in the case of an impending exacerbation, the participants had to contact their medical doctor as usual.	9 months	Satisfaction	The telehealth program with decision support showed good satisfaction. The program was accessed on 86% of the treatment days, especially the diary. Patient adherence with the exercise scheme was low (21%).
Paneroni et al^Citation69 (2015) Italy	Multicenter, prospective, controlled, non randomized pilot study	36	Home-based reinforcement telerehabilitation program. 28 sessions of strength exercises (60 min) and cycle training (40 min) using a satellite platform provided telemonitoring, tele-prescription, video-assistance and phone-calls. Patients were equipped with an oximeter, steps-counter, bicycle, remote control and interactive TV software.	Standard outpatient rehabilitation program. 28 sessions of strength exercises (60 min) and cycle training (40 min). Program included strength exercises, cycle ergometer training, and an educational intervention to promote an appropriate lifestyle and self-management.	Maximum 40 days	Feasibility, adherence and satisfaction	The telerehabilitation patients completed all sessions without side effects, used the remote control 1394 ± 2329 times being in the 84% of the cases satisfied with the service. In 22% of the cases patients found the technology unfriendly.
Zanaboni et al^Citation70 (2013) Norway	Feasibility study	10	A long-term telerehabilitation service comprising exercise training at home with a 2-year follow-up program by a physiotherapist. Equipment included a treadmill, a pulse oximeter and a tablet computer. Participants had weekly videoconference sessions with the physiotherapist. A website was used to access a training program and to fill in a daily diary and a training diary.	None	Long-term intervention with a 2-year follow-up	Number of hospital admissions	There was a reduction of 27% in the COPD-related hospital costs. No drop-outs. Feedback from the participants was very positive.
Holland et al^Citation71 (2013) Australia	Feasibility study	8	Supervised aerobic training twice a week, with 2 participants and a physiotherapist attending each class via videoconferencing from separate locations.	None	8 weeks	Adverse events, sessions attended, and system usability.	No significant adverse events occurred during the study. Participants attended 76% of possible sessions. System usability ratings were excellent when sessions were delivered via the university network (mean 94 out of 100) but lower when using the hospital network (mean 59 out of 100), with 67% of technical problems related to data network capability.
Marquis et al^Citation72 (2015) Canada	Pre-/postintervention study	26	15 in-home teletreatment sessions via videoconference from a service center to their home. Education provided via self-learning health capsules.	None	8 weeks	Changes in exercise tolerance (6MWT, CET) and quality of life CRQ.	Significant improvements between pre-and postintervention on the 6MWT (32 m; p<0.001), CET (41 s; p=0.005), and three of four CRQ domains (dyspnea [p<0.001], fatigue [p=0.002], and emotion [p=0.002]). Participants’ satisfaction and adherence rate with telerehabilitation were very high.
Tousignant et al^Citation73 (2012) Canada	Pre-experimental pilot study	3	Telerehabilitation sessions (15 sessions) were conducted by 2 trained physiotherapists from a service center to the patient’s home. Locomotor function (walking performance) and quality of life were measured in person prior to and at the end of the treatment by an independent assessor.	None	8 weeks	Feasibility	Clinical outcomes improved for all subjects except for locomotor function in the first participant. All participants showed a trend towards better quality of life (dyspnea, fatigue, emotions, mastery).
Tsai et al^Citation74 (2017) Australia	RCT (assessor and statistician blinded)	37	The same physiotherapist who was based in the hospital supervised up to 4 participants remotely exercising at home in each session using real‐time desktop videoconferencing software.	Usual medical management including optimal pharmacological intervention and an action plan was provided. This group did not participate in any exercise training.	8 weeks	Endurance exercise capacity	The telerehabilitation group showed a significant increase in endurance shuttle walk test time (mean difference = 340 s (95% CI: 153–526, p < 0.001)).
Hansen et al^Citation75 (2020) Denmark	RCT (assessor and statistician blinded), superiority, multicenter	134	A group-based, supervised and standardized program performed by the patients in their homes 3 times weekly 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.	A group-based, supervised and standardized and was performed twice a week. The exercise sessions lasted 60 min and incorporated warm-up, endurance and resistance training and a cool-down period. The patient education sessions lasted 60 to 90 min and took place once a week after the exercise session.	10 weeks	Change in the 6MWT on completion of the program	No statistically significant between-group differences for changes in 6MWT after intervention or at 22 weeks’ follow-up.
Cox et al^Citation77 (2018) Australia	RCT (assessor and statistician blinded), equivalence, multicenter	Unknown	Home-based training twice a week, in groups of 4–6 participants at a time, supervised by an experienced physiotherapist. Exercise training will comprise 30 min of lower limb aerobic training and individualized strength training exercises. Participants will undertake a total of 30 min of cycle training, in two or more bouts, in each session. Disease-specific education and collaborative self-management training.	A standard outpatient pulmonary program at the center where they were recruited. Twice-weekly supervised sessions in groups of 8–12 participants, supervised by a health professional experienced in the delivery of pulmonary rehabilitation and qualified assistants. At least 30 min of lower limb aerobic training each session, which may be completed in shorter intervals if continuous training is limited by symptoms.	8 weeks	Change in CRQ-D from baseline to end of intervention	Results have not been published.

Abbreviations: RCT, randomized controlled study; COPD, chronic obstructive lung disease; TV, television; 6MWT, 6-minute walk test; CET, cycle endurance test; CRQ, Chronic Respiratory Questionnaire; CRQ-D, CRQ dyspnea domain.

Figure 2 Practical changes and barriers in pulmonary rehabilitation for COPD patients in the post-COVID world. The COVID-19 pandemic has resulted in dramatic changes in the way in which pulmonary rehabilitation (PR) is delivered. These include changes in venue and increased use of telerehabilitation. The pandemic has also revealed the long-standing structural barriers of PR, such as the lack of financial support, resources, and healthcare professionals, which have been exacerbated during the COVID pandemic.

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