What is the current best evidence for virtual pulmonary rehabilitation for chronic obstructive pulmonary disease (COPD) in the context of the COVID-19 pandemic?

The following information resources have been selected by the National Health Library and Knowledge Service Evidence Virtual Team in response to your question. The resources are listed in our estimated order of relevance to practicing healthcare professionals confronted with this scenario in an Irish context. In respect of the evolving global situation and rapidly changing evidence base, it is advised to use hyperlinked sources in this document to ensure that the information you are disseminating to the public or applying in clinical practice is the most current, valid and accurate. For further information on the methodology used in the compilation of this document – including a complete list of sources consulted – please see our National Health Library and Knowledge Service Summary of Evidence Protocol.

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Main Points

  1. For people with COPD, lowcertainty evidence suggests that, compared with usual care, smart technology interventions may lead to increased physical activity and a small improvement in quality of life (QoL).
  2. Telerehabilitation services are an alternative to traditional rehabilitation approaches to reduce outpatient resource utilisation and improve QoL. However, more methodologically rigorous studies are needed to investigate their effectiveness.
  3. NICE recommends the use of online pulmonary rehabilitation resources such as those available in the British Thoracic Society pulmonary rehabilitation resource pack.
  4. The Canadian Thoracic Society has published a  position statement on the delivery of pulmonary rehabilitation during the COVID-19 pandemic. Programs may be designed to provide education and exercise, and also in some cases remote monitoring of exercise performance. Hybrid models that include in-person assessment and exercise testing and a combination of in-person and virtual exercise training, education and self-management may be used to optimise exercise safety and training effectiveness while decreasing disease transmission and infection rates.

List of Abbreviations

AbbreviationDefinition
PRpulmonary rehabilitation – an important part of the management and health maintenance of people with chronic respiratory disease who remain symptomatic or continue to have decreased function; defined by the American Thoracic Society and the European Respiratory Society as an evidence-based, multidisciplinary and comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and may often have decreased activities of daily living
COPDchronic obstructive pulmonary disease – pulmonary disease such as emphysema or bronchitis which is characterised by chronic airway obstruction resulting in a slowed rate of exhalation
mHealthmobile health – defined by the World Health Organization as the use of mobile and wireless technologies to support the achievement of health objectives
QoLquality of life – the degree to which a person is healthy, comfortable and able to enjoy the activities of daily living
TelePRpulmonary tele-rehabilitation – the use of information and communication technologies to provide rehabilitation services to people at home or in other remote, non-acute settings
VRvirtual reality
ETexercise therapy
6MWD6-minute walking distance – a sub-maximal exercise test which involves measuring the distance a person walks in 6 minutes
HBRhome-based rehabilitation
CATChronic Obstructive Pulmonary Disease (COPD) Assessment Test – a questionnaire designed to measure the impact of COPD on a person’s life
SGRQSt. George’s Registry Questionnaire – a self-reported, disease-specific, health-related quality of life questionnaire originally developed to measure the impact of COPD on a person’s life
FEVforced expiration volume – the amount of air a person can exhale during a forced breath measured during the first (FEV1), second (FEV2) and/or third (FEV3) seconds
FVCforced vital capacity – the total amount of air exhaled during the FEV test
HRQoLhealth-related quality of life
TMtele-monitoring – the transmission of symptom scores and physiological data including heart rate, blood pressure and oxygen saturation to care providers either via automated electronic means or via web- or phone-based data entry

Summary of Evidence

In April 2020 the National Institute for Health and Care Excellence (NICE) in Britain published a COVID-19 rapid guideline2 with the purpose of maximising the safety of patients with chronic obstructive pulmonary disease (COPD) during the COVID-19 pandemic. NICE recommended the use of online pulmonary rehabilitation resources such as those available in the British Thoracic Society pulmonary rehabilitation resource pack ¾ including resources for self-management and home exercise, and educational materials1.  Modifications to usual care and service delivery should take into account access to digital resources and digital literacy.

The Canadian Thoracic Society position statement3 provides guidance on the resumption of pulmonary rehabilitation (PR) services during the post-peak phase of the COVID-19 pandemic. Considerations for the provision of PR virtually include:

  1. People with chronic respiratory diseases who have COVID-19 are at high risk of developing severe illness. Therefore, it is important to limit any potential exposure to the SARS-CoV-2 virus.
  2. Public Health advisories on reducing the risk of SARS-CoV2 infection should be emphasised.
  3. Options for the remote delivery of PR include home-based, computer-based or telerehabilitation virtual programs. Programs may be designed to provide education and exercise, and also in some cases remote monitoring of exercise performance.
  4. The ability to individualise and monitor exercise intensity may be limited when in-person PR is not possible.
  5. In-person PR may be considered when community spread of COVID-19 is low, when patients have needs that are difficult to address remotely or when patient access to technology is limited.
  6. Hybrid models that include in-person assessment and exercise testing and a combination of in-person and virtual exercise training, education and self-management may be used to optimise exercise safety and training effectiveness while decreasing disease transmission and infection rates.
  7. Strict attention to mask use, physical distancing and disinfection protocols must be observed by staff and patients where in-person PR is offered. Equipment should not be shared among patients unless appropriate disinfecting and cleaning protocols are utilised.

For people with COPD, low‐certainty evidence suggests that compared with usual care smart technology interventions may lead to increased physical activity ¾ on average, by 864 steps/d ¾ and a small improvement in quality of life. Evidence for the impact of smart technology interventions on other outcomes is absent or derives from underpowered trials that yield imprecise results38.

Bentley et al6 observe that digital mobile health (mHealth) solutions show promise in helping people with COPD self-manage their physical activity levels. However, mHealth interventions for COPD self-management may be more acceptable to people with prior experience of using digital technology and may be more beneficial if used at an earlier stage of COPD. Simplicity and usability were more important for engagement with the SMART-COPD intervention than personalisation.

Bonnevie et al7 concluded that compared with no exercise therapy (ET), home-based exercise therapy delivered using advanced telehealth technology (ATT-ET) improves exercise capacity, functional dyspnoea and quality of life (QoL), although some benefits may be small. Its benefits are generally similar to in- or outpatient ET and similar to or better than home-based ET without ATT.

Cerdán de Las Heras et al10 assert that the development of a user-centered telerehabilitation platform responding to the preferences of patients with chronic disease will remove barriers that limit participation in rehabilitation programmes and improve patient empowerment.

Galdiz et al14 conclude that although a maintenance pulmonary telerehabilitation (TelePR) programme is both feasible and safe, the programme failed to show superiority over usual care, despite improvements in some health-related QoL domains.

Jiménez-Reguera B et al19 assert that mHealth systems designed for COPD patients improve adherence to maintenance programs as long as they are accompanied by disease awareness and patient involvement in management.

Jung et al20 identified 11 themes specific to the delivery of a virtual reality (VR) supported intervention for pulmonary rehabilitation of COPD patients: increased compliance; increased engagement; physical improvements; improved psychological wellbeing; improved health-related QoL; improved confidence; patient satisfaction; increased feeling of security; the effectiveness of immersive learning; a recommendation to provide personalized programmes according to level of COPD; and the need for technological improvements. Rutkowski et al27 suggest that a pulmonary rehabilitation program supplemented with VR training a is beneficial intervention to improve physical fitness in patients with COPD.

Koff et al22 conclude that linking integrated care with remote monitoring improves the lives of people with advanced COPD. The authors assert that their findings may have been made more relevant by COVID-19.

In a randomized controlled trial comparing standard care, self-monitoring, and remote monitoring, Stamenova et al29 found no significant differences among any of the groups. Despite regular use of the technology, patients with COPD assigned to remote monitoring or self-monitoring did not have any improvement in patient outcomes such as self-management skills, knowledge, or symptoms, or in healthcare use compared with each other or with a standard care group.

Velayati et al31 compared the effectiveness of telerehabilitation interventions with traditional rehabilitation services for therapeutic purposes in the elderly. Findings showed that overall there was no significant difference between the intervention and control groups and the level of improvements was similar for most outcomes.

International Guidance

What does the British Thoracic Society say?

British Thoracic Society (2020) BTS Advice for Community Respiratory Services in relation to COVID-19 (updated 26 May 2020)[1]

See section: Pulmonary Rehabilitation. Face-to-face classes were in general stopped to reduce the risk to patients and enable staff redeployment to acute community settings. There is now a need to actively select and implement alternative methods of rehabilitation such as online and web-based resources. There is a separate need to consider how community respiratory services may be able to assist in the holistic rehabilitation of people following COVID-19, and the BTS has initiated work on a collection of resources; current resources on components of a rehabilitation programme may be found at britthoracic.org.uk.  

What does the National Institute for Health and Care Excellence (NICE) say?

NICE (2020) COVID-19 rapid guideline: community-based care of patients with chronic obstructive pulmonary disease (COPD) 9 April 2020[2]

NICE recommends signposting to online pulmonary rehabilitation resources such as those available in the BTS pulmonary rehabilitation resource pack. The NICE rapid guideline includes recommendations on:

  1. Communicating with patients and minimizing risk
  2. Treatment and care planning
  3. Equipment
  4. Modifications to usual care and service delivery, which should take into account people’s access to digital resources and digital literacy

What does the Canadian Thoracic Society say?

Dechman et al (Nov 2020) Delivering pulmonary rehabilitation during the COVID-19 pandemic: A Canadian Thoracic Society position statement[3]

The Canadian Thoracic Society position statement provides guidance on the resumption of pulmonary rehabilitation (PR) services during the post-peak phase of the COVID-19 pandemic; offers alternatives to face-to-face or in-person PR; and provides useful links to resources. Considerations for the provision of PR virtually include:

  1. People with chronic respiratory diseases who have COVID-19 are at high risk of developing severe illness. Therefore, it is important to limit any potential exposure to the SARS-CoV-2 virus.
  2. Public Health advisories on reducing the risk of SARS-CoV2 infection should be emphasised.
  3. Options for the remote delivery of PR include home-based, computer-based or telerehabilitation virtual programs. Programs may be designed to provide education and exercise, and also in some cases remote monitoring of exercise performance.
  4. The ability to individualise and monitor exercise intensity may be limited when in-person PR is not possible.
  5. In-person PR may be considered when community spread of COVID-19 is low, when patients have needs that are difficult to address remotely or when patient access to technology is limited.
  6. Hybrid models that include in-person assessment and exercise testing, and a combination of in-person and virtual exercise training, education and self-management can be used to optimise exercise safety and training effectiveness while decreasing disease transmission and infection rates.
  7. Strict attention to mask use, physical distancing and disinfection protocols must be observed by staff and patients where in-person PR is offered. Equipment should not be shared among patients unless appropriate disinfecting and cleaning protocols are utilised.

International Literature

Alwashmi MF et al (2o2o) Features of a mobile health intervention to manage chronic obstructive pulmonary disease: a qualitative study[4]

Background: The use of mobile health (mHealth) interventions has the potential to support COPD treatment outcomes. Further research is needed to determine which mHealth features are required to potentially enhance COPD self-management.

Aim: To explore the potential features of an mHealth intervention for COPD management with healthcare providers (HCPs) and patients with COPD.

Methods: A qualitative study which incorporated semi-structured individual interviews with HCPs including nurses, pharmacists and physicians who work directly with patients who have COPD; and a diverse sample of patients with COPD. Interview topics included demographics, mHealth usage, the potential use of medical devices and recommendations for features that would enhance an mHealth intervention for COPD management.

Results: The study recruited a total of 40 participants. Recommendations for the proposed mHealth intervention were categorised into patient and HCP interface. Prevalent features suggested for the patient interface included education; collecting baseline data; collecting subjective data; collecting objective data via compatible medical devices; providing a digital action plan; allowing patients to track their progress; enabling family members to access the mHealth intervention; tailoring features based on a patient’s unique needs; reminding patients about critical management tasks; and rewarding patients for their positive behaviours. The most common features of the HCP interface included allowing HCPs to track their patients’ progress; allowing HCPs to communicate with their patients; educating HCPs; and rewarding HCPs.

Barbosa MT et al (Oct 2020) Telemedicine in COPD: An Overview by Topics[5]

COPD is a major cause of morbidity and mortality worldwide and carries a huge and growing economic and social burden. Telemedicine may facilitate the care of patients with limited access to health services; improve self-management; and, in the context of the COVID-19 pandemic, better assure patient safety. The authors conducted a literature search and found a positive tendency toward benefits in telerehabilitation, health-education and self-management; early detection of COPD exacerbations; and psychosocial support and smoking cessation. However, the heterogeneity of the included clinical trials and reviews limits the extent to which clinical value may be inferred.

Bentley CL et al (June 2020) The Use of a Smartphone App and an Activity Tracker to Promote Physical Activity in the Management of Chronic Obstructive Pulmonary Disease: Randomized Controlled Feasibility Study[6]

Background: COPD is highly prevalent and significantly affects the daily functioning of patients. Self-management strategies including increasing physical activity can help people with COPD have better health and a better QoL. Digital mobile health (mHealth) techniques have the potential to aid the delivery of self-management interventions for COPD. An mHealth intervention ¾ Self-Management supported by Assistive, Rehabilitative, and Telehealth technologies-COPD [SMART-COPD] ¾ was developed and delivered via a smartphone app and an activity tracker to help people with COPD maintain or increase physical activity after undertaking PR.

Objective: To determine the feasibility and acceptability of using the SMART-COPD intervention for the self-management of physical activity and to explore the feasibility of conducting a future RCT to investigate its effectiveness.

Methods: A randomised feasibility study including 30 participants with COPD who were randomly allocated to receive the SMART-COPD intervention (n=19) or control (n=11). Participants used SMART-COPD throughout PR and for 8 weeks subsequent maintenance to set physical activity goals and monitor progress. Questionnaire-based and physical activity-based outcome measures were taken at baseline, the end of PR, and the end of maintenance. Participants and healthcare professionals involved in PR delivery were interviewed about their experiences with the technology.

Results: Overall, 47% (14/30) of participants withdrew from the study. Difficulty in using the technology was a common reason for withdrawal. Participants who completed the study had better baseline health and more prior experience with digital technology compared with participants who withdrew. Participants who completed the study were generally positive about the technology and found it easy to use. Some participants responded that their health had benefitted from using the technology and that it assisted them in achieving physical activity goals. Activity tracking and self-reporting were both found to be problematic as outcome measures of physical activity. There was dissatisfaction among some control group members regarding their allocation.

Conclusions: mHealth shows promise in helping people with COPD self-manage their physical activity levels. However, mHealth interventions for COPD self-management may be more acceptable to people with prior experience of using digital technology and may be more beneficial if used at an earlier stage of COPD. Simplicity and usability were more important for engagement with the SMART-COPD intervention than personalisation.; therefore, the intervention should be simplified for future use. Provision of education, training, persuasion and environmental restructuring and enablement increase the social and physical opportunity for patients to engage in self-management. Future evaluation will require consideration of individual factors and their effect on mHealth efficacy and use; within-subject comparison of step count values; and an opportunity for control group participants to use the intervention if an RCT were to be carried out. Sample size calculations for a future evaluation would need to consider the high attrition rates.

Bonnevie T et al (2021) Advanced telehealth technology improves home-based exercise therapy for people with stable chronic obstructive pulmonary disease: a systematic review[7]

Questions: How effective is home-based exercise therapy delivered using advanced telehealth technology (ATT-ET) for people with COPD compared with no exercise therapy (ET), in- or outpatient ET, and home-based ET without ATT?

Design: Systematic review and meta-analysis of randomised trials.

Participants: People with stable COPD referred for ET.

Intervention: ATT-ET.

Outcome measures: Exercise capacity, QoL, functional dyspnoea, cost-effectiveness and various secondary outcomes.

Results: 15 eligible trials including 1,522 participants. Compared with no ET, ATT-ET improved exercise capacity (4 studies, 6-minute walk test mean difference (MD) 15 minutes (m), 95% CI 5 to 24) and probably improved QoL (4 studies, standardised mean difference (SMD) 0.22, 95% CI 0.00 to 0.43) and functional dyspnoea (2 studies, Chronic Respiratory Questionnaire-Dyspnoea MD 2, 95% CI 0 to 4). ATT-ET had a similar effect as in- or outpatient ET on functional dyspnoea (2 studies, SMD -0.05, 95% CI -0.39 to 0.29) and a similar or better effect on QoL (2 studies, SMD 0.23, 95% CI -0.04 to 0.50) but its relative effect on exercise capacity was very uncertain (3 studies, 6-minute walk test MD 6 m, 95% CI -26 to 37). ATT-ET had a similar effect as home-based ET without ATT on exercise capacity (3 studies, 6-minute walk test MD 2 m, 95% CI -16 to 19) and similar or better effects on QoL (3 studies, SMD 0.79, 95% CI -0.04 to 1.62) and functional dyspnoea (2 studies, Chronic Respiratory Questionnaire-Dyspnoea MD 2, 95% CI 0 to 4). ATT-ET had effects on most secondary outcomes that were similar to or better than each comparator.

Authors Conclusion: ATT-ET improves exercise capacity, functional dyspnoea and QoL compared with no ET, although some benefits may be small. Its benefits are generally similar to in- or outpatient ET and similar to or better than home-based ET without ATT.

Bonnevie T et al (May 2020) Mid-Term Effects of Pulmonary Rehabilitation on Cognitive Function in People with Severe Chronic Obstructive Pulmonary Disease[8]

Purpose: Cognitive dysfunction is a common impairment associated with COPD. However, little is known about: 1. its prevalence among those subjects referred for PR; 2. how it may affect the benefit of PR; 3. whether PR improves cognitive function; and 4. whether cognitive dysfunction affects the usability of telehealth technology usually used to deliver in-home PR.

Patients and methods: 56 subjects with stable COPD (54% females, mean age 62 years (SD 9) and median forced expiration volume (FEV1) 0.9 L (IQR 0.7 to 1.1)) participated in this multicentre observational study and performed 24 sessions of PR. The Montreal Cognitive Assessment Tool (MoCA) was used to assess the occurrence of mild cognitive dysfunction (using a screening cut-off <26) at baseline, completion of PR and 3 month follow-up.

Results: Mild cognitive dysfunction was found in 41 subjects (73% [95% CI: 60 to 83%]). The MoCA score significantly improved following PR for those people with baseline mild cognitive dysfunction (p<0.01). There was no significant difference in clinical outcomes between those people with or without mild cognitive dysfunction following PR nor in the proportion of subjects who were autonomous in using the telemonitoring system (83% compared with 71%, p=0.60).

Conclusion: Mild cognitive dysfunction is highly prevalent among those people with COPD referred for PR but does not affect the benefits of PR or the usability of a telemonitoring system. PR may improve short- and mid-term cognitive function for those people who experience mild cognitive dysfunction at the time they are referred to PR.

Bourbeau J et al (Sept 2020) Pulmonary Rehabilitation[9]

PR is an essential intervention in the management of patients with COPD. To guide healthcare professionals in the implementation and evaluation of a PR program, the authors discuss the current key concepts regarding exercise testing; prescription and training; self-management; and post-rehabilitation maintenance. New approaches – alternative forms of organization and delivery, tele-rehabilitation, exercise adjuncts – and unique and challenging scenarios – patients experiencing acute exacerbations, advanced disease – are also reviewed. Validated point-of-care resources and online tools are provided.

Cerdán de Las Heras J et al (Aug 2020) Augmented reality glasses as a new tele-rehabilitation tool for home use: patients’ perception and expectations[10]

Materials and methods: A qualitative approach was employed to track perspectives from a range of patients with chronic lung and/or heart diseases. COPD, idiopathic pulmonary fibrosis (IPF) and myocardial infarction (MI) outpatients from Denmark and Finland were invited to participate. Data were collected through a focus group and semi-structured in-depth interviews. Qualitative analysis was performed using standard thematic analytical approaches. A topic guide was used to explore experiences and perceptions of the augmented reality glasses (ARG) telerehabilitation device among participants.

Results: 13 patients (4 MI, 2 IPF and 7 COPD), 3 women and 10 men aged 56 to 75 years (mean age 63.3 years) were allocated into one focus group (9 patients) and 4 interviews (4 patients). 12 patients reported the added value of ARG and suggested constructive changes such as the adjustable screen/brightness, robust head fixation for exercise performance, easy to navigate interface and supported feedback based on exercise performance.

IMPLICATIONS FOR REHABILITATION: Patients with chronic pulmonary and heart diseases have difficulties in changing behaviour to a more active and healthy lifestyle. Offers from the health sector to participate in rehabilitation programmes are feasible and improve QoL and exercise capacity. Not all patients are capable of participating in such rehabilitation programmes due to frailty or long distance to the hospital. Telerehabilitation seems to be a potential treatment in such circumstances. The development of a user-centered telerehabilitation platform responding to the preferences of patients with chronic disease will remove barriers that limit use and compliance and improve empowerment in future research projects.

Colombo V et al (Dec 2020) Virtual reality for COPD rehabilitation: a technological perspective[11]

Virtual reality (VR) is a promising technology for implementing personalised, motivating and controlled rehabilitation scenarios. In spite of its potential benefits, VR has been poorly investigated in pulmonary rehabilitation. The authors conducted a state-of-the-art review of the scientific and grey literature regarding the use of VR for the rehabilitation of patients with COPD.

Although the application of VR to PR is still developing, the authors’ review supports its feasibility, and its potential effectiveness to improve patients’ motivation and engagement ¾ thus maintaining the benefits of rehabilitation over a longer period of time. The included studies are mainly focused on physical training. Several studies consider a combination of breathing and physical exercise. This is in line with standard practice for PR, which regards physical training as a cornerstone. The effects of breathing exercises on dyspnoea and overall patient health is variable, and the role of breathing exercises in the comprehensive management of COPD is not as widespread as physical activity. 

Ding M et al (2020) Remote rehabilitation applied in patients with stable stage of chronic obstructive pulmonary disease: A meta-analysis[12]

Due to the inconveniences of mobility, lack of transport and travel costs, it is difficult for patients with COPD to have access to a centre-based lung rehabilitation service. Remote rehabilitation technology provides these patients with the opportunity for lung rehabilitation.

OBJECTIVE(S): To explore the effect of remote rehabilitation in pulmonary rehabilitation of patients with stable stage COPD.

RESULTS AND CONCLUSION(S): A total of 3033 patients with stable stage of COPD were enrolled in 21 RCTs. Meta-analysis results indicated that compared with the control group, the forced expiratory volume in 1 second/forced vital capacity was significantly increased [MD=5.11, 95%CI (4.05,6.17), Z=9.49, P < 0.000 01] and COPD Assessment Test (CAT) score was significantly decreased [MD=-3.54, 95%CI (-5.61, -1.46), Z=3.34, P=0.000 8] in the intervention group (P < 0.05). No difference was found in the 6-minute walking distance, the predicted forced expiratory volume in 1 second%, Modified Medical Research Council Dyspnea Scale (mMRC) score or St. George’s Registry Questionnaire (SGRQ) score (P > 0.05).

CONCLUSION: Remote rehabilitation provides a new lung rehabilitation method for COPD patients which can promote disease recovery and strengthen self-management.

Formiga MF et al (Sept 2020) Novel versus Traditional Inspiratory Muscle Training Regimens as Home-Based, Stand-Alone Therapies in COPD: Protocol for a Randomized Controlled Trial[13]

Background: Subjects with COPD frequently develop considerable weakness and deconditioning of the inspiratory musculature which can be corrected with inspiratory muscle training (IMT). While rehabilitation centres may be able to provide IMT as part of the rather complex management of COPD, there is currently a lack of rehabilitation services in the Czech Republic. Remote IMT may benefit subjects with COPD who are unable to attend or do not have access to rehabilitation programs. The authors evaluate the utility of the Test of Incremental Respiratory Endurance (TIRE) as an at-home IMT intervention in subjects with COPD.

Methods/design: A prospective RCT comprising 8 weeks of at-home IMT sessions with remote supervision followed by 4 months of unsupervised, independent IMT. Eligible subjects will be randomly assigned to one of the following three distinct home-based IMT protocols: 1. TIRE; 2. threshold loading; and 3. sham training. Subjects allocated to the TIRE group will train once daily using an advanced IMT electronic system (PrO2), while the other two groups will receive threshold devices. Study outcomes will include measures of inspiratory muscle strength and endurance, pulmonary function, COPD-specific symptomatology, functional exercise capacity, surrogate markers of mortality risk, mental health status and health-related QoL.

Discussion: The authors argue that the TIRE training method has the potential to provide additional clinical benefits in COPD given its sophisticated remote tracking system and ability to modulate all aspects of muscular performance including not only strength but also endurance, power and work capacity, allowing users to achieve considerably higher inspiratory pressures throughout the full range of inspiration when compared to other more traditionally used IMT methods.

Galdiz JB et al (May 2020) Telerehabilitation Programme as a Maintenance Strategy for COPD Patients: A 12-Month Randomized Clinical Trial[14]

Background: There is uncertainty regarding the efficacy of telehealth-based approaches in COPD patients for sustaining benefits achieved with intensive PR.

Research question: To determine whether a maintenance pulmonary telerehabilitation (TelePR) programme, after intensive initial PR, is superior to usual care in sustaining over time benefits achieved by intensive PR.

Study design and methods: A multicentre open-label pragmatic parallel-group RCT was conducted. Two groups were created at completion of an 8-week intensive outpatient hospital PR programme. Intervention group (IG) patients were given appropriate training equipment and instructed to perform three weekly training sessions and send performance data through an app to a web-based platform. Patients in the control group (CG) were advised to exercise regularly [usual care].

Results: 94 patients (46 IG, 48 CG) were randomised. The analysis of covariance showed non-significant improvements in 6-min walk distance [19.9m (95% CI -4.1/+43.8)] and Chronic Respiratory Disease Questionnaire – Emotion score [0.4 points (0-0.8)] in the IG. Secondary linear mixed models showed improvements in the IG in Short Form-36 mental component summary [9.7, (4.0-15.4)] and Chronic Respiratory Disease Questionnaire – Emotion [0.5, (0.2-0.9)] scores, but there was no association between compliance and outcomes. Acute exacerbations were associated with a marginally significant decrease in 6-minute walk distance of 15.8m (-32.3/0.8) in linear models.

Conclusions: The TelePR maintenance strategy was both feasible and safe but failed to show superiority over usual care, despite improvements in some health-related QoL domains. Acute exacerbations may have an important negative influence on long-term physical function.

Godtfredsen N et al (Oct 2020) 12-months follow-up of pulmonary tele-rehabilitation versus standard pulmonary rehabilitation: A multicentre randomised clinical trial in patients with severe COPD[15]

Between March 2016 and October 2017, 134 patients with severe COPD from 8 hospitals in the Capital Region of Denmark were randomised to participate in either standardised outpatient pulmonary rehabilitation or online, supervised and home-based telerehabilitation. There was no difference between the groups in the primary outcome: 6-minute walking distance (6MWD) after completion of the programme. The authors present results from the 12-month follow-up with assessment of the 6MWD and analyses of hospitalisation and mortality. There were no significant differences between or within the groups in the 6MWD one year after completion of the programme.

Hansen H et al (May 2020) Supervised pulmonary tele-rehabilitation versus pulmonary rehabilitation in severe COPD: a randomised multicentre trial[16]

Rationale: Pulmonary rehabilitation (PR) is an effective, key standard treatment for people with COPD. Nevertheless, low participant uptake, insufficient attendance and high drop-out rates are reported. Investigation is warranted of the benefits achieved through alternative approaches such as pulmonary tele-rehabilitation (PTR).

Objective: To investigate whether PTR is superior to conventional PR on 6 min walk distance (6MWD) and secondarily on respiratory symptoms, QoL, physical activity and lower limb muscle function in patients with COPD and FEV1 <50% eligible for routine hospital-based, outpatient PR.

Methods: In this single-blinded, multicentre, superiority RCT, patients were assigned 1:1 to 10 weeks of groups-based PTR (60 min, three times weekly) or conventional PR (90 min, two times weekly). Assessments were performed by blinded assessors at baseline, end of intervention and at 22 weeks’ follow-up from baseline. The primary analysis was based on the intention-to-treat principle.

Measurements and main results: The primary outcome was change in 6MWD from baseline to 10 weeks; 134 participants (74 females, mean±SD age 68±9 years, FEV1 33%±9% predicted, 6MWD 327±103 metres) were included and randomised. The analysis showed no between-group differences for changes in 6MWD after intervention (9.2 metres (95% CI: -6.6 to 24.9)) or at 22 weeks’ follow-up (-5.3 metres (95% CI: -28.9 to 18.3)). More participants completed the PTR intervention (n=57) than conventional PR (n=43) (χ2 test p<0.01).

Conclusion: PTR was not superior to conventional PR on the 6MWD and we found no differences between groups. As more participants completed PTR, supervised PTR would be relevant to compare with conventional PR in a non-inferiority design. 

Hosseiniravandi M et al (April 2020) Home-based telerehabilitation software systems for remote supervising: a systematic review[17]

Objectives: In the past decade, with the ever-increasing growth of information and communication technologies, telerehabilitation, especially home-based rehabilitation (HBR), has been widely considered by researchers. Many software systems are developed to address HBR programs, which includes various functionalities. The aim of this study is to review the functional features of these systems designed for remote supervising of HBR programs.

Methods: Scopus, PubMed, EMBASE, ISI Web of Science, Cochrane Library, IEEE Xplore Digital Library, and ProQuest databases were searched for English-language articles published between January 2008 and February 2018 to retrieve studies reporting a home-based telerehabilitation software system aiming to remotely supervise HBR program.

Results: A total of 50 studies that reported 22 unique systems met the inclusion criteria. Various functional features were identified including but not limited to exercise plan management, report/statistics generating, patient education, and task scheduling. Disorders or diseases addressed by these systems could mainly be grouped into five categories: musculoskeletal, neurological, respiratory, cardiovascular, and other health-related problems. Usability and acceptability, and clinical/patient outcomes were the most reported outcomes and data analysis was used by the majority of included studies to measure the outcomes.

Conclusions: Systems developed for supervising of HBR program are diverse. However, preliminary results of this review revealed that these systems share more or less common functionalities. Further research is needed to determine the requirements, structure, and effectiveness of these systems in real-life settings.

Jiang Y et al (April 2020) Evaluating an Intervention Program Using WeChat for Patients With Chronic Obstructive Pulmonary Disease: Randomized Controlled Trial[18]

Background: The application of telemedicine in home pulmonary rehabilitation interventions for the management of patients with COPD has achieved promising results.

Objective: This study aimed to develop a WeChat official account (Pulmonary Internet Explorer Rehabilitation [PeR]) based on social media. It further evaluated the effect of PeR on the QoL, symptoms, and exercise self-efficacy of patients with COPD.

Methods: The functional modules of PeR were developed by a multidisciplinary team according to the electronic health-enhanced chronic care model (eCCM) components. A total of 106 patients were randomly selected (53 in the PeR group and 53 in the outpatient face-to-face group [FtF]). Pulmonary rehabilitation intervention was conducted for 3 months, and the outcome was observed for 3 months. The primary outcome was patient quality of life (QoL) measured with the COPD Assessment Test (CAT). The secondary outcomes were evaluated using the modified Medical Research Council scale (mMRC), exercise self-regulatory efficacy scale (Ex-SRES), and St George’s Respiratory Questionnaire (SGRQ).

Results: Intention-to-treat analysis was used in the study. A total of 94 participants completed the 6-month pulmonary rehabilitation program. No statistically significant differences were observed in CAT (F1,3=7.78, P=.001), Ex-SRES (F1,3=21.91, P<.001), and mMRC scores (F1,3=29.64, P<.001) between the two groups with the variation in time tendency. The Ex-SRES score had a significant effect on the CAT score (P=.03). The partial regression coefficient of Ex-SRES to CAT was 0.81, and Exp (B) was 2.24.

Conclusions: The telemedicine technology was effective using the eCCM combined with a behavioral intervention strategy centred on self-efficacy. Pulmonary rehabilitation at home through PeR and FtF could improve the sense of self-efficacy and QoL and alleviate symptoms in patients with COPD.

Jiménez-Reguera B et al (July 2020) Development and Preliminary Evaluation of the Effects of an mHealth Web-Based Platform (HappyAir) on Adherence to a Maintenance Program After Pulmonary Rehabilitation in Patients With Chronic Obstructive Pulmonary Disease: Randomized Controlled Trial[19]

Background: Pulmonary rehabilitation is one of the main interventions to reduce the use of health resources and promotes a reduction in COPD costs. mHealth systems in COPD aim to improve adherence to maintenance programs after pulmonary rehabilitation by promoting the change in attitude and behaviour necessary for patient involvement in the management of the disease.

Objective: The authors aimed to assess the effects of an integrated care plan based on a mHealth web-based platform (HappyAir) on adherence to a 1-year maintenance program applied after pulmonary rehabilitation in COPD patients.

Methods: COPD patients from three hospitals were randomised to a control group or an intervention group [HappyAir group]. Patients from both groups received an 8-week program of pulmonary rehabilitation and educational sessions about their illness. After completion of the process, only the HappyAir group completed an integrated care plan for 10 months, supervised by a mHealth system and therapeutic educator. The control group only underwent scheduled check-ups. Adherence to the program was rated using a respiratory physiotherapy adherence self-report (CAP FISIO) questionnaire. Other variables analysed were adherence to physical activity (Morisky-Green Test), QoL (Chronic Obstructive Pulmonary Disease Assessment Test, St. George’s Respiratory Questionnaire, and EuroQOL-5D), exercise capacity (6-Minute Walk Test), and lung function.

Results: In total, 44 patients were recruited and randomised in the control group (n=24) and HappyAir group (n=20). 8 patients dropped out for various reasons. The CAP FISIO questionnaire results showed an improvement in adherence during follow-up period for the HappyAir group, which was statistically different compared with the control group at 12 months (56.1 [SD 4.0] vs 44.0 [SD 13.6]; P=.004) after pulmonary rehabilitation.

Conclusions: mHealth systems designed for COPD patients improve adherence to maintenance programs as long as they are accompanied by disease awareness and patient involvement in management.

Jung T et al (July 2020) A Virtual Reality-Supported Intervention for Pulmonary Rehabilitation of Patients With Chronic Obstructive Pulmonary Disease: Mixed Methods Study[20]

Background: The uptake of traditional pulmonary rehabilitation classes by patients with COPD is poor because of personal factors that prevent accessibility to the venue. Therefore, there is a need for innovative methods of pulmonary rehabilitation, and virtual reality (VR) could be a promising technology for patients with COPD to access services remotely.

Objective: The authors aimed to investigate whether VR improves compliance with pulmonary rehabilitation among patients with COPD, a particularly vulnerable patient group (Medical Research Council [MRC] 4 or 5), and whether VR provides a credible alternative to traditional pulmonary rehabilitation programs.

Methods: An 8-week patient trial using an innovative VR pulmonary rehabilitation program. A purposive sample of 10 patients with COPD graded MRC 4 or 5 and registered at a selected healthcare centre and a hospital in Cumbria, England, were included. Qualitative (focus groups and interviews) data were collected, and to further support the qualitative findings, quantitative data (self-report patient surveys) were gathered before and after the 8-week trial. The 5 self-reported surveys included the Patient Activation Measure, Generalized Anxiety Disorder-7, Patient Health Questionnaire-9, Short Physical Performance Battery, and the Edmonton Frail Scale.

Results: In a thematic analysis of the qualitative data, 11 themes emerged specific to delivering pulmonary rehabilitation using VR. The quantitative data further support the qualitative findings by revealing significant improvements in all physical measures.

Theme
Increased ComplianceSignificant increase in the patients’ compliance with pulmonary rehabilitation ¾ ie doing their exercises
Increased EngagementIncreased engagement in pulmonary rehabilitation when using virtual reality because of enjoyment
Physical ImprovementsSignificant improvements in patients’ physical health ¾ ie strength, mobility, and flexibility
Improved Psychological WellbeingPatients’ psychological wellbeing significantly improved
Improved Health-Related Quality of LifePatients feel healthier and fitter: they can confidently leave the house and socialize more than before
Increased ConfidenceSignificant improvements in confidence in terms of the patients managing their condition and performing daily activities and physical exercises
Patient SatisfactionPatients are satisfied with completing the Pulmonary Rehabilitation in Virtual Reality program and achieving their short-term and long-term goals
Increased Feeling of SecurityPatients feel more secure, reassured and confident to exercise, knowing their physiological data are being remotely supervised
Effective Immersive LearningEffectiveness of immersive learning for patients with COPD was demonstrated
Personalized ProgramsA recommendation to provide programs tailored to suit various levels of COPD
Need for Technological ImprovementsNeed for technological improvements of both the device (eg a more lightweight headset) and the content of the app (eg additional functions to control the pace and standing-up exercises) to improve patient experience

Conclusions: Remotely supervised VR-based pulmonary rehabilitation could help to overcome current issues and limitations associated with providing services to patients with COPD at scale.

King D et al (Aug 2020) Optimizing Telehealth Experience Design Through Usability Testing in Hispanic American and African American Patient Populations: Observational Study[21]

Background: Telehealth-delivered pulmonary rehabilitation (telePR) has been shown to be as effective as standard pulmonary rehabilitation (PR) at improving the QoL in patients living with COPD. However, it is not known how effective telePR may prove to be among low-income, urban Hispanic American and African American patient populations. To address this question, a collaborative team at Northwell Health developed a telePR intervention and assessed its efficacy among low-income Hispanic American and African American patient populations. The telePR intervention system components included an ergonomic recumbent bike, a tablet with a built-in camera, and wireless monitoring devices.

Objective: The objective of the study was to assess patient adoption and diminish barriers to use by initiating a user-centered design approach, which included usability testing to refine the telePR intervention prior to enrolling patients with COPD into a larger telePR study.

Methods: Usability testing was conducted in two phases to identify opportunities to streamline and improve the patient experience. The first phase included a prefield usability testing phase to evaluate technical, patient safety and environmental factors comprising the system architecture. This was followed by an ergonomic evaluation of user interactions with the bicycle, telehealth tablets and connected wearable devices to ensure optimal placement and practical support for all components of the intervention. The second phase of research included feasibility testing to observe and further optimize the system based on iterative rounds of telePR sessions.

Results: During usability and feasibility research, we identified and addressed multiple opportunities for system improvements. These included physical and environmental changes, modifications to accommodate individual patient factors, safety improvements, and technology upgrades. Each enrolled patient was subsequently identified and classified into one of the following 3 categories: 1. Independent; 2. Intermediate; or 3. dependent. This categorization was used to predict the level of training and support needed for successful participation in the telePR sessions. Feasibility results revealed that patients in the dependent category were unable to perform the rehab sessions without in-person support due to low technical acumen and difficulty with certain features of the system, even after modifications had been made. Intermediate and independent users, however, did exhibit increased independent utilization of telePR due to iterative improvements.

Conclusions: Usability testing helped reduce barriers to use for two subsets of our population, the intermediate and independent users. In addition, it identified a third subset, dependent users, for whom the telePR solution was deemed unsuitable without in-person support. The study established the need for the development of standard operating procedures, and guides were created for both patients and remote respiratory therapists to facilitate the appropriate use of the telePR system intervention. Observational research also led to the development of standard protocols for the first and all subsequent telePR sessions. The primary goals in developing standardization protocols were to establish trust, ensure a positive experience, and encourage future patient engagement with telePR sessions.

Koff PB et al (Nov 2020) Impact of Proactive Integrated Care on Chronic Obstructive Pulmonary Disease[22]

Background: Proactive Integrated Care (Proactive iCare), a healthcare delivery model that couples integrated care with remote monitoring, was developed to address the fact that up to 50% of COPD patients do not receive recommended care for COPD.

Methods: A prospective, quasi-RCT in 511 patients with advanced COPD or a recent COPD exacerbation was conducted, to test whether Proactive iCare impacts patient-centred outcomes and healthcare utilisation. Patients were allocated to Proactive iCare (n = 352) or Usual Care (n = 159), and were examined for changes in QoL using the St. George’s Respiratory Questionnaire (SGRQ), symptoms, guideline-based care, and healthcare utilisation.

Findings: Proactive iCare improved total SGRQ by 7 – 9 units (p < 0.0001), symptom SGRQ by 9 units (p < 0.0001), activity SGRQ by 6 – 7 units (p < 0.001) and impact SGRQ by 7 – 11 units (p < 0.0001) at 3, 6 and 9 months compared with Usual Care. Proactive iCare increased the 6-minute walk distance by 40 m (p < 0.001), reduced annual COPD-related urgent office visits by 76 visits per 100 subjects (p < 0.0001), identified unreported exacerbations, and decreased smoking (p = 0.01). Proactive iCare also improved symptoms, the BODE index and oxygen titration (p < 0.05). Mortality in the Proactive iCare group (1.1%) was not significantly different than mortality in the Usual Care group (3.8%; p = 0.08).

Interpretation: Linking integrated care with remote monitoring improves the lives of people with advanced COPD, findings that may have been made more relevant by COVID-19.

Lahham A et al (April 2020) The impact of home-based pulmonary rehabilitation on people with mild chronic obstructive pulmonary disease: A randomised controlled trial[23]

Introduction: People with mild COPD experience exercise intolerance, dyspnoea and poor QoL. However, the role of PR in this group is unclear.

Objectives: This RCT aimed to explore the effects of home-based PR in people with mild COPD.

Methods: People with mild COPD (FEV1 /FVC < 70%; FEV1 > 80%predicted) with a smoking history of ≥10 packet years were randomised to either 8 weeks of home-based PR (one home visit and seven once-weekly telephone calls) or standard care (weekly social telephone calls). 6-minute walk distance (6MWD), Modified Medical Research Council Dyspnoea Scale (mMRC) and Chronic Respiratory Disease Questionnaire (CRQ) scores were compared.

Results: A total of 58 participants (34 males, mean age 68 (SD 9) years, FEV1 %predicted 90 (7), 6MWD 496 (105) m) were included with 31 participants randomised to home-based PR. Participants attended an average of 6.8 of the 8 scheduled sessions, ranging from 3 to 8 sessions. Both groups showed improvements in exercise capacity, symptoms and health-related quality of life (HRQoL) over time, however there was no difference in 6MWD at end-intervention (mean difference -3 m, 95% confidence interval (CI) -64 to 58) or 6 months (7 m, 95% CI -59 to 72). At 6 months home-based PR participants were more likely to have clinically important improvements in CRQ emotional function (50% of home PR vs 0% control, P < 0.001) and CRQ total score (45% vs 17%, P = 0.05).

Conclusion: For people with mild COPD, home-based PR did not improve exercise capacity more than standard care. 

Liu S et al (Oct 2020) The Cost-Effectiveness of Pulmonary Rehabilitation for COPD in Different Settings: A Systematic Review[24]

Background:  COPD has high morbidity and mortality rates. COPD impairs body functioning, reduces quality of life, and creates a great economic burden for society. PR has become an important nonpharmacological treatment for COPD. The authors systematically review economic evaluations of PR in COPD patients in different settings.

Methods: A literature search of 8 databases from inception to 23 November 2019. The results were presented in terms of an incremental cost-effectiveness ratio (ICER), and the decision uncertainty was expressed by cost-effectiveness acceptability curves (CEACs). The Consensus on Health Economic Criteria was used to assess study quality.

Results: 10 studies that matched the selection criteria were included. 5 studies compared PR with usual care in primary healthcare or outpatient departments. 2 studies compared community-based PR with hospital PR or usual care. In the other studies, PR was mainly carried out at home. Compared with usual care, PR was cost-effective in primary healthcare institutions or outpatient departments. According to CEACs, community-based PR had a 50% probability of cost-effectiveness at £30,000/quality-adjusted life year (QALY) compared with hospital PR in the UK. Based on the ICER, community-based PR was “moderately” cost-effective, with a ratio of €32,425/QALY compared with usual care in the Netherlands. Home-based PR was dominant compared with usual care, and tele-rehabilitation was dominant compared with traditional home-based PR.

Conclusions: PR conducted in different settings can potentially be cost-effective, as measured using QALY or the Chronic Respiratory Questionnaire (CRQ).

Lu Y et al (March 2020) Effects of home-based breathing exercises in subjects with COPD[25]

The authors investigated the effects of home-based breathing exercises on pulmonary function, respiratory muscle strength, exercise capacity, dyspnea, and HRQoL in patients with COPD.

METHODS: A literature search for all RCTs involving the use of home-based breathing exercises as an intervention in patients with COPD. Two researchers independently extracted data and assessed the quality of the literature that met the inclusion criteria.

RESULTS: A total of 13 studies were eligible, including998 subjects. The intervention methods consisted of diaphragmatic breathing, yoga breathing, breathing gymnastics, and singing. The meta-analysis showed that, compared with the control group, home-based breathing exercises had significant effects on the percentage of predicted FEV1 (mean difference = 3.26, 95% CI 0.52-5.99, P =.02), FEV1/FVC (mean difference = 2.84, 95% CI 1.04-4.64, P =.002), maximum inspiratory pressures (mean difference = 20.20, 95% CI 11.78- 28.61, P <.001), maximum expiratory pressures (mean difference = 26.35, 95% CI 12.64 to 40.06, P<.001), 6-min walk distance (mean difference = 36.97, 95% CI 25.06-48.89, P <.001), the modified Medical Research Council dyspnea scale (mean difference=-0.80, 95% CI-1.06 to-0.55, P <001), and the St George Respiratory Questionnaire (mean difference=-8.62, 95% CI-13.09 to-4.16, P <.001).

CONCLUSION(S): As an alternative method of home-based pulmonary rehabilitation program, breathing exercises can improve pulmonary function, respiratory muscle strength, exercise capacity, dyspnea, and HRQoL in patients with COPD.

Pekmezaris R et al (Jan 2020) A Telehealth-Delivered Pulmonary Rehabilitation Intervention in Underserved Hispanic and African American Patients With Chronic Obstructive Pulmonary Disease: A Community-Based Participatory Research Approach[26]

Background: Although home telemonitoring (TM) is a promising approach for patients managing their chronic disease, rehabilitation using home TM has not been tested for use with individuals living with COPD residing in underserved communities.

Objective: To analyse qualitative data from focus groups with key stakeholders to ensure the acceptability and usability of the TM COPD intervention.

Methods: We utilised a community-based participatory research (CBPR) approach to adapt a home TM COPD intervention to facilitate acceptability and feasibility in low-income African-American and Hispanic patients. The study engaged community stakeholders in the process of modifying the intervention in the context of 2 community advisory board meetings. Discussions were audio recorded and professionally transcribed and lasted approximately 2 hours each. Structural coding was used to mark responses to topical questions in interview guides.

Results: The authors describe the formative process of a CBPR study aimed at optimizing telehealth utilization among African American and Latino patients with COPD from underserved communities. A total of 5 major themes emerged from qualitative analyses of community discussions: equipment changes; recruitment process; study logistics; self-efficacy; and access. The identification of themes was instrumental in understanding the concerns of patients and other stakeholders in adapting the PR home-based intervention for acceptability among patients with COPD from underserved communities.

Conclusions: These findings identify important adaptation recommendations from the stakeholder perspective that should be considered when implementing in-home PR via TM for underserved COPD patients.

Rutkowski S et al (Jan 2020) Virtual Reality Rehabilitation in Patients with Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial[27]

Purpose: To compare the effects of inpatient-based rehabilitation program of patients with COPD using non-immersive virtual reality (VR) training with a traditional pulmonary rehabilitation program.

OBJECTIVES: To determine: 1. whether rehabilitation featuring both VR as well as exercise training provides benefits over exercise training (ET) alone; and 2. whether rehabilitation featuring VR training instead of exercise training provides equivalent benefits.

Patients and methods: The study recruited 106 patients with COPD to a 2-week high-intensity, 5 times per week intervention. Randomized into three groups; 34 patients participated in a traditional pulmonary rehabilitation program including endurance exercise training (ET); 38 patients participated in traditional pulmonary rehabilitation, including both endurance exercise training and virtual reality training (ET+VR); and 34 patients participated in pulmonary rehabilitation program including virtual reality training but no endurance exercise training (VR). The traditional pulmonary rehabilitation program consisted of fitness exercises, resistance respiratory muscle and relaxation training. Xbox 360® and Kinect® Adventures were used for the VR training of lower and upper body strength, endurance, trunk control and dynamic balance. Comparison of the changes in the Senior Fitness Test was the primary outcome. Analysis was performed using linear mixed-effects models.

Results: The comparison between ET and ET+VR groups showed that ET+VR group was superior to ET group in Arm Curl (p<0.003), Chair stand (p<0.008), Back scratch (p<0.002), Chair sit and reach (p<0.001), Up and go (p<0.000), 6-min walk test (p<0.011). The comparison between ET and VR groups showed that VR group was superior to ET group in Arm Curl (p<0.000), Chair stand (p<0.001), 6-min walk test (p<0.031).

Conclusion: Results suggest that a pulmonary rehabilitation program supplemented with VR training is a beneficial intervention to improve physical fitness in patients with COPD.

Santos CD et al (2020) Novel Input for Designing Patient-Tailored Pulmonary Rehabilitation: Telemonitoring Physical Activity as a Vital Sign-SMARTREAB Study[28] 

Physical inactivity may be a consequence of chronic diseases but also a potential modifiable risk factor. Therefore, it should be clinically assessed as a vital sign of patients’ general physical condition prior to any exercise-based intervention. This cross-sectional study describes physical activity in the daily life of 100 chronic respiratory patients before pulmonary rehabilitation, comparing subjective and objective measures. The assessment combined the International Physical Activity Questionnaire (IPAQ) and 4-day accelerometer and oximeter telemonitoring with SMARTREAB technology, assessing heart rate, transcutaneous oxygen saturation and activity-related energy expenditure by metabolic equivalent of task (MET). According to IPAQ, 49% of patients had a moderate level of physical activity in daily life (PADL), a weekly mean level of 2844 ± 2925 MET.min/week, and a mean sedentary time of 5.8 ± 2.7 h/day. Alongside this, SMARTREAB telemonitoring assessed maximum activity ranging from 1.51 to 4.64 METs, with 99.6% daytime spent on PADL below 3 METs and 93% of patients with daily desaturation episodes. Regardless of the self-reported IPAQ, patients spend at least 70% of daytime on PADL below 2 METs. SMARTREAB was demonstrated to be an innovative methodology to measure PADL as a vital sign, combining oximetry with accelerometry, crossmatched with qualitative patient data, providing important input for designing patient-tailored pulmonary rehabilitation.

Stamenova V et al (July 2020) Technology-Enabled Self-Management of Chronic Obstructive Pulmonary Disease With or Without Asynchronous Remote Monitoring: Randomized Controlled Trial[29]

Background:  COPD is a leading cause of mortality and leads to frequent hospital admissions and emergency department (ED) visits. COPD exacerbations are an important patient outcome, and reducing their frequency would result in significant cost savings. Remote monitoring and self-monitoring could both help patients manage their symptoms and reduce the frequency of exacerbations, but they have different resource implications and have not been directly compared.

Objective: To compare the effectiveness of implementing a technology-enabled self-monitoring program versus a technology-enabled remote monitoring program in patients with COPD compared with a standard care group.

Methods: We conducted a 3-arm RCT evaluating the effectiveness of a remote monitoring and a self-monitoring program relative to standard care. Patients with COPD were recruited from outpatient clinics and a pulmonary rehabilitation program. Patients in both interventions used a Bluetooth-enabled device kit to monitor oxygen saturation, blood pressure, temperature, weight, and symptoms, but only patients in the remote monitoring group were monitored by a respiratory therapist. All patients were assessed at baseline and at 3 and 6 months after program initiation. Outcomes included self-management skills, as measured by the Partners in Health (PIH) Scale; patient symptoms measured with the St George’s Respiratory Questionnaire (SGRQ); and the Bristol COPD Knowledge Questionnaire (BCKQ). Patients were also asked to self-report on health system use, and data on health use were collected from the hospital.

Results: A total of 122 patients participated in the study: 40 in the standard care, 41 in the self-monitoring, and 41 in the remote monitoring groups. Although all 3 groups improved in PIH scores, BCKQ scores, and SGRQ impact scores, there were no significant differences among any of the groups. No effects were observed on the SGRQ activity or symptom scores or on hospitalizations, ED visits, or clinic visits.

Conclusions: Despite regular use of the technology, patients with COPD assigned to remote monitoring or self-monitoring did not have any improvement in patient outcomes such as self-management skills, knowledge, or symptoms, or in healthcare use compared with each other or with a standard care group. Results may be explained by low healthcare use at baseline, the lack of structured educational components in the intervention groups, and the lack of integration of the action plan with the technology.

Schachner T et al (Sept 2020) Artificial Intelligence-Based Conversational Agents for Chronic Conditions: Systematic Literature Review[30]

Background: A rising number of conversational agents or chatbots are equipped with artificial intelligence (AI) architecture. They are increasingly prevalent in healthcare applications such as those providing education and support to patients with chronic diseases, one of the leading causes of death in the 21st century. AI-based chatbots enable more effective and frequent interactions with such patients.

Objective: To review the characteristics, healthcare conditions, and AI architectures of AI-based conversational agents designed specifically for chronic diseases.

Methods: A systematic literature review using PubMed MEDLINE, EMBASE, PyscInfo, CINAHL, ACM Digital Library, ScienceDirect, and Web of Science. Included primary research studies involved the prevention, treatment or rehabilitation of chronic diseases, involved a conversational agent, and included any mode of AI architecture. Two independent reviewers conducted screening and data extraction, and Cohen kappa was used to measure interrater agreement. A narrative approach was applied for data synthesis.

Results: The literature search found 2052 studies. 10 studies met the inclusion criteria. The small number of identified studies together with the prevalence of quasi-experimental studies (n=7) and prevailing prototype nature of the chatbots (n=7) revealed the immaturity of the field. The reported chatbots addressed a broad variety of chronic diseases (n=6), showcasing a tendency to develop specialized conversational agents for individual chronic conditions. However, there is a deficit of comparison of these chatbots within and between chronic diseases. In addition, the reported evaluation measures were not standardized, and the addressed health goals showed a large range. Together, these study characteristics complicated comparability and open room for future research. While natural language processing represented the most used AI technique (n=7) and the majority of conversational agents allowed for multimodal interaction (n=6), the identified studies demonstrated broad heterogeneity, lack of depth of reported AI techniques and systems, and inconsistent usage of taxonomy of the underlying AI software, further aggravating comparability and generalizability of study results.

Conclusions: The literature on AI-based conversational agents for chronic conditions is scarce and mostly consists of quasi-experimental studies with chatbots in prototype stage that use natural language processing and allow for multimodal user interaction. Future research may profit from evidence-based evaluation of the AI-based conversational agents and comparison within and between different chronic health conditions. The quality of chatbots developed for specific chronic conditions and their subsequent impact on the target patients could be enhanced by more structured development and standardized evaluation processes.

Velayati F et al (May 2020) A Systematic Review of the Effectiveness of Telerehabilitation Interventions for Therapeutic Purposes in the Elderly[31]

Background: Many elderly people suffer from chronic health conditions and mobility limitations. Therefore, they may benefit from traditional rehabilitation or telerehabilitation interventions as an alternative for this type of services.

Objective: To compare the effectiveness of telerehabilitation interventions with traditional rehabilitation services for therapeutic purposes in the elderly.

Methods: A systematic review conducted in 2018. Selected papers included RCT studies in which elderly people aged 60 and over used telerehabilitation services for treatment purposes. The quality of the studies was evaluated by using the physiotherapy evidence database (PEDro) scale. Data were extracted by using a data extraction form and findings were narratively synthesized.

Results: 8 studies were selected for inclusion. According to the findings, telerehabilitation was used for the elderly after stroke, COPD, total knee replacement, and in patients with the comorbidity of COPD and chronic heart failure. In most studies, there was no significant difference between the intervention and control groups and the level of improvements was similar for most outcomes.

Conclusion: Telerehabilitation services can be regarded as an alternative to traditional rehabilitation approaches to reduce outpatient resource utilization and improve QoL. However, more rigorous studies are suggested to investigate the effectiveness of telerehabilitation services for specific diseases or health conditions.

Wang YQ et al (May 2020) Active Video Games as an Adjunct to Pulmonary Rehabilitation of Patients With Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis[32]

Objective: To investigate the effectiveness of active video games as an adjunct to pulmonary rehabilitation for patients with COPD.

Design: All entries to the following databases were searched up until April 3, 2019: PubMed, Embase Ovid, the Cochrane Central Register of Randomized Controlled Trials, Web of Science, Wanfang, Weipu, and the Chinese National Knowledge Infrastructure.

Results: A total of 7 articles ¾ 3 RCTs and 4 quasi-experimental studies ¾ with 249 patients were included. Active video games can increase the 6-min walk distance by 30.9 meters on average. 4 studies assessed QoL and showed significant improvement. 4 studies have reported that patients with chronic obstructive pulmonary disease found active video games to be enjoyable. Patient adherence was assessed in 2 studies and showed high adherence with active video games. No adverse events related to active video games were reported.

Conclusions: Active video games as an adjunct to pulmonary rehabilitation of patients with COPD may prove to be useful and enjoyable.

Zhang A et al (May 2020) Effectiveness and Economic Evaluation of Hospital-Outreach Pulmonary Rehabilitation for Patients with Chronic Obstructive Pulmonary Disease[33]

Objective: Hospital-outreach pulmonary rehabilitation (PR) can improve health status and reduce health-care utilization by patients with COPD. However, its long-term effects and costs versus benefits are still not clear. This study was conducted to develop, deliver, and evaluate the effects and monetary savings of a hospital-outreach PR program for patients with COPD.

Methods: An RCT was conducted. Patients with COPD (n=208) were randomly assigned to the hospital-outreach PR program (treatment) or treatment as usual (control). The treatment group received a 3-month intensive intervention, including supervised physical exercise, smoking cessation, self-management education, and psychosocial support, followed by long-term access to a nurse through telephone follow-up and home visits up to 24 months. The control group received routine care, including discharge education and a self-management education brochure. Main outcomes were collected at 3, 6, 12, and 24-months post randomization. Primary outcomes included health-care utilization and medical costs. Secondary outcomes included lung function (FEV1, FEV1% predicted, FVC), dyspnea (mMCR), exercise capacity (6MWD), impact on quality of life (CAT), and self-management (CSMS).

Results: At the end of 24 months, 85 (81.7%) in the treatment group and 89 (85.6%) in the control group had completed the whole program. Compared with the control group, patients in the treatment group had lower readmission rates, times and days at 6 and 12 months and during 12-24 months. Regarding costs during the 2 years, the program achieved CN¥3,655.94 medical savings per patient per year, and every ¥1 spent on the program led to ¥3.29 in savings. Patients in the treatment group achieved improvements in FEV1, FEV1% predicted, exercise capacity, and self-management. It also achieved relief of dyspnea symptoms and improvement in COPD’s impact on quality of life.

Conclusion: The hospital-outreach PR program for patients with COPD achieved reductions in health-care utilization, monetary savings, and improvements in patient health outcomes. The effects of the program were sustained for at least 2 years.

Other

Mishlanov V et al (2020) COPD patient tele-monitoring using interactive questionnaires and electronic patient record[34]

[Abstract presented at the 2020 ERS International Congress in the session Respiratory Viruses in the “pre COVID-19” Era]

The aim of the prospective study is to evaluate the effectiveness of two methods of COPD patient monitoring: 1. traditional, based on mMRC scale, exacerbation frequencies registration, and spirometry tests; and 2. a new method, which differs by adding interactive questioning and television sessions with the pulmonologist. Results showed that the new method increased motivation among COPD  and resulted in active therapeutic program modifications in accordance with patient status.

Holmedahl NH et al (2020). Feasibility of digital long term follow up after pulmonary rehabilitation in patients with COPD: a pilot study[35]

[Abstract presented at the 2020 ERS International Congress in the session Respiratory Viruses in the “pre COVID-19” Era]  

Background: Pulmonary rehabilitation (PR) has well known positive effects on quality of life and physical performance in patients with COPD. PR is organized in different ways. Although all PR-programs aim for sustained long-term effects, the beneficial effects tend to diminish with time. Digital collection of patient reported outcomes (PROMS) may be a feasible method to follow up effects after PR.
Aim(s): To evaluate the feasibility of collecting data through an online digital solution assessing the effects of a 4-week inpatient interdisciplinary PR-program before, after and 6 months after PR in patients with COPD (T0, T1 and T2).
Method(s): Patients admitted to PR received an online assessment at T0, T1 and T2. The patients logged on to a secure eHealth solution to report data on PROMS (EQ5D, CAT and HADS) and smoking habits. Background characteristics were extracted from the medical records.
Result(s): 158 patients (FEV1%pred 43 (17)%) were included. 97%, 81% and 58% answered the questionnaires at T0, T1 and T2 resp. EQ5D-VAS increased from T0 (42,7 (17,5) to T1 55,7 (19,3), p<0,001) and remained increased at T2 (50,0 (18,9)). CAT-score decreased from T0 to T1 (21,9 (6,8) to 18,2 (7,0) p<0,001) and remained decreased at T2 (19,8 (7,3)). HADS-anxiety decreased from T0 to T1 (7,5 (3,6) to 6,3 (3,5), p<0,001), and were at T2 7,0 (4,0). At T0, 31 (19,6%) of the patients were smokers. 23 patients (74,2%) quit smoking during PR and 88% of them remained non-smokers after 6 months.
Conclusion(s): A high proportion of patients with COPD answered the digital questionnaires. Our data shows that the positive effects of an inpatient PR-program persist 6 months after PR.

De Las Heras JC et al (2020) Is Virtual Autonomous Physiotherapist Tele-rehabilitation Program in Chronic Obstructive Pulmonary Disease equal to Hospital-Based Pulmonary Rehabilitation?[36]

[Abstract was presented at the 2020 ERS International Congress, in session Respiratory Viruses in the “pre COVID-19” Era] Background: Tele-rehabilitation (TR) may be as effective as hospital based pulmonary rehabilitation (PR) for Chronic Obstructive Pulmonary Disease (COPD), but there is still a need for feasibility and efficacy studies.

Method(s): Single-center, prospective, non-inferiority, 2 arms, 1:1 randomized study including stable patients with COPD for 8 weeks (W) of tele-rehabilitation: video and chat-consultations with a real physiotherapist and workout sessions with a virtual autonomous physiotherapist agent (VAPA). Exercise capacity was evaluated with 6-minute-walk-test (6MWT) at baseline, 8W, 3 and 6 months (M) follow up. Control patients received standard hospital-based PR (HBPR). Mean differences in 6MWT between groups and 95% confidence interval of the differences were estimated. The difference margin acceptable for this study was 35 meters and quantifies the maximum efficiency loss clinically acceptable to the treatment to be declared non-inferior to the control.

Result(s): In total, 54 patients (age 69.2+/-9.5 years, male 73.8%, FEV1% 34.91+/-12.12, FVC% 68.72+/-18.42, 6MWT 377.80+/-94.42) were included. 6MWT non-inferiority test at 8W, 3 and 6M is shown.
Conclusion(s): TR with VAPA is feasible and non-inferior to HBPR after 8W, 3 and 6M follow up in exercise capacity for COPD.

Assaf S (2020) Moving pulmonary rehabilitation into home: a veterans hospital administration initiative to develop a home-based pulmonary rehabilitation progam[37]  

[CHEST 2020 Annual Meeting Abstracts]

Pulmonary rehabilitation (PR) is a proven comprehensive and multidisciplinary therapeutic strategy to improve healthcare related quality of life (HRQOL) and healthcare utilization in patients with COPD. However, there are multiple barriers to PR including insufficient capacity, lack of access, patient inconvenience and cost. Creative solutions to increase the availability and access of PR are necessary. The authors present a quality improvement project to examine the feasibility and effectiveness of PR delivered via telehealth through a home-bound PR program (HBPR) at a veteran’s affairs medical center.

METHODS: A HBPR was designed and involved real-time 12-week interactive rehabilitation sessions with a pulmonologist, a physical therapist and a respiratory therapist. Baseline characteristics of 20 participants enrolled in the pilot study were collected between December 2019 and January 2020. Pre-program and post program assessments were performed. The primary outcome measure was the change in quality of life as evaluated by the St George’s Respiratory Questionnaire (SGRQ). Other outcomes included changes in functional ability, depression severity scales as well as utilization of healthcare services,

RESULTS: The mean age of participants in our study was 71 years. The mean FEV1 % predicted was 46.4+/-14.9. About 62% of enrolled patients had advanced COPD defined as GOLD stage D. HBPR resulted in clinically and statistically significant improvements in SGRQ scores (27.7+/-13.5, P<0.05). Similarly, improvements were noted in the patient health questionnaire-9 (PHQ-9) and Duke activity status index (DASI) scores as well as BODE indices. A trend toward reduced healthcare utilization was observed but was underpowered to indicate clinical significance. The dropout rate was 21% and the overall satisfaction score with this new modality was high.
CONCLUSION(S): HBPR was an effective tool for increasing access to COPD PR services and demonstrated improvements in QoL measures. The low dropout rate indicates that it is feasible to use even in an elderly population if familiarization to the connection process and technical preparation are well explained.

CLINICAL IMPLICATIONS:

  1. HBPR offers a potential for convenience and greater accessibility of PR
  2. Older population did not seem to be psychologically disconnected from the concept of e- health
  3. Promising results on statistical and clinical significance of the effectiveness of HBPR in HRQOL (dyspnea, exercise capacity)
  4. Healthcare utilization reduction was noted but higher sample size needed to further comment
  5. Dropout rate relatively low indicating the feasibility of administering the program

Tort S, Burch J (July 2020) [Cochrane Clinical Answers] Do smart technology interventions facilitate self‐management for people with chronic obstructive pulmonary disease (COPD)?[38]

For people with COPD, low‐certainty evidence suggests that compared with usual care smart technology interventions may lead to increased physical activity ¾ on average, by 864 steps/d ¾ and a small improvement in quality of life. Evidence for the impact of smart technology interventions on other outcomes is absent or derives from underpowered trials that yield imprecise results.

Canadian Thoracic Society (2020) [Website] Pulmonary rehabilitation during COVID-19[39] Includes a series of exercise programme videos and information for healthcare professionals and patients


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Produced by the members of the National Health Library and Knowledge Service Evidence Team. Current as at 30 October 2020. This evidence summary collates the best available evidence at the time of writing and does not replace clinical judgement or guidance. Emerging literature or subsequent developments in respect of COVID-19 may require amendment to the information or sources listed in the document. Although all reasonable care has been taken in the compilation of content, the National Health Library and Knowledge Service Evidence Team makes no representations or warranties expressed or implied as to the accuracy or suitability of the information or sources listed in the document. This evidence summary is the property of the National Health Library and Knowledge Service and subsequent re-use or distribution in whole or in part should include acknowledgement of the service.

Marie Carrigan, Librarian, St. Luke’s Radiation Oncology Network [Author; Editor]; Sinead O’Neill, Health Services Researcher (HRB-CICER), Health Information and Quality Authority [Editor]; Brendan Leen, Area Library Manager, HSE South [Editor]

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