How does using technology to deliver pulmonary rehabilitation (PR) compare to centre-based PR, or no PR in people with chronic lung disease?

Background

For people with chronic lung conditions, pulmonary rehabilitation is proven to improve physical functioning and general well-being, and to reduce symptoms, particularly breathlessness. Pulmonary rehabilitation is a program of exercise training and education that is traditionally offered as an in-person program at a healthcare facility such as a hospital, where people attend program appointments but are not hospitalised overnight. To make it easier for more people to access pulmonary rehabilitation, new ways of delivering programs using technology have been investigated. Pulmonary rehabilitation delivered using technology is known as telerehabilitation. Telerehabilitation models can include (but are not limited to) talking with a health professional and/or other patients on the telephone, using a website or mobile application, or via video-conferencing. In some circumstances, undertaking telerehabilitation may require patients to have access to their own device (e.g. telephone, smart phone, tablet or computer) in order to participate.

Study characteristics

This review included 15 studies involving 1904 people with chronic lung disease, the majority (99%) of whom had chronic obstructive pulmonary disease (COPD). The studies described a variety of different ways to use technology to deliver pulmonary rehabilitation including over the telephone, using mobile phone applications, via video-conferencing in a virtual group and through the use of websites. The studies of telerehabilitation were collectively compared to traditional in-person PR, or to no rehabilitation. The variety of technology used, as well as differing levels of support from health professionals in the different studies, makes it difficult to determine if there is one best type of technology, amount of assistance or place to which to deliver a telerehabilitation program.

Key results

Across multiple studies using different types of technology to deliver pulmonary rehabilitation, telerehabilitation probably produces similar results to the traditional in-person outpatient pulmonary rehabilitation programs. Telerehabilitation may help people walk further when compared to no rehabilitation, but we have low certainty in these results. People were more likely to finish a full program of telerehabilitation compared to traditional pulmonary rehabilitation (93% compared to 70% completion). Very few of the studies followed people up after the intervention was finished, so it is difficult to say what the long-term effect is of telerehabilitation.

Certainty of the evidence

The certainty of evidence (our confidence that the statistical effect estimates are correct) was generally low, because the number of studies, patients, and lung conditions in which telerehabilitation was studied is small. This means these results may not apply to all people with chronic lung disease or to all types of technology used to deliver pulmonary rehabilitation.

Authors' conclusions: 

This review suggests that primary pulmonary rehabilitation, or maintenance rehabilitation, delivered via telerehabilitation for people with chronic respiratory disease achieves outcomes similar to those of traditional centre-based pulmonary rehabilitation, with no safety issues identified. However, the certainty of the evidence provided by this review is limited by the small number of studies, of varying telerehabilitation models, with relatively few participants. Future research should consider the clinical effect of telerehabilitation for individuals with chronic respiratory diseases other than COPD, the duration of benefit of telerehabilitation beyond the period of the intervention, and the economic cost of telerehabilitation.

Read the full abstract...
Background: 

Pulmonary rehabilitation is a proven, effective intervention for people with chronic respiratory diseases including chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD) and bronchiectasis. However, relatively few people attend or complete a program, due to factors including a lack of programs, issues associated with travel and transport, and other health issues. Traditionally, pulmonary rehabilitation is delivered in-person on an outpatient basis at a hospital or other healthcare facility (referred to as centre-based pulmonary rehabilitation). Newer, alternative modes of pulmonary rehabilitation delivery include home-based models and the use of telehealth.

Telerehabilitation is the delivery of rehabilitation services at a distance, using information and communication technology. To date, there has not been a comprehensive assessment of the clinical efficacy or safety of telerehabilitation, or its ability to improve uptake and access to rehabilitation services, for people with chronic respiratory disease.

Objectives: 

To determine the effectiveness and safety of telerehabilitation for people with chronic respiratory disease.

Search strategy: 

We searched the Cochrane Airways Trials Register, and the Cochrane Central Register of Controlled Trials; six databases including MEDLINE and Embase; and three trials registries, up to 30 November 2020. We checked reference lists of all included studies for additional references, and handsearched relevant respiratory journals and meeting abstracts.

Selection criteria: 

All randomised controlled trials and controlled clinical trials of telerehabilitation for the delivery of pulmonary rehabilitation were eligible for inclusion. The telerehabilitation intervention was required to include exercise training, with at least 50% of the rehabilitation intervention being delivered by telerehabilitation.

Data collection and analysis: 

We used standard methods recommended by Cochrane. We assessed the risk of bias for all studies, and used the ROBINS-I tool to assess bias in non-randomised controlled clinical trials. We assessed the certainty of evidence with GRADE. Comparisons were telerehabilitation compared to traditional in-person (centre-based) pulmonary rehabilitation, and telerehabilitation compared to no rehabilitation. We analysed studies of telerehabilitation for maintenance rehabilitation separately from trials of telerehabilitation for initial primary pulmonary rehabilitation.

Main results: 

We included a total of 15 studies (32 reports) with 1904 participants, using five different models of telerehabilitation. Almost all (99%) participants had chronic obstructive pulmonary disease (COPD). Three studies were controlled clinical trials. For primary pulmonary rehabilitation, there was probably little or no difference between telerehabilitation and in-person pulmonary rehabilitation for exercise capacity measured as 6-Minute Walking Distance (6MWD) (mean difference (MD) 0.06 metres (m), 95% confidence interval (CI) -10.82 m to 10.94 m; 556 participants; four studies; moderate-certainty evidence). There may also be little or no difference for quality of life measured with the St George's Respiratory Questionnaire (SGRQ) total score (MD -1.26, 95% CI -3.97 to 1.45; 274 participants; two studies; low-certainty evidence), or for breathlessness on the Chronic Respiratory Questionnaire (CRQ) dyspnoea domain score (MD 0.13, 95% CI -0.13 to 0.40; 426 participants; three studies; low-certainty evidence). Participants were more likely to complete a program of telerehabilitation, with a 93% completion rate (95% CI 90% to 96%), compared to a 70% completion rate for in-person rehabilitation. When compared to no rehabilitation control, trials of primary telerehabilitation may increase exercise capacity on 6MWD (MD 22.17 m, 95% CI -38.89 m to 83.23 m; 94 participants; two studies; low-certainty evidence) and may also increase 6MWD when delivered as maintenance rehabilitation (MD 78.1 m, 95% CI 49.6 m to 106.6 m; 209 participants; two studies; low-certainty evidence). No adverse effects of telerehabilitation were noted over and above any reported for in-person rehabilitation or no rehabilitation.

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