Nonadherence in Home-Based Pulmonary Rehabilitation Program for COPD Patients

Influence of home-based pulmonary rehabilitation program among people with interstitial lung disease: A pre-post study

INTRODUCTION

Access to interstitial lung disease programs may not be available in rural settings. Home-based pulmonary rehabilitation (PR) programs have been proposed as an alternative to hospital-based programs.

METHOD

Forty participants with ILD underwent a structured unsupervised home-based pulmonary rehabilitation program from September 2020 to September 2022. Quality of life was assessed using St. George Respiratory Questionnaire (SGRQ) and functional capacity using 6-minute walk test (6MWT). The outcome measures were assessed at baseline and 4 weeks post-unsupervised home-based PR program.

RESULT

We recruited 40 participants with ILD. There was statistically significant improvement in the 6-minute walk distance (353.8 m and 368 m, effect size - 0.5, p ≤ .001) and quality of life using SGRQ total score (38.6 and 42.35, effect size - 2.5, p ≤ .001) between before and after receiving home-based PR among all 40 participants with ILD.

CONCLUSION

Four weeks of home-based PR program, using minimal resources, deliver short-term improvements in functional exercise capacity and quality of life among ILD participants. Our home-based PR program resulted in a quarter percentage improvement in functional capacity, and we believe that if consistency is maintained, it will result in similar changes corresponding to the already established Minimal Clinically Important Difference (MCID) of 35 m.

Smartphone application-based rehabilitation in patients with chronic respiratory and cardiovascular diseases

Rehabilitation improves symptoms, quality of life, and survival in patients with chronic respiratory or cardiovascular disease. We evaluated smartphone application-based rehabilitation programs for patients with chronic respiratory or cardiovascular diseases. This was a single-center prospective single arm study. Participants underwent smartphone application-based pulmonary or cardiac rehabilitation for 12 weeks. A total of 93 participants were recruited, and 75 visited after rehabilitation. Their median age was 67.0 (interquartile range, 60.0-70.8) years, and 60 (80.0%) were men. For patients with chronic respiratory disease (n = 41), VO2peak (median 13.7 to 15.4 ml/kg/min, P = 0.049), chronic obstructive pulmonary disease assessment test (median 14 to 6, P < 0.001), Euro-QoL 5-Dimension 5-Level (EQ-5D-5L) index (median 0.795 to 0.862, P = 0.001), and Health-related Quality of Life Instrument with 8 Items (HINT-8) index (median 0.784 to 0.855, P < 0.001) were significantly improved. For patients with chronic cardiovascular disease (n = 34), VO2peak (median 21.8 to 23.3, P = 0.007), EQ-5D-5L index (median 0.871 to 1.000, P = 0.037), and HINT-8 index (median 0.890 to 0.903, P < 0.001) were significantly improved. The smartphone application-based rehabilitation program improved exercise capacity and quality of life in patients with chronic respiratory or cardiovascular disease.Trial registration: https://clinicaltrials.gov/ct2/show/NCT05383950 (20/05/2022).

Clinical Efficacy of Mobile App-Based, Self-Directed Pulmonary Rehabilitation for Patients With Chronic Obstructive Pulmonary Disease: Systematic Review and Meta-Analysis

Background

Pulmonary rehabilitation is well known to improve clinical symptoms (including dyspnea), quality of life, and exercise capacity in patients with chronic obstructive pulmonary disease (COPD). However, researchers have reported difficulties in practicing center-based pulmonary rehabilitation. Recently, mobile app-based pulmonary rehabilitation has become available in clinical practice. We investigated the clinical outcomes of mobile app-based pulmonary rehabilitation in patients with COPD.

Objective

The objective of our study was to evaluate the clinical efficacy of mobile app-based pulmonary rehabilitation versus conventional center-based pulmonary rehabilitation for patients with COPD, using a systematic review and meta-analysis.

Methods

A systematic search of the literature published between January 2007 and June 2023 was performed, using the PubMed, Embase, Cochrane, and CINAHL databases to identify relevant randomized controlled trials involving patients with COPD. Pulmonary rehabilitation programs needed to provide an exercise program on a smartphone app. Study outcomes, including exercise capacity, symptom scores, quality of life, and hospitalization, were evaluated. The meta-analysis evaluated mean differences in 6-minute walk test distances (6MWDs), COPD Assessment Test (CAT) scores, modified Medical Research Council (mMRC) dyspnea scale scores, St. George Respiratory Questionnaire (SGRQ) scores, and risk ratios for hospitalization resulting from disease exacerbation.

Results

Of the 1173 screened studies, 10 were included in the systematic review and 9 were included in the meta-analysis. Further, 6 studies were multicenter studies. There were a total of 1050 participants, and most were aged ≥65 years. There were discrepancies in the baseline participant characteristics, smartphone apps, interventions, and study outcomes among the included studies. In the meta-analysis, 5 studies assessed 6MWDs (mean difference 9.52, 95% CI -3.05 to 22.08 m), 6 studies assessed CAT scores (mean difference -1.29, 95% CI -2.39 to -0.20), 3 studies assessed mMRC dyspnea scale scores (mean difference -0.08, 95% CI -0.29 to 0.13), 2 studies assessed SGRQ scores (mean difference -3.62, 95% CI -9.62 to 2.38), and 3 studies assessed hospitalization resulting from disease exacerbation (risk ratio 0.65, 95% CI 0.27-1.53). These clinical parameters generally favored mobile app-based pulmonary rehabilitation; however, a statistically significant difference was noted only for the CAT scores (P=.02).

Conclusions

Despite some discrepancies in the baseline participant characteristics and interventions among studies, mobile app-based pulmonary rehabilitation resulted in favorable exercise capacity, symptom score, quality of life, and hospitalization outcomes when compared with conventional pulmonary rehabilitation. In the meta-analysis, the CAT scores of the mobile app-based pulmonary rehabilitation group were significantly lower than those of the control group (P=.02). In real-world practice, mobile app-based pulmonary rehabilitation can be a useful treatment option when conventional center-based pulmonary rehabilitation is not feasible.

Barriers to adherence to home-based pulmonary rehabilitation among patients with chronic obstructive pulmonary disease in Iran: a descriptive qualitative study

OBJECTIVES

Chronic obstructive pulmonary disease is a chronic disease with numerous complications. Therefore, its effective management depends on home-based pulmonary rehabilitation. The effectiveness of home-based pulmonary rehabilitation programmes in turn depends on patient adherence to them. The aim of this study was to explore the barriers to adherence to home-based pulmonary rehabilitation among patients with chronic obstructive pulmonary disease.

DESIGN

Qualitative descriptive design.

SETTING

The lung care wards of Al-Zahra and Khorshid teaching hospitals and the comprehensive lung care clinic of Khorshid hospital, Isfahan, Iran.

PARTICIPANTS

Participants patients with chronic obstructive pulmonary disease (n=20), their family caregivers (n=15) and healthcare providers (n=14) recruited via purposive sampling.

RESULTS

The five main categories of the barriers to adherence to home-based pulmonary rehabilitation among patients with chronic obstructive pulmonary disease were patient-related barriers, caregivers' caregiving burden, limited support for patients, healthcare providers' limited professional competence and ineffective home-based pulmonary rehabilitation planning.

CONCLUSION

Different and complex factors related to patients, families and healthcare providers can affect adherence to home-based pulmonary rehabilitation among patients with chronic obstructive pulmonary disease. Healthcare authorities can use the findings of this study to develop strategies to support patients with chronic obstructive pulmonary disease and their family caregivers and thereby reduce the physical and mental complications of Chronic obstructive pulmonary disease.

Embedding Pulmonary Rehabilitation for Chronic Obstructive Pulmonary Disease in the Home and Community Setting: A Rapid Review

This paper presents a rapid review of the literature for the components, benefits, barriers, and facilitators of pulmonary rehabilitation for chronic obstructive pulmonary disease (COPD) people in-home and community-based settings. seventy-six studies were included: 57 home-based pulmonary rehabilitation (HBPR) studies and 19 community-based pulmonary rehabilitation (CBPR) studies. The benefits of HBPR on exercise capacity and health-related quality of life were observed in one-group studies, studies comparing HBPR to usual care, and studies comparing to hospital-based pulmonary rehabilitation, although the benefits were less pronounced in the latter. HBPR reduced hospital admissions compared to usual care and was more cost-effective than hospital pulmonary rehabilitation. Most HBPRs were designed with low-density or customized equipment, are minimally supervised, and have a low intensity of training. Although the HBPR has flexibility and no travel burden, participants with severe disease, physical frailty, and complex comorbidities had barriers to complying with HBPR. The telerehabilitation program, a facilitator for HBPR, is feasible and safe. CBPR was offered in-person supervision, despite being limited to physical therapists in most studies. Benefits in exercise capacity were shown in almost all studies, but the improvement in health-related quality of life was controversial. Patients reported the benefits that facilities where they attended the CBPR including social support and the presence of an instructor. They also reported barriers, such as poor physical condition, transport difficulties, and family commitments. Despite the minimal infrastructure offered, HBPR and CBPR are feasible, safe, and provide clinical benefits to patients with COPD. Home and community settings are excellent opportunities to expand the offer of pulmonary rehabilitation programs, as long as they follow protocols that ensure quality and safety following current guidelines.

Effect of a Telerehabilitation program in sarcoidosis

Background

Sarcoidosis can lead to variable periods of sickness and unemployment. Rehabilitation is recommended in sarcoidosis to improve exercise capacity. Therefore, focus on creating different and flexible rehabilitation options adapted to the needs of working patients is warranted to keep patients with sarcoidosis employed and to reduce the socioeconomic burden. Telerehabilitation (TR) might be an alternative. We investigated the usefulness and effectiveness of TR on exercise capacity in patients with sarcoidosis.

Method

Single-center, prospective, randomized study including stable patients with sarcoidosis who were enrolled in either a control group where they received the usual standard of care (not including rehabilitation) or in the 3 months TR group composed of video and chat-consultations with a physiotherapist and workout sessions with a virtual autonomous physiotherapist agent (VAPA) (1). 6-minute-walk-test (6MWT), forced vital capacity (FVC), diffusion capacity of the lung for carbon monoxide (DLCO), isometric voluntary contraction (MVC), 7 days pedometry, Saint George Respiratory Questionnaire for interstitial lung disease (SGRQ-I), The King's Brief Interstitial Lung Disease Questionnaire (KBILD) and General Anxiety Disorder-7 Questionnaire (GAD7) were tested before and after 3 months of TR, and after 3- and 6 months follow-up. Patient satisfaction was measured with a 5-point scale (5 very satisfied) and adherence was calculated as percent of tasks and time spent training. Adverse events were documented.

Results

Thirty patients aged 53.9±13.5 years, male 63.3%, FVC% 88.9±18.8, DLCO% 65.2±16.0, 6MWT 513.1±141.3 were included. Fifteen patients were randomized to TR with VAPA and 15 patients to the control group. Differences in meters walked (6MWTD) between groups was at baseline (-28.9 m (p=0.58)), after 3 (+25.8 m (p=0.57)), 6 (+48.4 m (p=0.39)) and 9 months (+77.3 m (p=0.18)) follow-up in favor of telerehabilitation. No differences were observed in MVC, 7 days pedometry, SGRQ-I, KBILD or GAD7. Exercise adherence in the intervention group was 64% and average exercise time was 28 minutes per exercise session during the first 3 months. Patient satisfaction scored 3.8 ± 0.7. No adverse events were reported.

Conclusion

VAPA TR did not result in any change in exercise capacity or patient-reported outcomes in this pilot study in patients with sarcoidosis. However, a statistically non-significant trend for improved 6MWTD was observed during follow-up. VAPA TR was safe, had high patient satisfaction and acceptable adherence. Further randomized studies including larger numbers of participants are needed.

Effect of a New Tele-Rehabilitation Program versus Standard Rehabilitation in Patients with Chronic Obstructive Pulmonary Disease

In chronic obstructive pulmonary disease (COPD), rehabilitation is recommended, but attendance rates are low. Tele-rehabilitation may be key. We evaluate the effect of a tele-rehabilitation program vs. standard rehabilitation on COPD. A randomized, non-inferiority study comparing eight weeks of tele-rehabilitation (physiotherapist video/chat-consultations and workout sessions with a virtual-autonomous-physiotherapist-agent (VAPA)) and standard rehabilitation in stable patients with COPD. At baseline, after 8 weeks and 3 and 6 months of follow-up, 6 min walk test distance (6MWTD), 7-day pedometry, quality of life, exercise tolerance, adherence, patient satisfaction and safety were assessed. Fifty-four patients (70 ± 9 years, male 57%, FEV1% 34.53 ± 11.67, FVC% 68.8 ± 18.81, 6MWT 376.23 ± 92.02) were included. Twenty-seven patients were randomized to tele-rehabilitation. Non-inferiority in Δ6MWTD at 8 weeks (47.4 ± 31.4), and at 3 (56.0 ± 38.0) and 6 (95.2 ± 47.1) months follow-up, was observed. No significant difference was observed in 7-day pedometry or quality of life. In the intervention group, 6MWTD increased by 25% and 66% at 3 and 6 months, respectively; adherence was 81%; and patient satisfaction was 4.27 ± 0.77 (Likert scale 0-5). Non-inferiority between groups and high adherence, patient satisfaction and safety in the intervention group were found after rehabilitation and at 3 and 6 months of follow-up. Tele-rehabilitation with VAPA seems to be a promising alternative.

Trajectory of adherence to home rehabilitation among older adults with hip fractures and cognitive impairment

This study aimed to identify different trajectories of adherence to home rehabilitation for older adults with hip fracture and cognitive impairment, to examine associations between different adherence trajectories and postoperative recovery outcomes, and to explore the predictors of adherence trajectories. Group-based trajectory modeling showed two adherence trajectories: low (39.06%) and high (60.94%) adherence. The high adherence group had better activities of daily living (β=11.77, p<.001), instrumental activities of daily living (β=0.56, p<.01), femoral muscular strength (β=3.35, p<.01) on the fractured side and quality of life (β=-0.81, p=.02) than the low adherence group. Participants who established exercise habits (OR=6.49, p<.01) and consulted a physical therapist (OR=4.29, p=.03) during hospitalization were more likely to be in the high adherence group.

Tele-Rehabilitation Program in Idiopathic Pulmonary Fibrosis-A Single-Center Randomized Trial

We investigated the usefulness and effectiveness of tele-rehabilitation on exercise capacity in patients with idiopathic pulmonary fibrosis (IPF). A randomized study was carried out, including stable patients with IPF for 3 months of tele-rehabilitation: video and chat consultations with a physiotherapist and workout sessions with a virtual physiotherapist agent (VAPA). Moreover, 6-min walk test distance (6MWTD), forced vital capacity (FVC), diffusion capacity for carbon monoxide (DLCO), 7 days pedometry, Saint George Respiratory Questionnaire for interstitial lung disease, The King’s Brief Interstitial Lung Disease Questionnaire, and General Anxiety Disorder 7 Questionnaire were tested before and after 3 months of tele-rehabilitation, as well as after 3 and 6 months follow-up. Patient satisfaction and adherence were also measured for tele-rehabilitation with VAPA. Twenty-nine patients aged 70.9 ± 8.6 years, male 72.4%, FVC% 83.5 ± 17.7, DLCO% 50.6 ± 13.0, 6MWTD 468.4 ± 14.8 were included. Fifteen patients were randomized to tele-rehabilitation with VAPA and 14 to the control group. Differences in 6MWTD between groups were at baseline (+10 m (p = 0.11)) and after 3 (+39.5 m (p = 0.03)), 6 (+34.3 m (p = 0.02)), and 9 months (+40.5 m (p = 0.15)) follow-up. No difference was observed in pedometry and quality of life. Adherence was above 63%. Patient satisfaction was high. Tele-rehabilitation with VAPA appears to be useful in patients with IPF. Exercise capacity was better at follow up at 3 and 6 months compared with the control group. There was no change in quality of life or pedometry. Adherence and patient satisfaction were all high.

The Cost-Effectiveness of Pulmonary Rehabilitation for COPD in Different Settings: A Systematic Review

BACKGROUND

Chronic obstructive pulmonary disease (COPD) has high morbidity and mortality rates. COPD impairs body functioning, reduces quality of life, and creates a great economic burden for society. Pulmonary rehabilitation (PR) has become an important nonpharmacological treatment for COPD. This paper systematically reviews economic evaluations of PR in COPD patients in different settings.

OBJECTIVES

We aimed to understand the cost-effectiveness of PR in different settings for COPD to provide economic evidence for decision-makers.

METHODS

We searched eight databases from their 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). We used the Consensus on Health Economic Criteria to assess study quality.

RESULTS

This review included ten studies that matched the selection criteria. Five studies compared PR with usual care in primary healthcare or outpatient departments. Two 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 PR.

CONCLUSIONS

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

Patient's treatment burden related to care coordination in the field of respiratory diseases

The management of respiratory diseases requires various levels of care: multidisciplinary teams, educational and behavioural interventions, self-management and home-based technical support are vital to ensure adequate care management. However, it is often difficult to access these networks due to fragmentation of patient care and treatment burden. Care coordination aims to ensure patients have a central role and that there is continuity of care among various levels and professionals involved. Moreover, the coronavirus disease pandemic has caused strain on the global healthcare system, with care coordination becoming increasingly important in increasing the resilience of health systems, supporting healthcare professionals and ensuring the right treatment and adequate level of care for these patients.

What are the barriers to the completion of a home-based rehabilitation programme for patients awaiting surgery for lung cancer: a prospective observational study

OBJECTIVES

Home-based rehabilitation programmes (H-RPs) could facilitate the implementation of pulmonary rehabilitation prior to resection for non-small cell lung cancer (NSCLC), but their feasibility has not been evaluated. The aim of this study was to identify determinants of non-completion of an H-RP and the factors associated with medical events occurring 30 days after hospital discharge.

DESIGN

A prospective observational study.

INTERVENTION

All patients with confirmed or suspected NSCLC were enrolled in a four-component H-RP prior to surgery: (i) smoking cessation, (ii) nutritional support, (iii) physiotherapy (at least one session/week) and (iv) home cycle-ergometry (at least three times/week).

OUTCOMES

The H-RP was defined as 'completed' if the four components were performed before surgery.

RESULTS

Out of 50 patients included, 42 underwent surgery (80% men; median age: 69 (IQR 25%-75%; 60-74) years; 64% Chronic Obstructive Pulmonary Disease (COPD); 29% type 2 diabetes). Twenty patients (48%) completed 100% of the programme. The median (IQR) duration of the H-RP was 32 (19; 46) days. Multivariate analysis showed polypharmacy (n=24) OR=12.2 (95% CI 2.0 to 74.2), living alone (n=8) (single vs couple) OR=21.5 (95% CI 1.4 to >100) and a long delay before starting the H-RP (n=18) OR=6.24 (95% CI 1.1 to 36.6) were independently associated with a risk of non-completion. In univariate analyses, factors associated with medical events at 30 days were H-RP non-completion, diabetes, polypharmacy, social precariousness and female sex.

CONCLUSION

Facing multiple comorbidities, living alone and a long delay before starting the rehabilitation increase the risk of not completing preoperative H-RP.

TRIAL REGISTRATION NUMBER

NCT03530059.

BEAM study (Breathing, Education, Awareness, Movement): a randomised controlled feasibility trial of tai chi exercise in patients with COPD

BACKGROUND

Despite therapeutic advances, the management of chronic obstructive pulmonary disease (COPD) remains complex. There is growing interest in multidimensional, mind-body exercises to improve both physical and psychosocial aspects of COPD burden. Few US data are available in this population on tai chi (TC) a mind-body exercise incorporating physical activity, breathing and mindful awareness. We explored feasibility and preliminary efficacy of TC in COPD in an US academic medical setting.

METHODS

Patients with COPD Global Obstructive Lung Disease (GOLD) stages 2-4 were randomised to a 12-week TC programme or education control. At 12 weeks, those in TC were randomised again to continue in maintenance classes or not to further explore optimal duration. All groups were followed to 24 weeks. Feasibility/safety parameters were analysed descriptively. Preliminary between-group differences were estimated in symptoms (dyspnoea, fatigue), health-related quality-of-life (Chronic Respiratory Questionnaire CRQ), cognitive-emotional measures (mood, COPD self-efficacy) and functional status (6 min walk test, lower body strength, flexibility, physical activity).

RESULTS

Ninety-two subjects were randomised (N=61 TC, N=31 education). Mean age was 68±8 years, 66% male, mean forced expiratory volume in 1 s % predicted 57±13, 28% were GOLD stage 3-4. Overall retention was 85%. Nineteen adverse events occurred, most being study-unrelated COPD exacerbations. From baseline to 12 weeks, there were between-group improvements favouring TC, in CRQ-total (Cohen's d effect size (ES)=0.46; adj mean diff (AMD)=0.31), CRQ-emotion (ES=0.54; AMD=0.49), Centre for Epidemiologic Studies Depression (ES=-0.37; AMD=2.39) and Patient-Reported Outcome Measurement Information System (PROMIS)-fatigue (ES=-0.34; AMD=-0.17). From baseline to 24 weeks, there was an improvement favouring TC in CRQ-dyspnoea (ES=0.41; AMD=0.46). Among TC participants, there was a positive effect of maintenance classes on self-efficacy (ES=-0.69; AMD=-0.40), 6 min walk (ES=0.56; AMD=49.26 feet), PROMIS-fatigue (ES=-0.41; AMD=-0.28) and chair stand (0.43; AMD=0.56).

CONCLUSION

TC in patients with COPD is feasible and safe. Preliminary analyses support a potential modest role in improving quality-of-life, cognitive-emotional health and function that should be further studied.

TRIAL REGISTRATION NUMBER

NCT01551953.

IRB REFERENCE

BIDMC 2010P-000412; VA 2540.