Reporting of exercise attendance rates for people with chronic obstructive pulmonary disease: a systematic review

Adherence to exercise intervention for community-dwelling older adults with sarcopenia: a systematic review and meta-analysis

BACKGROUND

Exercise is a highly recommended nonpharmacological intervention for older adults with sarcopenia. Poor exercise adherence is a main factor affecting treatment efficacy. However, evidence for overall adherence to exercise and intervention characteristics affecting adherence in this population remains unknown.

OBJECTIVE

To determine whether community-dwelling older adults with sarcopenia adhere to exercise programmes, what intervention components are used to improve adherence and how adherence relates to intervention characteristics and efficacy.

METHODS

Seven electronic databases and relevant systematic reviews were searched to identify randomised controlled trials (RCTs). The capability, opportunity, motivation and behaviour model with behaviour change techniques (BCTs) were used to categorise adherence intervention components. Random-effects meta-analysis and meta-regression analyses were employed.

RESULTS

Seventeen RCTs with 2975 participants were included in this review. The pooled estimate of adherence rates for exercise interventions amongst older adults with sarcopenia was 85% (95% CI: 0.79-0.89, range: 71%-100%). Nine BCTs were identified from the included studies. Exercise with programme durations (<24 weeks) (P = 0.01) might be associated with higher adherence rates compared with programme durations (≥24 weeks). However, exercise adherence was not associated with intervention efficacy.

CONCLUSION

Adherence to exercise interventions in community-dwelling older adults with sarcopenia is relatively high and may be affected by programme duration. Most studies incorporated only a small number of BCTs into their exercise interventions. Such an approach may be insufficient to enhance adherence in this population effectively. Future studies with theory-informed interventions to improve adherence in the field of exercise for older people with sarcopenia are needed.

Cumulative Dispensing of Oral Corticosteroids Over 12 Months in People with COPD

Purpose

Oral corticosteroids (OCS) are recommended for the treatment of exacerbations in people with COPD; however, high cumulative lifetime doses (≥1000mg prednisolone-equivalent) are associated with adverse health effects. This issue is well defined in asthma but is less well understood in COPD. The aim of this study was to examine cumulative OCS dispensed to people with COPD over 12 months.

Patients and Methods

This was a secondary analysis of data from two randomised controlled trials involving people with COPD followed up for 12 months following pulmonary rehabilitation. Clinical and administrative (respiratory-related hospital admissions and emergency presentations, dispensed OCS and COPD maintenance medications) data were examined to determine cumulative OCS dose relative to the 1000mg threshold and the relationship with clinical features.

Results

Of 232 participants (126 females, age mean 68 ± SD 9 years, FEV1 53 ± 22% predicted), 48% (n = 112) were dispensed OCS at least once over 12 months. Sixty-two participants (26%) were dispensed ≥1000mg. Participants with a high cumulative dose were more likely to have had a respiratory admission (OR 4.1, 95% CI 2.3 to 8.7) and greater breathlessness (modified Medical Research Council scale ≥2, OR 2.5, 95% CI 1.3 to 5.0); no relationship with disease severity or maintenance medications was demonstrated.

Conclusion

One in four people with COPD were dispensed unsafe lifetime cumulative OCS doses over a period of only 12 months. Further work is needed to determine the magnitude of this issue in COPD and strategies to address exposure to high doses of OCS.

What are the hidden shortcomings of balance training research in older adults that prevent its transfer into practice? Scoping review

BACKGROUND

Although a lot of attention is paid to the flaws of balance training research in older adults, the low methodological quality and incomplete reporting of studies still limit the knowledge transfer between research and practice. These known shortcomings are considered also as barriers for creating recommendations for balance training in older adults. Despite the considerable efforts to improve the scientific quality of studies, such recommendations have not yet been formulated to date. Therefore, this scoping review aims (1) to analyze the literature that addresses balance training in older adults, (2) to identify and summarize gaps in the existing literature, and (3) to propose future research on this topic.

METHODS

We focused on studies that evaluated the effect of balance training on balance control in apparently healthy older adults over 60 years of age.

RESULTS

Out of 6910 potentially relevant studies, only 26 met the eligibility criteria. The identified shortcomings were as follows: missing a priori criteria for training session attendance and leisure-time physical activities, insufficiently described exercises and training load, and inappropriately chosen tests.

CONCLUSIONS

Among the shortcomings of the balance training research, the insufficiently described balance training program and inappropriately chosen tests can be considered the most important. For this reason, even with an excellently designed experiment, it is almost impossible for practitioners to apply the results of such studies into practice. Therefore, researchers should pay more attention to possible users of the acquired knowledge, which is more than desirable in the case of exercise programs for older adults.

Occupational therapy in rehabilitation of complex patients: protocol for a superiority randomized controlled trial

Patient-centered, interprofessional occupational therapy is feasible in complex patients in the early phase of rehabilitation, and it contributes to meet needs in the domains of self-care, productivity, and leisure, promoting social role. We planned this single-center single-blind two-arm parallel individual patient randomized controlled trial, to verify the superiority of interprofessional experimental occupational therapy (EOT) compared to standard rehabilitation (SR) in producing higher levels of patients' social participation assessed by the Reintegration to Normal Living Index. EOT is a patient-centered, hospital/home-based rehabilitation intervention based on the Canadian Model of Occupational Performance and Engagement. This appropriately powered study will provide evidence regarding the effectiveness of EOT on the recovery of social participation in the critical transition of complex patients from hospital to the home setting.

Effect of pulmonary rehabilitation duration on exercise capacity and health-related quality of life in people with chronic obstructive pulmonary disease (PuRe Duration Trial): A randomized controlled equivalence trial

BACKGROUND AND OBJECTIVE

There is no strong evidence on the optimal duration of pulmonary rehabilitation (PR) programmes. The aim of the study was to determine whether an 8-week PR programme was equivalent to a 12-week PR programme in improving endurance exercise capacity in people with chronic obstructive pulmonary disease (COPD).

METHODS

Participants with COPD were randomized to either an 8-week (8-wk Group) or 12-week (12-wk Group), twice weekly, supervised PR programme consisting of endurance and strength training and individualized self-management education. Between group comparisons were made at completion of each programme (i.e., week 8 or week 12), for both programmes at week 12, and at 6-12-month follow-up. The primary outcome was endurance exercise capacity measured by the endurance shuttle walk test (ESWT) with the minimally important difference of 186 s set as the equivalence limit.

RESULTS

Sixty-six participants [mean (SD); age 69 (7) years, FEV1 48 (17) %predicted] were randomized (33 per group). Between-group comparisons demonstrated that the ESWT time was equivalent for the 12-wk Group compared to the 8-wk Group at programme completion [mean (95% CI)] [71 s (-61 to 203)], week 12 [70 s (-68 to 208)], and 6-12-month follow-up [93 s (-52 to 239)], though superiority of the 12-wk Group could not be ruled out at each time point.

CONCLUSION

Equivalence was shown between 8-and 12-week PR programmes for endurance exercise capacity, but superiority could not be ruled out for the 12-wk Group. Decisions about programme duration may depend on local waitlist times, healthcare budgets and patient preference.

Telerehabilitation Compared to Center-based Pulmonary Rehabilitation for People with Chronic Respiratory Disease: Economic Analysis of a Randomized, Controlled Clinical Trial

RATIONALE

New pulmonary rehabilitation models can improve access to this effective but underutilised treatment for people with chronic respiratory disease, however cost effectiveness has not been determined.

OBJECTIVE

To compare the cost effectiveness of telerehabilitation, including videoconferencing and synchronous supervision, to standard center-based pulmonary rehabilitation.

METHODS

Prospective economic analyses were undertaken from a societal perspective alongside a randomised controlled equivalence trial in which adults with stable chronic respiratory disease undertook an 8-week outpatient center-based program or telerehabilitation. Clinical assessment for effectiveness (Chronic Respiratory Disease Questionnaire dyspnoea domain [CRQ-D] score) was undertaken at baseline, following pulmonary rehabilitation and 12-month follow-up. Individual-level administrative and self-report healthcare cost data were collected over 12 months following the program (Australian dollars, 2020) Results: There were no between-group differences for effectiveness (CRQ-D MD -0.2 [SE 1.0], p=0.61) or total costs ($565 [5452], p=0.92) over 12 months. On the cost effectiveness plane, 97.4% of estimates fell between the equivalence margins for effectiveness. Application of a range of values for cost margin demonstrated a 95% probability that telerehabilitation was equivalent to center-based pulmonary rehabilitation when the threshold was $11,000. Results were robust to approach, sensitivity and subgroup analyses. The internal rate of return was 134% over 5 years. Program completion (regardless of model) was associated with a significant reduction in total costs in the following 12 months (β $-17,960, 95%CI -29,967 to -5952). Conclusions This study supports delivery of telerehabilitation as a cost-effective alternative model of pulmonary rehabilitation for people with chronic respiratory disease.

A virtual reality-based endurance training program for COPD patients: acceptability and user experience

PURPOSE

To investigate the acceptability and user experience of an in-hospital endurance training program based on the Virtual Park, a semi-immersive Virtual Reality (VR) system for patients with Chronic Obstructive Pulmonary Disease (COPD).Materials and methodsPatients performed 20 min of cycling two times/day for around ten days. The evaluation included adherence, exercise capacity, physical performance, and user experience.

RESULTS

Fourteen patients (6 F/8 M; age = 71.29 ± 6.93 years) with mild/moderate COPD participated. The adherence rate was satisfying: 85.71% of patients attended the program without adverse events; the individual attendance rate (86.85% ± 27.43) was also high. The exercise capacity assessed before and after the training significantly improved in our group (6MWT pre-post: t(11)= -5.040, p < 0.05), as happens in standard PR programs. The physical performance metrics of each session indicate that all participants could sustain the proposed training protocol over the whole period. Patients judged the VR experience positively (User Experience Questionnaire = 1.84 ± 0.22) and were highly engaged in the activity for the whole period (Short Flow State Scale pre-post: 4.61 ± 0.27/4.40 ± 0.36).

CONCLUSIONS

Our preliminary results open the possibility for further investigations on long-term motivation and clinical effectiveness of more immersive VR interventions for COPD.

Supplementation with β-hydroxy-β-methylbutyrate after resistance training in post-acute care patients with sarcopenia: A randomized, double-blind placebo-controlled trial

OBJECTIVES

This study aimed to evaluate the efficacy of adding β-hydroxy-β- methylbutyrate (HMB) supplementation to a 12-week exercise-based rehabilitation program in older adults with sarcopenia after discharge from a post-acute geriatric rehabilitation unit.

STUDY DESIGN

A randomized, double-blind, placebo-controlled trial with two parallel groups. The intervention group received 3 g/day of Ca-HMB and participated in a 12- week resistance training program (3 sessions/week). The control group received a placebo and followed the same training program.

MAIN OUTCOME MEASURES

The primary outcomes were the improvements of handgrip strength and physical performance assessed through the Short Physical Performance Battery (SPPB) and 4-meter gait speed; and handgrip strength. All variables were assessed at baseline, post-intervention, and 1-year follow-up.

RESULTS

After completing the 12-week exercise program, the intervention group showed significant improvements in SPPB-Balance (1.3, 95 %CI 0.3 to 2.4) and total SPPB score (2.2, 95 %CI 0.4 to 4.0). Intra-group analysis demonstrated gains in the SPPB-Chair Stand (0.7 points, 95 %CI 0.0 to 1.4) and total SPPB score (2.1 points, 95 %CI 0.3 to 3.9) in the intervention group. Improvements in handgrip strength were observed in women (3.7 kg, 95 %CI: 0.2 to 7.3) at the end of the intervention, and persisted at the 1-year follow-up.

CONCLUSIONS

Our findings suggest that the supplementation of 3 g/day of Ca-HMB with resistance exercise may significantly enhance muscle strength and physical performance among older women with sarcopenia after recent hospitalization. Given this study's limitations, the intervention's effectiveness cannot be drawn, and further studies are needed.

Participant-selected music listening during pulmonary rehabilitation in people with chronic obstructive pulmonary disease: A randomised controlled trial

To evaluate the impact of participant-selected music listening as an adjunct to pulmonary rehabilitation (PR) in people with COPD. Adults with COPD referred to PR were randomly assigned to participant-selected music listening (intervention group, [IG]) or usual care (control group [CG]) during an 8-weeks PR program. Prior to training, the IG completed an interview with a registered music therapist to identify music preferences. IG participants listened to an individualised playlist; CG participants had usual care. Primary outcomes included end-6-min walk test symptoms (dyspnoea and exertion) and dyspnoea (Multidimensional Dyspnoea Profile [MDP]), measured pre and post PR and 6-months follow-up. 58 participants, FEV1 52.4 (25.9)% pd) were recruited. There were no between-group differences following the intervention (p > .05 for all outcomes at all time points). Within-group differences following PR were significant for MDP sensory quality: IG mean difference [95% CI] -2.2 [-3.3 to -1.2]; CG -1.5 [-2.5 to -0.5] points; MDP emotional response: IG -3.2 [-4.2 to -2.3]; CG -2.2 [-3.2 to -1.3] points). Participant-selected music listening during PR offered no greater benefit to symptoms of dyspnoea or exertion compared to usual care. With the study limited by COVID-19 restrictions, the role of this adjunct remains to be clarified.

The Impact of Patient Preference on Attendance and Completion Rates at Centre-Based and mHealth Pulmonary Rehabilitation: A Non-Inferiority Pragmatic Clinical Trial

Purpose

Pulmonary rehabilitation (PR) is vital in the management of chronic respiratory disorders (CRDs) although uptake, attendance and completion are poor. Differing models of delivering PR are emerging in an attempt to increase the uptake and completion of this intervention. This study aimed to evaluate participant rate of attendance and completion of PR when given a preference regarding model of delivery (centre-based and mPR). Secondary aims were to evaluate the factors affecting patient preference for model of delivery and determine whether mPR is non-inferior to centre-based PR in health outcomes.

Methods

A multi-centre non-inferiority preference based clinical trial in Auckland, New Zealand. Participants with a CRD referred for PR were offered the choice of centre-based or mHealth PR (mPR). The primary outcome was completion rate of chosen intervention.

Results

A total of 105 participants were recruited to the study with 67 (64%) preferring centre-based and 38 (36%) mPR. The odds of completing the PR programme were higher in the centre-based group compared to mPR (odds ratio 1.90 95% CI [0.83-4.35]). Participants opting for mPR were significantly younger (p = 0.002) and significantly more likely to be working (p = 0.0001). Results showed that mPR was not inferior to centre-based regarding changes in symptom scores (CAT) or time spent in sedentary behaviour (SBQ). When services were forced to transition to telehealth services during COVID-19 restrictions, the attendance and completion rates were higher with telephone calls and video conferencing compared to mPR - suggesting that synchronous interpersonal interactions with clinicians may facilitate the best attendance and completion rates.

Conclusion

When offered the choice of PR delivery method, the majority of participants preferred centre-based PR and this facilitated the best completion rates. mPR was the preferred choice for younger, working participants suggesting that mPR may offer a viable alternative to centre-based PR for some participants, especially younger, employed participants.

Lifestyle integrated functional exercise for people with interstitial lung disease (iLiFE): A mixed-methods feasibility study

BACKGROUND

People with interstitial lung disease (ILD) present low levels of physical activity (PA) and spend most of their time at home, especially in advanced stages of the disease. The Lifestyle Integrated Functional Exercise for people with ILD (iLiFE) embedding PA in patients' daily routines was developed and implemented.

OBJECTIVES

This study aimed to explore the feasibility of iLiFE.

METHODS

A pre/post mixed-methods feasibility study was conducted. Feasibility of iLiFE was determined by participant recruitment/retention, adherence, feasibility of outcome measures and adverse events. Measures of PA, sedentary behaviour, balance, muscle strength, functional performance/capacity, exercise capacity, impact of the disease, symptoms (i.e., dyspnoea, anxiety, depression, fatigue and cough) and health-related quality of life were collected at baseline and post-intervention (12-weeks). Semi-structured interviews with participants were conducted in-person immediately after iLiFE. Interviews were audio-recorded, transcribed and analysed by deductive thematic analysis.

RESULTS

Ten participants (5♀, 77±3y; FVCpp 77.1 ± 4.4, DLCOpp 42.4 ± 6.6) were included, but only nine completed the study. Recruitment was challenging (30%) and retention high (90%). iLiFE was feasible, with excellent adherence (84.4%) and no adverse events. Missing data were associated with one dropout and non-compliance with the accelerometer (n = 1). Participants reported that iLiFE contributed to (re)gain control in their daily life, namely through improving their well-being, functional status and motivation. Weather, symptoms, physical impairments and lack of motivation were identified as threats to keep an active lifestyle.

CONCLUSIONS

iLiFE seems to be feasible, safe and meaningful for people with ILD. A randomised controlled trial is needed to strengthen these promising findings.

A rehabilitation program to increase balance and mobility in ataxia of Charlevoix-Saguenay: An exploratory study

Autosomal recessive spastic ataxia of Charlevoix-Saguenay (ARSACS) is characterized by balance impairment and mobility limitations, which both increase the risk of falling. The objective of this study was to explore the effects of a rehabilitation program aimed at increasing trunk and lower limb motor control on balance and walking abilities, and accomplishment of activities of daily living. In this exploratory study, a group-supervised rehabilitation program was performed three times a week for 8 weeks (two sessions at a rehabilitation gym and one pool session). Outcome measures included the Ottawa Sitting Scale, Berg Balance Scale, modified Activities-specific Balance Confidence Scale, 30-Second Chair Stand Test, 10-Meter Walk Test, Barthel Index, and Scale for the Assessment and Rating of Ataxia. Significant improvements in balance, trunk control, maximal and self-selected walking speed difference, ataxia severity and accomplishment of specific activities of daily living were noted for the whole group at the end of the program. At the individual level, all participants improved beyond the standard error of measurement in at least two outcome measures. Also, most participants reported many perceived improvements related to balance, posture and functional mobility. This study provides encouraging results on the effects of a rehabilitation program for ambulatory people with ARSACS. Group intervention could have a positive impact on their daily lives and improve the health care service offered to this population. Future studies with larger sample sizes including control groups and other forms of ataxia are necessary to validate our results to generalize them.

The Impact of Dance Interventions on Patients with Noninfectious Pulmonary Diseases: A Systematic Review

Dance has been highlighted as one of the most enjoyable, safe, and feasible forms of physical activity, improving physical health, mental health, and general well-being, among various patients. Little is known about the effect and impact of dance interventions to improve health among patients with pulmonary diseases, and research lacks a robust synthesis of evidence. Therefore, this systematic review aimed to investigate the impact of dance intervention on patients with noninfectious pulmonary diseases. Following the PRISMA guidelines, six electronic databases were searched in May 2022. Of the 1308 unique records identified, seven studies (five quantitative, two qualitative) across four countries were included in this systematic review. Six studies investigated adult populations, and one study explored the effect of dance on children. The dance interventions lasted between 1 and 10 weeks. Overall, dance was perceived to have a broad range of physical/mental/social benefits, including quality of life, social cohesion, dyspnoea levels, balance, exercise tolerance, general well-being, and adherence to nutrition regimens. Furthermore, the dance session was the most enjoyable activity among children and adolescents with asthma. With available evidence, dance interventions are promising and may effectively improve health and well-being among patients with noninfectious pulmonary diseases. More organised and continuous long-term dance interventions in future may reveal a detailed impact on health outcomes.

High intensity interval training versus moderate intensity continuous training for people with interstitial lung disease: protocol for a randomised controlled trial

Background

Interstitial lung disease is a debilitating condition associated with significant dyspnoea, fatigue, and poor exercise tolerance. Pulmonary rehabilitation is an effective and key intervention in people with interstitial lung disease. However, despite the best efforts of patients and clinicians, many of those who participate are not achieving clinically meaningful benefits. This assessor-blinded, multi-centre, randomised controlled trial aims to compare the clinical benefits of high intensity interval exercise training versus the standard pulmonary rehabilitation method of continuous training at moderate intensity in people with fibrotic interstitial lung disease.

Methods

Eligible participants will be randomised to either a standard pulmonary rehabilitation group using moderate intensity continuous exercise training or high intensity interval exercise training. Participants in both groups will undertake an 8-week pulmonary rehabilitation program of twice-weekly supervised exercise training including aerobic (cycling) and strengthening exercises. In addition, participants in both groups will be prescribed a home exercise program.

Outcomes will be assessed at baseline, upon completion of the intervention and at six months following the intervention by a blinded assessor. The primary outcome is endurance time on a constant work rate test. Secondary outcomes are functional capacity (6-min walk distance), health-related quality of life (Chronic Respiratory Disease Questionnaire (CRQ), St George’s Respiratory Questionnaire idiopathic pulmonary fibrosis specific version (SGRQ-I), breathlessness (Dyspnoea 12, Modified Medical Research Council Dyspnoea Scale), fatigue (fatigue severity scale), anxiety (Hospital Anxiety and Depression Scale), physical activity level (GeneActiv), skeletal muscle changes (ultrasonography) and completion and adherence to pulmonary rehabilitation.

Discussion

The standard exercise training strategies used in pulmonary rehabilitation may not provide an optimal exercise training stimulus for people with interstitial lung disease. This study will determine whether high intensity interval training can produce equivalent or even superior changes in exercise performance and symptoms. If high intensity interval training proves effective, it will provide an exercise training strategy that can readily be implemented into clinical practice for people with interstitial lung disease.

Trial registration ClinicalTrials.gov Registry (NCT03800914). Registered 11 January 2019, https://clinicaltrials.gov/ct2/show/NCT03800914

Australian New Zealand Clinical Trials Registry ACTRN12619000019101. Registered 9 January 2019, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376050&isReview=true

Home-based pulmonary rehabilitation early after hospitalisation in COPD (early HomeBase): protocol for a randomised controlled trial

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is characterised by exacerbations of respiratory disease, frequently requiring hospital admission. Pulmonary rehabilitation can reduce the likelihood of future hospitalisation, but programme uptake is poor. This study aims to compare hospital readmission rates, clinical outcomes and costs between people with COPD who undertake a home-based programme of pulmonary rehabilitation commenced early (within 2 weeks) of hospital discharge with usual care.

METHODS

A multisite randomised controlled trial, powered for superiority, will be conducted in Australia. Eligible patients admitted to one of the participating sites for an exacerbation of COPD will be invited to participate. Participants will be randomised 1:1. Intervention group participants will undertake an 8-week programme of home-based pulmonary rehabilitation commencing within 2 weeks of hospital discharge. Control group participants will receive usual care and a weekly phone call for attention control. Outcomes will be measured by a blinded assessor at baseline, after the intervention (week 9-10 posthospital discharge), and at 12 months follow-up. The primary outcome is hospital readmission at 12 months follow-up.

ETHICS AND DISSEMINATION

Human Research Ethics approval for all sites provided by Alfred Health (Project 51216). Findings will be published in peer-reviewed journals, conferences and lay publications.

TRIAL REGISTRATION NUMBER

ACTRN12619001122145.

Defining Modern Pulmonary Rehabilitation. An Official American Thoracic Society Workshop Report

Pulmonary rehabilitation is a highly effective treatment for people with chronic lung disease but remains underused across the world. Recent years have seen the emergence of new program models that aim to improve access and uptake, including telerehabilitation and low-cost, home-based models. This workshop was convened to achieve consensus on the essential components of pulmonary rehabilitation and to identify requirements for successful implementation of emerging program models. A Delphi process involving experts from across the world identified 13 essential components of pulmonary rehabilitation that must be delivered in any program model, encompassing patient assessment, program content, method of delivery, and quality assurance, as well as 27 desirable components. Only those models of pulmonary rehabilitation that have been tested in clinical trials are currently considered as ready for implementation. The characteristics of patients most likely to succeed in each program model are not yet known, and research is needed in this area. Health professionals should use clinical judgment to determine those patients who are best served by a center-based, multidisciplinary rehabilitation program. A comprehensive patient assessment is critical for personalization of pulmonary rehabilitation and for effectively addressing individual patient goals. Robust quality-assurance processes are important to ensure that any pulmonary rehabilitation service delivers optimal outcomes for patients and health services. Workforce capacity-building and training should consider the skills necessary for emerging models, many of which are delivered remotely. The success of all pulmonary rehabilitation models will be judged on whether the essential components are delivered and on whether the expected patient outcomes, including improved exercise capacity, reduced dyspnea, enhanced health-related quality of life, and reduced hospital admissions, are achieved.

Telerehabilitation for chronic respiratory disease

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 METHODS

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.

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.

The Impact of Pulmonary Rehabilitation on 24-Hour Movement Behavior in People With Chronic Obstructive Pulmonary Disease: New Insights From a Compositional Perspective

BACKGROUND

Physical activity levels are low in people with chronic obstructive pulmonary disease, and there is limited knowledge about how pulmonary rehabilitation transforms movement behaviors. This study analyzed data from a pulmonary rehabilitation trial and identified determinants of movement behaviors.

METHODS

Objectively assessed time in daily movement behaviors (sleep, sedentary, light-intensity physical activity, and moderate- to vigorous-intensity physical activity) from a randomized controlled trial (n = 73 participants) comparing home- and center-based pulmonary rehabilitation was analyzed using conventional and compositional analytical approaches. Regression analysis was used to assess relationships between movement behaviors, participant features, and response to the interventions.

RESULTS

Compositional analysis revealed no significant differences in movement profiles between the home- and center-based groups. At end rehabilitation, conventional analyses identified positive relationships between exercise capacity (6-min walk distance), light-intensity physical activity, and moderate- to vigorous-intensity physical activity time. Compositional analyses identified positive relationships between a 6-minute walk distance and moderate- to vigorous-intensity physical activity time, accompanied by negative relationships with sleep and sedentary time (relative to other time components) and novel relationships between body mass index and light-intensity physical activity/sedentary time.

CONCLUSION

Compositional analyses following pulmonary rehabilitation identified unique associations between movement behaviors that were not evident in conventional analyses.

Effect of a pulmonary rehabilitation programme of 8 weeks compared to 12 weeks duration on exercise capacity in people with chronic obstructive pulmonary disease (PuRe Duration): protocol for a randomised controlled trial

Introduction

Pulmonary rehabilitation (PR) is a key component in the management of chronic obstructive pulmonary disease (COPD). There is no strong evidence on the optimal duration of PR programmes. The aim of this study is to determine whether an 8-week PR programme is equivalent to a 12-week PR programme in people with COPD.

Methods and analysis

This study will be a prospective, multisite, randomised controlled, equivalence trial with assessors blinded to group allocation and intention-to-treat analysis. 72 participants with COPD will be recruited and randomised to either a supervised, twice weekly for 8 weeks or a 12-week PR programme of exercise training and education. Primary outcome: endurance shuttle walk test. Secondary outcomes: will include St George’s Respiratory Questionnaire, 6-min walk distance, COPD assessment test, Hospital Anxiety and Depression Scale, physical activity monitoring and hospital admissions at 6 months and 12 months. Repeated measures analysis of variance will be used to analyse differences between the groups for all outcomes.

Ethics and dissemination

Ethics approval was gained from all participating sites. Results of the trial will be submitted for publication in a peer-reviewed journal.

Trial registration number

ACTRN12616001586404.

Telerehabilitation versus traditional centre-based pulmonary rehabilitation for people with chronic respiratory disease: protocol for a randomised controlled trial

BACKGROUND

Pulmonary rehabilitation is an effective therapeutic intervention for people with chronic respiratory disease. However, fewer than 5% of eligible individuals receive pulmonary rehabilitation on an annual basis, largely due to limited availability of services and difficulties associated with travel and transport. The Rehabilitation Exercise At Home (REAcH) study is an assessor-blinded, multi-centre, randomised controlled equivalence trial designed to compare the efficacy of home-based telerehabilitation and traditional centre-based pulmonary rehabilitation in people with chronic respiratory disease.

METHODS

Participants will undertake an 8-week group-based pulmonary rehabilitation program of twice-weekly supervised exercise training, either in-person at a centre-based pulmonary rehabilitation program or remotely from their home via the Internet. Supervised exercise training sessions will include 30 min of aerobic exercise (cycle and/or walking training). Individualised education and self-management training will be delivered. All participants will be prescribed a home exercise program of walking and strengthening activities. Outcomes will be assessed by a blinded assessor at baseline, after completion of the intervention, and 12-months post intervention. The primary outcome is change in dyspnea score as measured by the Chronic Respiratory Questionnaire - dyspnea domain (CRQ-D). Secondary outcomes will evaluate the efficacy of telerehabilitation on 6-min walk distance, endurance cycle time during a constant work rate test, physical activity and quality of life. Adherence to pulmonary rehabilitation between the two models will be compared. A full economic analysis from a societal perspective will be undertaken to determine the cost-effectiveness of telerehabilitation compared to centre-based pulmonary rehabilitation.

DISCUSSION

Alternative models of pulmonary rehabilitation are required to improve both equity of access and patient-related outcomes. This trial will establish whether telerehabilitation can achieve equivalent improvement in outcomes compared to traditional centre-based pulmonary rehabilitation. If efficacious and cost-effective, the proposed telerehabilitation model is designed to be rapidly deployed into clinical practice.

TRIAL REGISTRATION

Clinical trial registered with the Australian and New Zealand Clinical Trials Register at ( ACTRN12616000360415 ). Registered 21 March 2016.

The impact of a social prescribing service on patients in primary care: a mixed methods evaluation

Background

Social prescribing is targeted at isolated and lonely patients. Practitioners and patients jointly develop bespoke well-being plans to promote social integration and or social reactivation. Our aim was to investigate: whether a social prescribing service could be implemented in a general practice (GP) setting and to evaluate its effect on well-being and primary care resource use.

Methods

We used a mixed method evaluation approach using patient surveys with matched control groups and a qualitative interview study. The study was conducted in a mixed socio-economic, multi-ethnic, inner city London borough with socially isolated patients who frequently visited their GP. The intervention was implemented by ‘social prescribing coordinators’. Outcomes of interest were psychological and social well-being and health care resource use.

Results

At 8 months follow-up there were no differences between patients referred to social prescribing and the controls for general health, depression, anxiety and ‘positive and active engagement in life’. Social prescribing patients had high GP consultation rates, which fell in the year following referral. The qualitative study indicated that most patients had a positive experience with social prescribing but the service was not utilised to its full extent.

Conclusion

Changes in general health and well-being following referral were very limited and comprehensive implementation was difficult to optimise. Although GP consultation rates fell, these may have reflected regression to the mean rather than changes related to the intervention. Whether social prescribing can contribute to the health of a nation for social and psychological wellbeing is still to be determined.

PUREAIR protocol: randomized controlled trial of intensive pulmonary rehabilitation versus standard care in patients undergoing surgical resection for lung cancer

Background

Non-small cell lung cancer is the most common type of lung cancer. Surgery is proven to be the most effective treatment in early stages, despite its potential impact on quality of life. Pulmonary rehabilitation, either before or after surgery, is associated with reduced morbidity related symptoms and improved exercise capacity, lung function and quality of life.

Methods

We describe the study protocol for the open-label randomized controlled trial we are conducting on patients affected by primary lung cancer (stages I-II) eligible for surgical treatment. The control group receives standard care consisting in one educational session before surgery and early inpatient postoperative physiotherapy. The treatment group receives, in addition to standard care, intensive rehabilitation involving 14 preoperative sessions (6 outpatient and 8 home-based) and 39 postoperative sessions (15 outpatient and 24 home-based) with aerobic, resistance and respiratory training, as well as scar massage and group bodyweight exercise training.

Assessments are performed at baseline, the day before surgery and one month and six months after surgery. The main outcome is the long-term exercise capacity measured with the Six-Minute Walk Test; short-term exercise capacity, lung function, postoperative morbidity, length of hospital stay, quality of life (Short Form 12), mood disturbances (Hospital Anxiety and Depression Scale) and pain (Numeric Rating Scale) are also recorded and analysed. Patient compliance and treatment-related side effects are also collected. Statistical analyses will be performed according to the intention-to-treat approach. T-test for independent samples will be used for continuous variables after assessment of normality of distribution. Chi-square test will be used for categorical variables. Expecting a 10% dropout rate, assuming α of 5% and power of 80%, we planned to enrol 140 patients to demonstrate a statistically significant difference of 25 m at Six-Minute Walk Test.

Discussion

Pulmonary Resection and Intensive Rehabilitation study (PuReAIR) will contribute significantly in investigating the effects of perioperative rehabilitation on exercise capacity, symptoms, lung function and long-term outcomes in surgically treated lung cancer patients. This study protocol will facilitate interpretation of future results and wide application of evidence-based practice.

Trial registration

ClinicalTrials.gov Registry n. NCT02405273 [31.03.2015].

Longer Versus Shorter Duration of Supervised Rehabilitation After Lung Transplantation: A Randomized Trial

OBJECTIVE

To investigate the effects of a supervised longer- (14wk) versus shorter-duration (7wk) rehabilitation program after lung transplantation (LTX).

DESIGN

Randomized controlled trial.

SETTING

Outpatient rehabilitation gym setting.

PARTICIPANTS

Post-LTX patients aged ≥18 years (N=66; 33 women; mean age, 51±13y) who had undergone either single LTX or bilateral LTX.

INTERVENTION

Outpatient rehabilitation program consisting of thrice-weekly sessions with cardiovascular training on bike ergometer and treadmill plus upper and lower limb strength training.

MAIN OUTCOME MEASURES

Measures were taken at baseline, 7 weeks, 14 weeks, and 6 months by assessors who were blinded to group allocation. Functional exercise capacity was measured by the 6-minute walk test (6MWT). Strength of quadriceps and hamstrings was measured on an isokinetic dynamometer and recorded as average peak torque of 6 repetitions for both muscles. Quality of life (QOL) was assessed with the Medical Outcomes Study 36-Item Short-Form Health Survey.

RESULTS

Of the participants, 86% had bilateral LTX and 41% had primary diagnosis of chronic obstructive pulmonary disease. The 6MWT increased in both groups with no significant difference between groups at any time point (mean 6mo 6MWD: short, 590±85m vs long, 568±127m; P=0.5). Similarly, at 6 months, there was no difference between groups in quadriceps average peak torque (mean, 115±38Nm vs 114±40Nm, respectively; P=.59), hamstring average peak torque (57±18Nm vs 52±19Nm, respectively; P=.36), or mental or physical health domains of quality of life.

CONCLUSIONS

Shorter duration (7wk) of rehabilitation achieves comparable outcomes with 14 weeks of supervised rehabilitation for functional exercise capacity, lower limb strength, and quality of life at 6 months after LTX.

Home-based rehabilitation for COPD using minimal resources: a randomised, controlled equivalence trial

BACKGROUND

Pulmonary rehabilitation is a cornerstone of care for COPD but uptake of traditional centre-based programmes is poor. We assessed whether home-based pulmonary rehabilitation, delivered using minimal resources, had equivalent outcomes to centre-based pulmonary rehabilitation.

METHODS

A randomised controlled equivalence trial with 12 months follow-up. Participants with stable COPD were randomly assigned to receive 8 weeks of pulmonary rehabilitation by either the standard outpatient centre-based model, or a new home-based model including one home visit and seven once-weekly telephone calls from a physiotherapist. The primary outcome was change in 6 min walk distance (6MWD).

RESULTS

We enrolled 166 participants to receive centre-based rehabilitation (n=86) or home-based rehabilitation (n=80). Intention-to-treat analysis confirmed non-inferiority of home-based rehabilitation for 6MWD at end-rehabilitation and the confidence interval (CI) did not rule out superiority (mean difference favouring home group 18.6 m, 95% CI -3.3 to 40.7). At 12 months the CI did not exclude inferiority (-5.1 m, -29.2 to 18.9). Between-group differences for dyspnoea-related quality of life did not rule out superiority of home-based rehabilitation at programme completion (1.6 points, -0.3 to 3.5) and groups were equivalent at 12 months (0.05 points, -2.0 to 2.1). The per-protocol analysis showed the same pattern of findings. Neither group maintained postrehabilitation gains at 12 months.

CONCLUSIONS

This home-based pulmonary rehabilitation model, delivered with minimal resources, produced short-term clinical outcomes that were equivalent to centre-based pulmonary rehabilitation. Neither model was effective in maintaining gains at 12 months. Home-based pulmonary rehabilitation could be considered for people with COPD who cannot access centre-based pulmonary rehabilitation.

TRIAL REGISTRATION NUMBER

NCT01423227, clinicaltrials.gov.

Long-term exercise maintenance in COPD via telerehabilitation: a two-year pilot study

Introduction Pulmonary rehabilitation (PR) is an integral part of the management of chronic obstructive pulmonary disease (COPD). However, many patients do not access or complete PR, and long-term exercise maintenance has been difficult to achieve after PR. This study aimed to investigate feasibility, long-term exercise maintenance, clinical effects, quality of life and use of hospital resources of a telerehabilitation intervention. Methods Ten patients with COPD were offered a two-year follow-up via telerehabilitation after attending PR. The intervention consisted of home exercise, telemonitoring and self-management via a webpage combined with weekly videoconferencing sessions. Equipment included a treadmill, a pulse oximeter and a tablet. Data collected at baseline, one year and two years were six-minute walking distance (6MWD), COPD assessment test (CAT), EuroQol 5 dimensions (EQ-5D), hospitalisations and outpatient visits. Results No dropout occurred. Physical performance, lung capacity, health status and quality of life were all maintained at two years. At one year, 6MWD improved by a mean of 40 metres from baseline, CAT decreased by four points and EQ visual analogue scale (EQ VAS) improved by 15.6 points. Discussion Long-term exercise maintenance in COPD via telerehabilitation is feasible. Results are encouraging and suggest that telerehabilitation can prevent deterioration and improve physical performance, health status and quality of life.