Telerehabilitation for chronic respiratory disease
Narelle S Cox, Simone Dal Corso, Henrik Hansen, Christine F McDonald, Catherine J Hill, Paolo Zanaboni, Jennifer A Alison, Paul O'Halloran, Heather Macdonald, Anne E Holland, Narelle S Cox, Simone Dal Corso, Henrik Hansen, Christine F McDonald, Catherine J Hill, Paolo Zanaboni, Jennifer A Alison, Paul O'Halloran, Heather Macdonald, Anne E Holland
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 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.
Trial registration: ClinicalTrials.gov NCT02269618 NCT02706613 NCT02667171 NCT01423227 NCT03432117 NCT00169897 NCT02618746 NCT00512837 NCT00563745 NCT00752531 NCT01724684 NCT01987544 NCT02085187 NCT03489642 NCT04284865 NCT04521608 NCT04533412 NCT04550741 NCT02258646 NCT02404831 NCT03443817 NCT03548181 NCT03569384 NCT03634553 NCT03914027 NCT03981783 NCT03997513.
Conflict of interest statement
NSC: Dr Cox holds a National Health and Medical Research Council (NHMRC) Australia Early Career Fellowship (GNT1119970). She presented workshops relating to pulmonary rehabilitation (including alternative models of delivery) at the 2018 National General Practitioners Meeting sponsored by Boeringher Ingelheim and monies were paid to her host institution. Dr Cox is an author on trials included in this review.
SDC: Professor Dal Corso was supported by funding from Sao Paulo Research Foundation (FAPESP SPRINT grant 17/50273‐4), Brazil.
HH: Dr Hansen has received a personal post doctoral grants from the Capital Region of Copenhagen (governmental funding), teaching fee from GSK (private company), The association of Danish Physiotherapist (NGO) and royalties from educational books chapters written for Munksgaard Denmark (publisher). He is an author on trials included in this review.
CFM: Professor McDonald has developed educational presentations sponsored by Menarini and Astra Zeneca with monies to her institution. She has also received in kind support from Air Liquide for a clinical trial of oxygen therapy. She has received competitive research funding from the National Health and Medical Research Council (Australia) (GNT1101616) for a trial of telerehabilitation in COPD, and is an author on one of the trials included in this review. Professor McDonald is an author on trials included in this review.
CJH: none known
PZ: Dr Zanaboni holds a Research Council of Norway Project Grant (228919/H10) titled 'Long‐term integrated telerehabilitation of COPD patients: a multi centre randomised controlled trial'.
JAA: Professor Alison has received competitive research funding from the National Health and Medical Research Council (Australia) (GNT1101616) for a trial of telerehabilitation in COPD, and is an author on one of the trials included in this review.
POH: Dr O'Halloran is an author on one of the trials included in this review.
HM: none known
AEH: Professor Holland has received competitive research funding from the National Health and Medical Research Council (Australia) (GNT1101616) for a trial of telerehabilitation in COPD, and is an author on trials included in this review. The NHMRC supports the independent conduct and publication of this Cochrane Review.
Seven review authors (NSC, CFM, CJH, JAA, POH, HH, AEH) were co‐authors on at least one study included in this review. As such, at least one independent co‐author undertook data extraction and the assessment of risks of bias.
Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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Source: PubMed