Anne E Holland and Narelle S Cox

Although there is no doubt that pulmonary rehabilitation is highly effective, there are many people with chronic lung disease who never complete a program. Travel, transport and location are consistently identified as barriers to uptake and completion of pulmonary rehabilitation.(1) Over the last few years there has been increasing interest in alternative delivery methods, including use of technology to reach patients who would not otherwise be able to participate.

Telerehabilitation refers to the delivery of rehabilitation services via information and communication technologies. This may include patient assessment, goal setting, supervision of exercise training, delivery of education and self-management training, monitoring of physiological signals and peer support. A wide variety of telerehabilitation models are being tested in people with chronic lung disease, with growing numbers of randomised controlled trials (RCTs), most of which have suggested benefits. These models can be broadly classified as:

Center-based telerehabilitation – linking a larger/expert center to one or more smaller centers, to support delivery of pulmonary rehabilitation at a remote site. A Canadian model uses videoconferencing to support local health professionals at remote sites to deliver effective exercise training, and to deliver a multidisciplinary education program from the central site. A non- randomised clinical trial involving over 400 patients with COPD showed that those at the telerehabilitation sites had equivalent improvements in exercise capacity and quality of life when compared to those who undertook a standard center-based program.(2)

Home-based telerehabilitation – patients undergo supervised rehabilitation in their own homes, often using videoconferencing and sometimes using telemonitoring of physiological signals like oxyhaemoglobin saturation and pulse rate. A RCT of supervised group exercise training using videoconferencing showed significant gains in endurance walking capacity compared to usual care, although quality of life benefits were smaller than anticipated.(3) This program model included provision of an exercise bike in the home. Home-based telerehabilitation may also be useful as a maintenance strategy following completion of pulmonary rehabilitation,(4) although it may be no more effective than a hospital-based program.(5)

Web-based telerehabilitation – mobile phone and web applications may allow pulmonary rehabilitation to take place anywhere. Two recent RCTs, testing different platforms, have reported that online pulmonary rehabilitation had similar benefits to center-based pulmonary rehabilitation program in people with COPD.(6, 7) One study used online exercise and education videos(6) and the other used an online workbook.(7) Participants in both trials were already familiar with the internet.

These trials of telerehabilitation show promising results, however it is early days. No data on cost- effectiveness are yet available and some models are likely to be expensive, which will affect uptake. We hope that a telerehabilitation trial we are conducting in Australia will provide cost-effectiveness data soon.(8) Patients excluded from recent trials include those on home oxygen,(3) those who desaturate on exertion (6) and those without existing internet access. (6, 7) The ‘best’ model of telerehabilitation is not known and it is likely that this will vary according to the setting, available resources and patient needs. A recent study reported that 60% of pulmonary rehabilitation participants would be willing to undertake telerehabilitation;(9) this percentage is likely to increase over time, as older people become increasingly connected.

Telerehabilitation for chronic lung disease is an attractive proposition, because we have an intervention of known effectiveness (pulmonary rehabilitation) that can be delivered in new ways, allowing more people to experience its benefits. The technology provides the vehicle for delivery of evidence-based care and is not an end in itself. Successful telerehabilitation models are multidimensional, delivering all the essential components of pulmonary rehabilitation including exercise, education and support. (3, 6, 7) Models that have been adopted in clinical practice use simple technology,(2, 3) reducing the requirement for IT support. Sustainable funding for telerehabilitation models will need to be considered if wider uptake is to be achieved.

Patient interacting with physiotherapist via zoom

Group session of telerehabilitation

Patients interacting with each other via zoom

References

1. Cox NS, Oliveira CC, Lahham A, Holland AE. Pulmonary rehabilitation referral and participation are commonly influenced by environment, knowledge, and beliefs about consequences: a systematic review using the Theoretical Domains Framework. Journal of Physiotherapy. 2017;63(2):84-93.

2. Stickland M, Jourdain T, Wong EY, Rodgers WM, Jendzjowsky NG, Macdonald GF. Using Telehealth technology to deliver pulmonary rehabilitation in chronic obstructive pulmonary disease patients. Canadian Respiratory Journal. 2011;18(4):216-20.

3. Tsai LL, McNamara RJ, Moddel C, Alison JA, McKenzie DK, McKeough ZJ. Home-based telerehabilitation via real-time videoconferencing improves endurance exercise capacity in patients with COPD: The randomized controlled TeleR Study. Respirology. 2017;22(4):699-707.

4. Bernocchi P, Vitacca M, La Rovere MT, Volterrani M, Galli T, Baratti D, et al. Home-based telerehabilitation in older patients with chronic obstructive pulmonary disease and heart failure: a randomised controlled trial. Age Ageing. 2018;47(1):82-8.

5. Vasilopoulou M, Papaioannou AI, Kaltsakas G, Louvaris Z, Chynkiamis N, Spetsioti S, et al. Home-based maintenance tele-rehabilitation reduces the risk for acute exacerbations of COPD, hospitalisations and emergency department visits. Eur Respir J. 2017;49: 1602129.

6. Bourne S, DeVos R, North M, Chauhan A, Green B, Brown T, et al. Online versus face-to-face pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: randomised controlled trial. BMJ Open. 2017;7(7):e014580.

7. Chaplin E, Hewitt S, Apps L, Bankart J, Pulikottil-Jacob R, Boyce S, et al. Interactive web- based pulmonary rehabilitation programme: a randomised controlled feasibility trial. BMJ Open. 2017;7(3):e013682.

8. Cox NS, McDonald CF, Alison JA, Mahal A, Wootton R, Hill CJ, et al. Telerehabilitation versus traditional centre-based pulmonary rehabilitation for people with chronic respiratory disease: protocol for a randomised controlled trial. BMC Pulmonary Medicine. 2018;18(1):71.

9. Seidman Z, McNamara R, Wootton S, Leung R, Spencer L, Dale M, et al. People attending pulmonary rehabilitation demonstrate a substantial engagement with technology and willingness to use telerehabilitation: a survey Journal of Physiotherapy. 2017;63(3):175-81.