A telerehabilitation intervention for patients with Chronic Obstructive Pulmonary Disease: a randomized controlled pilot trial

Just-in-Time Adaptive Interventions for Behavior Change in Physiological Health Outcomes and the Use Case for Knee Osteoarthritis: Systematic Review

BACKGROUND

The prevalence of knee osteoarthritis (KOA) in the adult population is high and patients profit from individualized therapy approaches. Just-in-time adaptive interventions (JITAIs) are upcoming digital interventions for behavior change.

OBJECTIVE

This systematic review summarizes the features and effectiveness of existing JITAIs regarding important physiological health outcomes and derives the most promising features for the use case of KOA.

METHODS

The electronic databases PubMed, Web of Science, Scopus, and EBSCO were searched using keywords related to JITAIs, physical activity (PA), sedentary behavior (SB), physical function, quality of life, pain, and stiffness. JITAIs for adults that focused on the effectiveness of at least 1 of the selected outcomes were included and synthesized qualitatively. Study quality was assessed with the Quality Assessment Tool Effective Public Health Practice Project.

RESULTS

A total of 45 studies with mainly weak overall quality were included in this review. The studies were mostly focused on PA and SB and no study examined stiffness. The design of JITAIs varied, with a frequency of decision points from a minute to a day, device-based measured and self-reported tailoring variables, intervention options including audible or vibration prompts and tailored feedback, and decision rules from simple if-then conditions based on 1 variable to more complex algorithms including contextual variables.

CONCLUSIONS

The use of frequent decision points, device-based measured tailoring variables accompanied by user input, intervention options tailored to user preferences, and simple decision rules showed the most promising results in previous studies. This can be transferred to a JITAI for the use case of KOA by using target variables that include breaks in SB and an optimum of PA considering individual knee load for the health benefits of patients.

Patient and Provider Experiences With Compassionate Care in Virtual Physiatry: Qualitative Study

BACKGROUND

Telemedicine in the realm of rehabilitation includes the remote delivery of rehabilitation services using communication technologies (eg, telephone, emails, and video). The widespread application of virtual care grants a suitable time to explore the intersection of compassion and telemedicine, especially due to the impact of COVID-19 and how it greatly influenced the delivery of health care universally.

OBJECTIVE

The purpose of this study was to explore how compassionate care is understood and experienced by physiatrists and patients engaged in telemedicine.

METHODS

We used a qualitative descriptive approach to conduct interviews with patients and physiatrists between June 2021 and March 2022. Patients were recruited across Canada from social media and from a single hospital network in Toronto, Ontario. Physiatrists were recruited across Canada through social media and the Canadian Association for Physical Medicine and Rehabilitation (CAPM&R) email listserve. Interviews were recorded and transcribed. Data were analyzed thematically.

RESULTS

A total of 19 participants were interviewed-8 physiatrists and 11 patients. Two themes capturing physiatrists' and patients' experiences with delivering and receiving compassionate care, especially in the context of virtual care were identified: (1) compassionate care is inherently rooted in health care providers' inner intentions and are, therefore, expressed as caring behaviors and (2) virtual elements impact the delivery and receipt of compassionate care.

CONCLUSIONS

Compassionate care stemmed from physiatrists' caring attitudes which then manifest as caring behaviors. In turn, these caring attitudes and behaviors enable individualized care and the establishment of a safe space for patients. Moreover, the virtual care modality both positively and negatively influenced how compassion is enacted by physiatrists and received by patients. Notably, there was large ambiguity around the norms and etiquette surrounding virtual care. Nonetheless, the flexibility and person-centeredness of virtual care cause it to be useful in health care settings.

Comparison of a Supervised Home-Based Tele-Rehabilitation with Center-Based Pulmonary Rehabilitation: Protocol for a Randomized Non-Inferiority Multicenter Study in Ningxia

Background

Pulmonary rehabilitation (PR) is an effective intervention for people with chronic obstructive pulmonary disease (COPD). However, fewer than 5% of eligible individuals receive pulmonary rehabilitation, largely due to limited by the accessibility of rehabilitation and difficulties associated with travel and transport. Supervised home-based tele-rehabilitation (SHTR) is an alternative model to center-based pulmonary rehabilitation. We will determine whether supervised home-based tele-rehabilitation is non-inferior to center-based pulmonary rehabilitation.

Methods

The participants will undergo an 8-week rehabilitation program. Pulmonary rehabilitation comprises four main modules: exercise training, education, nutritional support, and psychological and behavioral interventions. We mainly focus on the module of exercise training and education. The education module includes information on exercise training, nutrition, and psychology, which are presented in an educational booklet provided to each participant. Blinded assessors will evaluate the outcomes at baseline, post-intervention, and 6 months after the intervention. The primary outcome is the change in the 6-minute walking distance. Secondary outcomes will assess changes in the patients' 1-minute sit-to-stand test, maximal inspiratory pressure (MIP), scales (CAT, mMRC, HAD), diaphragm ultrasound (TD, DE, DIF), changes in extrathoracic muscle volume and mass, completion rate of patient exercise prescriptions, occurrence of adverse events, as well as disease exacerbation and rehospitalization rates after rehabilitation and during the 6-month follow-up.

Discussion

In order to improve the accessibility of pulmonary rehabilitation and patient-related outcomes, it is necessary to propose an alternative model of pulmonary rehabilitation. This trial will establish whether a supervised home-based tele-rehabilitation is not inferior to traditional center-based pulmonary rehabilitation.

Trial Registration

Chinese Clinical Trial Registry ChiCTR2300076969. Registered on October 25, 2023.

The Effects of Digital Health Interventions for Pulmonary Rehabilitation in People with COPD: A Systematic Review of Randomized Controlled Trials

Background and Objectives: Chronic Obstructive Pulmonary Disease (COPD) is the third most common cause of death globally. Pulmonary rehabilitation (PR) programmes are important to reduce COPD symptoms and improve the quality of life of people with COPD. Digital health interventions have recently been adopted in PR programmes, which allow people with COPD to participate in such programmes with low barriers. The aim of this study is to review and discuss the reported effects of digital health interventions on PR outcomes in people with COPD. Materials and Methods: To achieve the study goals, a systematic literature search was conducted using PubMed (MEDLINE), CINAHL, AMED, SPORTDiscus and the Physiotherapy Evidence Database. Randomised clinical trials (RCTs) were included if they met specified criteria. Two reviewers independently checked titles, abstracts, and performed full-text screening and data extraction. The quality assessment and risk of bias were performed in accordance with the PEDRO scale and Cochrane Risk of Bias tool 2, respectively. Results: Thirteen RCTs were included in this systematic review with 1525 participants with COPD. This systematic review showed the potential positive effect of digital health PR on the exercise capacity-measured by 6- and 12-min walking tests, pulmonary function, dyspnoea and health-related quality of life. There was no evidence for advantages of digital health PR in the improvement of anxiety, depression, and self-efficacy. Conclusions: Digital health PR is more effective than traditional PR in improving the pulmonary and physical outcomes for people with COPD, but there was no difference between the two PR programmes in improving the psychosocial outcomes. The certainty of the findings of this review is affected by the small number of included studies.

Effect of internet-based pulmonary rehabilitation on physical capacity and health-related life quality in patients with chronic obstructive pulmonary disease-a systematic review and meta-analysis

PURPOSE

Pulmonary rehabilitation (PR) is now recognized as the most effective treatments for individuals with chronic obstructive pulmonary disease (COPD), internet-based PR arises a promising method. The aim of this study was to conduct a systematic review and meta-analysis for assessing the effect of internet-based PR programs on physical capacity and health-related quality of life in patients with COPD.

MATERIALS AND METHODS

Randomized controlled trials were identified through systematically searches in PubMed, EMBASE, web of science, CENTRAL, Cochrane Library, and Google Scholar databases.

RESULTS

Twelve studies (1433 patients) were included. For physical capacity, there was no significant difference between groups was found according to the 6-min walk test (6MWT) (MD10.42, 95% CI -2.92 to 23.77, p = 0.13, I2 = 0%). For the health-related quality of life, no significant difference between groups was found regarding the St George's Respiratory Questionnaire (SGRQ) (MD -0.64, 95% CI -3.52 to 2.23, p = 0.66), COPD assessment test (CAT)(MD -0.34, 95% CI -1.62 to 0.94, p = 0.60), modified Medical Research Council scale (mMRC)(MD 0.17, 95% CI -0.06 to 0.39, p = 0.15) and Chronic Respiratory Questionnaire (CRQ)(MD 1.32 95% CI -5.88 to 8.53, p = 0.72).

CONCLUSIONS

This study has established the potential for delivery of PR via the internet in demonstrating non-inferiority of physical capacity and health-related quality of life (HRQoL) compared with conventional PR.IMPLICATIONS FOR REHABILITATIONLong-term rehabilitation training for patients with chronic obstructive pulmonary disease needs a more convenient and feasible way.In this study, internet-based rehabilitation showed similar effects as conventional rehabilitation on physical activity and health-related quality of life.Internet-based rehabilitation strategies would be helpful for this population.All internet-based rehabilitation strategies should be simple and sustainable.

Telehealth-Enabled In-Home Elbow Rehabilitation for Brachial Plexus Injuries Using Deep-Reinforcement-Learning-Assisted Telepresence Robots

Due to damage to the network of nerves that regulate the muscles and feeling in the shoulder, arm, and forearm, brachial plexus injuries (BPIs) are known to significantly reduce the function and quality of life of affected persons. According to the World Health Organization (WHO), a considerable share of global disability-adjusted life years (DALYs) is attributable to upper limb injuries, including BPIs. Telehealth can improve access concerns for patients with BPIs, particularly in lower-middle-income nations. This study used deep reinforcement learning (DRL)-assisted telepresence robots, specifically the deep deterministic policy gradient (DDPG) algorithm, to provide in-home elbow rehabilitation with elbow flexion exercises for BPI patients. The telepresence robots were used for a six-month deployment period, and DDPG drove the DRL architecture to maximize patient-centric exercises with its robotic arm. Compared to conventional rehabilitation techniques, patients demonstrated an average increase of 4.7% in force exertion and a 5.2% improvement in range of motion (ROM) with the assistance of the telepresence robot arm. According to the findings of this study, telepresence robots are a valuable and practical method for BPI patients' at-home rehabilitation. This technology paves the way for further research and development in telerehabilitation and can be crucial in addressing broader physical rehabilitation challenges.

Comparative effectiveness of interventions on promoting physical activity in older adults: A systematic review and network meta-analysis

Background

Despite the well-established health benefits of physical activity, a large population of older adults still maintain sedentary life style or physical inactivity. This network meta-analysis (NMA) aimed to compare the effectiveness of wearable activity tracker-based intervention (WAT), electronic and mobile health intervention (E&MH), structured exercise program intervention (SEP), financial incentive intervention (FI) on promoting physical activity and reducing sedentary time in older adults.

Methods

The systematic review based on PRISMA guidelines, a systematic literature search of PubMed, Web of Science, Google Scholar, EMbase, Cochrane Library, Scopus were searched from inception to December 10th 2022. The randomized controlled trials (RCT) were included. Two reviewers independently conducted study selection, data extraction, risk of bias and certainty of evidence assessment. The effect measures were standard mean differences (SMD) and 95% confidence interval (CI) in daily steps, moderate-to-vigorous physical activity (MVPA) and sedentary time.

Results

A total of 69 studies with 14,120 participants were included in the NMA. Among these included studies, the results of daily steps, MVPA and sedentary time was reported by 55, 25 and 15 studies, respectively. The NMA consistency model analysis suggested that the following interventions had the highest probability (surface under the cumulative ranking, SUCRA) of being the best when compared with control: FI + WAT for daily steps (SUCRA = 96.6%; SMD = 1.32, 95% CI:0.77, 1.86), WAT + E&MH + SEP for MVPA (SUCRA = 91.2%; SMD = 0.94, 95% CI: 0.36, 1.52) and WAT + E&MH + SEP for sedentary time (SUCRA = 80.3%; SMD = -0.50, 95% CI: -0.87, -0.14). The quality of the evidences of daily steps, MVPA and sedentary time was evaluated by very low, very low and low, respectively.

Conclusions

In this NMA, there's low quality evidence that financial incentive combined with wearable activity tracker is the most effective intervention for increasing daily steps of older adults, wearable activity tracker combined with electronic and mobile health and structured exercise program is the most effective intervention to help older adults to increase MVPA and reduce sedentary time.

Effects of Home-Based Training with Internet Telehealth Guidance in COPD Patients Entering Pulmonary Rehabilitation: A Systematic Review

Objective

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death worldwide. Telehealth rehabilitation may offer new opportunities in patient therapy. This systematic review aimed to evaluate the effects of internet-mediated telerehabilitation and compare them with the outcomes of conventional pulmonary rehabilitation in COPD patients.

Methods

Electronic databases PubMed, Prospero, Scopus, and Cochrane were searched for randomized controlled trials from January 2005 to December 2021. Two investigators reviewed studies for relevance and extracted study population, methods, and results data.

Results

Ten studies were eligible for systematic review from the initial selection (n = 1492). There was considerable heterogeneity in telerehabilitation approaches. Functional exercise capacity and quality of life were assessed in all studies. None of the results were inferior to conventional care. High adherence and high levels of safety were observed.

Conclusion

Telerehabilitation in COPD patients is a safe therapy approach that increases and maintains functional exercise capacity and quality of life, making it an equivalent option to conventional outpatient rehabilitation. However, there is currently a lack of a unified approach to the composition of therapy and the use of technology, which needs to be addressed in the future.

Technological features of smartphone apps for physical activity promotion in patients with COPD: A systematic review

INTRODUCTION

Low physical activity (PA) levels have a negative impact on the health status of patients with Chronic Obstructive Pulmonary Disease (COPD). Smartphone applications (apps) focused on PA promotion may mitigate this problem; however, their effectiveness depends on patient adherence, which can be influenced by the technological features of the apps. This systematic review identified the technological features of smartphone apps aiming to promote PA in patients with COPD.

METHODS

A literature search was performed in the databases ACM Digital Library, IEEE Xplore, PubMed, Scopus and Web of Science. Papers including the description of a smartphone app for PA promotion in patients with COPD were included. Two researchers independently selected studies and scored the apps features based on a previously developed framework (38 possible features).

RESULTS

Twenty-three studies were included and 19 apps identified, with an average of 10 technological features implemented. Eight apps could be connected to wearables to collect data. The categories 'Measuring and monitoring' and 'Support and Feedback' were present in all apps. Overall, the most implemented features were 'progress in visual format' (n = 13), 'advice on PA' (n = 14) and 'data in visual format' (n = 10). Only three apps included social features, and two included a web-based version of the app.

CONCLUSIONS

The existing smartphone apps include a relatively small number of features to promote PA, which are mostly related to monitoring and providing feedback. Further research is warranted to explore the relationship between the presence/absence of specific features and the impact of interventions on patients' PA levels.

Is telerehabilitation an effective maintenance strategy for patients with chronic obstructive pulmonary diseases: a systematic review

BACKGROUND

Pulmonary rehabilitation (PR) has proven to improve the physical and psychosocial function in patients with chronic obstructive pulmonary disease (COPD). However, the gains achieved during pulmonary rehabilitation diminish over time without an effective maintenance strategy. With several factors affecting access to pulmonary rehabilitation, calls for innovative models were made, which saw the emergence of studies exploring telerehabilitation (TR) as an alternative to traditional pulmonary rehabilitation models. Although there are current reviews exploring the effectiveness of telerehabilitation as an alternative for conventional PR, no review has considered telerehabilitation effectiveness in the long term. Hence, this review aims at examining the effectiveness of telerehabilitation following to pulmonary rehabilitation in patients with chronic obstructive pulmonary disease.

MAIN BODY

A systematic review of the literature using CINAHL, MEDLINE, SCOPUS, Web of science PEDRO, AMED and EMBASE databases was conducted to assess the effectiveness of telerehabilitation following PR in patients with COPD. Health-related quality of life (HRQoL) and exercise capacity was maintained within 6-12 months of a TR maintenance programme. However, there was no significant increase in HRQoL and exercise capacity between the intervention and control groups in 6-12 months.

CONCLUSIONS

This review suggests that a TR maintenance strategy effectively maintains benefits gained and may improve HRQoL and exercise capacity within 6-12 months for patients with COPD. Nonetheless, it is impossible to extrapolate the findings to the general population due to the paucity of included studies. Further high quality randomised controlled trials examining TR in the long-term is required in the future.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1186/s42269-023-00980-8.

The effectiveness of wearable activity trackers for increasing physical activity and reducing sedentary time in older adults: A systematic review and meta-analysis

Background

Traditional interventions such as education and counseling are successful in increasing physical activity (PA) participation, but are usually labor and resource intensive. Wearable activity trackers can objectively record PA and provide feedback to help users to achieve activity goals and are an increasingly popular tool among adults used to facilitate self-monitoring of PA. However, no reviews systematically explored the roles of wearable activity trackers in older populations.

Methods

We searched PubMed, Web of Science, Google Scholar, Embase, Cochrane Library, and Scopus from inception to September 10, 2022. Randomized controlled trials were included. Two reviewers independently conducted study selection, data extraction, risk of bias, and certainty of evidence assessment. A random-effects model was used to evaluate the effect size.

Results

A total of 45 studies with 7144 participants were included. A wearable activity tracker was effective in increasing daily steps (standard mean differences (SMD) = 0.59, 95% confidence interval (CI) (0.44, 0.75)), weekly moderate-to-vigorous PA (MVPA) (SMD = 0.54, 95% CI (0.36, 0.72)), and total daily PA (SMD = 0.21, 95% CI (0.01, 0.40)) and reducing sedentary time (SMD = -0.10, 95% CI (-0.19, -0.01)). Subgroup analysis showed that the effectiveness of wearable activity trackers for daily steps was not influenced by participants and intervention features. However, wearable activity trackers seemed more effective in promoting MVPA of participant's age <70 than participant's age ≥70. In addition, wearable activity trackers incorporated with traditional intervention components (e.g. telephone counseling, goal setting, and self-monitoring) could better promote MVPA than alone use. Short-term interventions potentially achieve better MVPA increase than long-term.

Conclusion

This review showed that wearable activity trackers are an effective tool to increase PA for the old population and also favor reducing sedentary time. When used together with other interventions, wearable activity trackers can achieve better MVPA increase, especially in the short term. However, how to more effectively improve the effectiveness of wearable activity trackers is an important direction of future research.

Telerehabilitation as a Form of Pulmonary Rehabilitation in Chronic Lung Disease: A Systematic Review

Introduction: Tele-rehabilitation is increasingly used to deliver pulmonary rehabilitation. The aim of this systematic review was to compare the effect between tele-pulmonary rehabilitation and classical supervised pulmonary rehabilitation. Method: Three databases were analysed (PubMed, PEDro, Scopus). The selection and evaluation of studies followed the PRISMA guidelines. The risk of bias was evaluated using the PEDro Scale. Results: From the initial selection (n = 245), ten studies were retrieved, including from 10 to 67 patients. All but two (IPF) included patients with COPD. Based on the FEV1, patients with COPD were mainly categorised as moderate and severe. The teleactivities were heterogenous in terms of proposed exercises and way of settings and often not in agreement with the guidelines about pulmonary rehabilitation. Despite this, the effects of the interventions were globally positive on functional exercise capacity, quality of life, anxiety and depression, and impact of COPD on personal life but not on dyspnoea. The PEDro scores varied from 4 to 8. The adherence was higher than 80% when supervision during the exercise was included. Conclusion: This review demonstrated that the telerehabilitation is safe and well accepted by the patients, and could be considered as one option of classical pulmonary rehabilitation to improve the functional exercise capacity, quality of life, anxiety and depression, and the impact of COPD on personal’s life. This conclusion cannot be extrapolated to the other chronic lung diseases due to the lack of data.

Telerehabilitation for upper limb disabilities: a scoping review on functions, outcomes, and evaluation methods

Background

Upper limb (UL) disabilities have attracted worldwide attention due to the high economic costs of health care and the negative effects on the quality of life of patients with these disabilities. Telerehabilitation technologies are one of the most important ways to reduce rehabilitation costs and increase the quality of life of patients. Therefore, the aim of this study was to investigate the role of telerehabilitation in improving the health status of patients with upper limb disabilities.

Methods

This scoping review was conducted by searching the Web of Science, PubMed, and Scopus until July 30, 2021. We used a data extraction form with 18 fields to extract data from primary studies. The selection of articles and data extraction was made by four researchers using a data collection form based on inclusion and exclusion criteria. Disagreements were resolved through consultation with the fifth and sixth researchers.Inclusion criteria were studies published in English, studies on upper limb disability, and telerehabilitation based on any technology (synchronous telerehabilitation, asynchronous, or both). Exclusion criteria were articles that did not focus on telerehabilitation and upper limb disabilities. Also, books, book chapters, letters to the editor, and conference abstracts were also removed.

Results

A total of 458 articles were retrieved, and after removing irrelevant and duplicate articles, 29 articles were finally included in this review. Most telerehabilitation was performed for patients with stroke (65%). Among the 15 different services provided with telerehabilitation technologies, "Evaluation of exercises and also a musculoskeletal function of patients by the therapist","Recording of patients' rehabilitation exercises and sending them to the therapist” and "Prescribing new rehabilitation exercises by the therapist" were the most widely used services, respectively. Virtual reality technologies, smart wearables, and robots were used to provide telerehabilitation services. Among the 13 types of evaluation used for telerehabilitation systems, “Evaluation and measurement of upper limb function” was the most used evaluation in the studies. "Improvement in musculoskeletal functions”, "Increasing patients' interest and motivation to perform rehabilitation exercises", and "Increasing adherence to rehabilitation exercises and greater participation in treatment processes" were the most important outcomes, respectively.

Conclusion

Our findings indicate that telerehabilitation provides individuals with equitable access to rehabilitation services, improves musculoskeletal function, and empowers individuals by providing a variety of rehabilitation capabilities.

[Efficacy of tele-rehabilitation in patients with chronic obstructive pulmonary disease: a systematic review]

The COVID-19 pandemic has required the use of new technologies to carry out rehabilitation sessions for COP D remotely. The aim of this systematic review was to analyse the available evidence on the efficacy of telerehabilitation in COPD patients. PubMed, WOS, PEDro and Cochrane databases were consulted. The systematic review included nine clinical trials, 55.5% of which display good methodological quality. The most commonly used rehabilitation methods were applications or software for real-time video-calls, visualisation of exercises and recording progress. TR was as effective as outpatient pulmonary rehabilitation, with greater benefits in functional capacity, self-efficacy, mental health, exacerbations and emergency care visits, offering a cost-effective option with high patient satisfaction. The small number of studies and the variety of rehabilitation methods examined limit the value of the evidence obtained.

Effectiveness of remote home monitoring for patients with Chronic Obstructive Pulmonary Disease (COPD): systematic review

Background

Although remote home monitoring (RHM) has the capacity to prevent exacerbations in patients with chronic obstructive pulmonary disease (COPD), evidence regarding its effectiveness remains unclear. The objective of this study was to determine the effectiveness of RHM in patients with COPD.

Methods

A systematic review of the scholarly literature published within the last 10 years was conducted using internationally recognized guidelines. Search strategies were applied to several electronic databases and clinical trial registries through March 2020 to identify studies comparing RHM to ‘no remote home monitoring’ (no RHM) or comparing RHM with provider’s feedback to RHM without feedback. To critically appraise the included randomized studies, the Cochrane Collaboration risk of bias tool (ROB) was used. The quality of included non-randomized interventional and comparative observational studies was evaluated using the ACROBAT-NRSI tool from the Cochrane Collaboration. The quality of evidence relating to key outcomes was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE) on the following: health-related quality of life (HRQoL), patient experience and number of exacerbations, number of emergency room (ER) visits, COPD-related hospital admissions, and adherence as the proportion of patients who completed the study. Three independent reviewers assessed methodologic quality and reviewed the studies.

Results

Seventeen randomized controlled trials (RCTs) and two comparative observational studies were included in the review. The primary finding of this systematic review is that a considerable amount of evidence relating to the efficacy/effectiveness of RHM exists, but its quality is low. Although RHM is safe, it does not appear to improve HRQoL (regardless of the type of RHM), lung function or self-efficacy, or to reduce depression, anxiety, or healthcare resource utilization. The inclusion of regular feedback from providers may reduce COPD-related hospital admissions. Though adherence RHM remains unclear, both patient and provider satisfaction were high with the intervention.

Conclusions

Although a considerable amount of evidence to the effectiveness of RHM exists, due to heterogeneity of care settings and the low-quality evidence, they should be interpreted with caution.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07938-y.

The Effectiveness of a Computer-Tailored Web-Based Physical Activity Intervention Using Fitbit Activity Trackers in Older Adults (Active for Life): Randomized Controlled Trial

BACKGROUND

Physical activity is an integral part of healthy aging; yet, most adults aged ≥65 years are not sufficiently active. Preliminary evidence suggests that web-based interventions with computer-tailored advice and Fitbit activity trackers may be well suited for older adults.

OBJECTIVE

The aim of this study was to examine the effectiveness of Active for Life, a 12-week web-based physical activity intervention with 6 web-based modules of computer-tailored advice to increase physical activity in older Australians.

METHODS

Participants were recruited both through the web and offline and were randomly assigned to 1 of 3 trial arms: tailoring+Fitbit, tailoring only, or a wait-list control. The computer-tailored advice was based on either participants' Fitbit data (tailoring+Fitbit participants) or self-reported physical activity (tailoring-only participants). The main outcome was change in wrist-worn accelerometer (ActiGraph GT9X)-measured moderate to vigorous physical activity (MVPA) from baseline to after the intervention (week 12). The secondary outcomes were change in self-reported physical activity measured by means of the Active Australia Survey at the midintervention point (6 weeks), after the intervention (week 12), and at follow-up (week 24). Participants had a face-to-face meeting at baseline for a demonstration of the intervention and at baseline and week 12 to return the accelerometers. Generalized linear mixed model analyses were conducted with a γ distribution and log link to compare MVPA and self-reported physical activity changes over time within each trial arm and between each of the trial arms.

RESULTS

A total of 243 participants were randomly assigned to tailoring+Fitbit (n=78, 32.1%), tailoring only (n=96, 39.5%), and wait-list control (n=69, 28.4%). Attrition was 28.8% (70/243) at 6 weeks, 31.7% (77/243) at 12 weeks, and 35.4% (86/243) at 24 weeks. No significant overall time by group interaction was observed for MVPA (P=.05). There were no significant within-group changes for MVPA over time in the tailoring+Fitbit group (+3%, 95% CI -24% to 40%) or the tailoring-only group (-4%, 95% CI -24% to 30%); however, a significant decline was seen in the control group (-35%, 95% CI -52% to -11%). The tailoring+Fitbit group participants increased their MVPA 59% (95% CI 6%-138%) more than those in the control group. A significant time by group interaction was observed for self-reported physical activity (P=.02). All groups increased their self-reported physical activity from baseline to week 6, week 12, and week 24, and this increase was greater in the tailoring+Fitbit group than in the control group at 6 weeks (+61%, 95% CI 11%-133%).

CONCLUSIONS

A computer-tailored physical activity intervention with Fitbit integration resulted in improved MVPA outcomes in comparison with a control group in older adults.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12618000646246; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12618000646246.

A Structured Review of Commercially Available Cardiac Rehabilitation mHealth Applications Using the Mobile Application Rating Scale

PURPOSE

This study systematically evaluated the quality and functionalities of patient-facing, commercially available mobile health (mHealth) apps for cardiac rehabilitation (CR).

METHODS

We performed our search in two of the most widely used commercial mobile app stores: Apple iTunes Appstore and Google Play Store (Android apps). Six search terms were used to query relevant CR apps: "cardiac rehabilitation," "heart disease and remote therapy," "heart failure exercise," "heart therapy and cardiac recovery," "cardiac recovery," and "heart therapy." App quality was evaluated using the Mobile Application Rating Scale (MARS). App functionality was evaluated using the IQVIA functionality scale, and app content was evaluated against the American Heart Association guidelines for CR. Apps meeting our inclusion criteria were downloaded and evaluated by two to three reviewers, and interclass correlations between reviewers were calculated.

RESULTS

We reviewed 3121 apps and nine apps met our inclusion criteria. On average, the apps scored a 3.0 on the MARS (5-point Likert scale) for overall quality. The two top-ranking mHealth apps for CR for all three quality, functionality, and consistency with evidence-based guidelines were My Cardiac Coach and Love My Heart for Women, both of which scored ≥4.0 for behavior change.

CONCLUSION

Overall, the quality and functionality of free apps for mobile CR was high, with two apps performing the best across all three quality categories. High-quality CR apps are available that can expand access to CR for patients with cardiovascular disease.

Design and delivery of home-based telehealth pulmonary rehabilitation programs in COPD: A systematic review and meta-analysis

RATIONALE

Home-based telehealth pulmonary rehabilitation (HTPR) for chronic obstructive pulmonary disease (COPD) is increasingly common partly due to the COVID-19 pandemic. However, optimal HTPR programming has not been described. This review provides a comprehensive overview of the design, delivery, and effects of HTPR for people with COPD.

METHODS

Relevant databases were searched to July 2021 for studies on adults with COPD utilizing information or communication technology to monitor or deliver HTPR. A meta-analysis was performed on a subset of randomized controlled trials.

RESULTS

Of 3124 records retrieved, 38 studies evaluating 1993 individuals with stable COPD (age 54-75 and FEV1 31-92% predicted) were included. Program components included exercise and education (n = 17) or exercise alone (n = 15) with in-clinic baseline assessments commonly conducted (n = 26). Few trials (n = 7) featured synchronous virtual exercise supervision. Aerobic exercise commonly involved walking (n = 14) and cycling (n = 11) and most programs included resistance training (n = 25). Exercise progressions and emergency action plans were inconsistently reported. Meta-analysis demonstrated HTPR was comparable to outpatient PR and had a greater effect than usual care for the modified Medical Research Council dyspnea scale (mean difference [95 %CI]: -0.49 [-0.77, -0.22], p < 0.01) and COPD Assessment Test score (-4.90 [-7.13, -2.67], p < 0.01). Neither HTPR nor outpatient PR impacted sedentary time or step count. Only 6% of studies reported race and no studies reported participant ethnicity.

CONCLUSION

This review revealed the heterogeneity of HTPR program designs in COPD. HTPR programs had similar effects to outpatient PR programs and greater effects than usual care for people with COPD.

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.

Impact of tele rehabilitation on clinical outcomes in patients recovering from COVID-19: a preliminary investigation

Pulmonary rehabilitation has proven to be an effective therapeutic intervention for people with chronic respiratory disease. Considering the highly contagious nature of coronavirus disease (COVID-19), it becomes imperative to develop a method which can effectively improve clinical disease outcomes of these patients without any physical contact. The purpose of the study was to investigate the impact of tele rehabilitation on dyspnoea, endurance and quality-of-life in patients recovering from COVID 19. Thirty-two participants (age: 42.5±13.94, height: 165.8±10.06, weight: 68.5±9.63, body mass index: 25.0±3.61) who are recovering from COVID-19 were recruited as per the eligibility criteria. They were randomly allocated into two groups, Tele rehabilitation (n=16) and Control (n=16) by lottery method. All the selected participants were assessed at baseline for perceived dyspnoea, endurance and quality-of-life. Patients in the Tele rehabilitation group received 14 sessions of rehabilitation on alternate days online via google meet over a period of 28 days. Control group received usual care during the study period. Standard statistical tests were employed to test the study hypothesis. Results suggested a significant improvement in both dyspnoea (P=0.001) and endurance (P<0.001) in response to tele rehabilitation. Domains of quality-of-life such as physical role (P=0.02), vitality (P=0.04), emotional role (P=0.03), mental health (P=0.02) and physical components score (P=0.007) also showed significant improvement with tele rehabilitation in patients recovering from COVID-19. Findings of this preliminary study concludes that tele rehabilitation may be considered a treatment of choice in patients recovering from COVID-19 for improving outcomes of dyspnoea, endurance and quality-of-life.

Efficacy of respiratory tele-rehabilitation in COPD patients: Systematic review and meta-analysis

Pulmonary rehabilitation (PR) is a proven and effective intervention for chronic obstructive pulmonary disease (COPD). The recent pandemic has raised interest on new services, such as telerehabilitation (Tele-R). The aim of this study was to systematically review the effects of Tele-R in COPD on: 1) exercise capacity evaluated by the 6-minute walk test (6MWT); 2) dyspnea (modified Medical Research Council - mMRC); 3) COPD control (the COPD assessment test - CAT). The analysis compared Tele-R versus no rehabilitation and Tele-R versus center-based rehabilitation. This meta-analysis was undertaken according to PRISMA recommendations. This pair-wise meta-analysis included data obtained from studies that enrolled 758 COPD patients. The tele-R compared to no rehabilitation improved the 6MWT distance of 48 m (CI: 24, 72; p<0.001) and the mMRC of -1.02U (CI: -1.49, -0.59; p<0.001), and the CAT of -5.74U (CI: -7.42, -0.407; p<0.001). The tele-R compared to center-based rehabilitation showed no difference on 6MWT distance (p=0.563), mMRC (p=0.911), and CAT (p=0.85). In COPD patients, Tele-R is effective in improving exercise tolerance and patient-reported outcomes and it seems to be a valid alternative to center-based rehabilitation, but more studies are needed to better understand how to select the right patients and which kind of Tele-R is more appropriate.

Web Portals for Patients With Chronic Diseases: Scoping Review of the Functional Features and Theoretical Frameworks of Telerehabilitation Platforms

Background

The COVID-19 pandemic has required an increased need for rehabilitation activities applicable to patients with chronic diseases. Telerehabilitation has several advantages, including reducing clinic visits by patients vulnerable to infectious diseases. Digital platforms are often used to assist rehabilitation services for patients in remote settings. Although web portals for medical use have existed for years, the technology in telerehabilitation remains a novel method.

Objective

This scoping review investigated the functional features and theoretical approaches of web portals developed for telerehabilitation in patients with chronic diseases.

Methods

PubMed and Web of Science were reviewed to identify articles associated with telerehabilitation. Of the 477 nonduplicate articles reviewed, 35 involving 14 portals were retrieved for the scoping review. The functional features, targeted diseases, and theoretical approaches of these portals were studied.

Results

The 14 portals targeted patients with chronic obstructive pulmonary disease, cardiovascular, osteoarthritis, multiple sclerosis, cystic fibrosis diseases, and stroke and breast cancer survivors. Monitoring/data tracking and communication functions were the most common, followed by exercise instructions and diary/self-report features. Several theoretical approaches, behavior change techniques, and motivational techniques were found to be utilized.

Conclusions

The web portals could unify and display multiple types of data and effectively provide various types of information. Asynchronous correspondence was more favorable than synchronous, real-time interactions. Data acquisition often required assistance from other digital tools. Various functions with patient-centered principles, behavior change strategies, and motivational techniques were observed for better support shifting to a healthier lifestyle. These findings suggested that web portals for telerehabilitation not only provided entrance into rehabilitation programs but also reinforced participant-centered treatment, adherence to rehabilitation, and lifestyle changes over time.

[Respiratory telerehabilitation in cases of COPD]

Telerehabilitation brings together a set of rehabilitation practices applied remotely by means of information and communication technologies. Even though it has been taking on increasing importance in many health fields over 10 years, telerehabilitation had yet to find its place in pulmonary rehabilitation before 2020, when the pandemic situation impelled numerous teams to put it to work. Pilot studies on respiratory diseases, primarily COPD, along with recent data from randomized or non-randomized studies, have enhanced our understanding of "remote" practice. In this review of the literature, we will show that pulmonary telerehabilitation is feasible, safe and likely to yield short-term (and possibly longer term) effects generally similar to those achieved in the pulmonary rehabilitation programs of specialized centers, especially as regards some indicators of exercise tolerance, dyspnea or patient quality of life. However, the number of studies and patients included in these programs remains too limited in terms of modalities, duration, long-term effects, or adaptations in case of exacerbation to be the subject of recommendations. The potential of respiratory telerehabilitation justifies continuing clinical trials and experiments, which need to be coordinated with the interventions characterizing a conventional program.

Home-Based Tele-Exercise in Musculoskeletal Conditions and Chronic Disease: A Literature Review

Exercise training is an essential component in the treatment or rehabilitation of various diseases and conditions. However, barriers to exercise such as the burdens of travel or time may hinder individuals' ability to participate in such training programs. Advancements in technology have allowed for remote, home-based exercise training to be utilized as a supplement or replacement to conventional exercise training programs. Individuals in these home-based exercise programs are able to do so under varying levels of supervision from trained professionals, with some programs having direct supervision, and others having little to no supervision at all. The purpose of this review is to examine the use of home-based, tele-exercise training programs for the treatment of different disease states and conditions, and how these programs compare to conventional clinic-based exercise training programs.

A Home-Based Multimedia Pulmonary Rehabilitation Program Improves Clinical Symptoms and Physical Performance of Patients with Chronic Obstructive Pulmonary Disease

Home-based pulmonary rehabilitation can decrease symptoms in chronic obstructive pulmonary disease (COPD) patients. The purpose of this study was to compare the effects of a home-based pulmonary rehabilitation by instructive multimedia in the form of videos and flip charts on clinical symptoms and exercise performance in COPD patients. An eight-week home-based pulmonary rehabilitation program was performed with twenty COPD patients older than 60 years of age with moderate to severe stages. They were separated into two groups: a multimedia group (n = 10) and a control group, which was only provided with telephone monitoring (n = 10). Clinical symptoms were measured by using the clinical COPD questionnaire (CCQ), and exercise performance was measured using a six-minute walk test (6MWT) and an upper-lower limb muscle strengthening test. After 8 weeks, the results showed that both groups showed a statistically significant decrease in the CCQ (p < 0.05). The multimedia group showed a statistically significant increase in the lower-limb muscle strengthening (p < 0.05), while the control group was not found to show a statistically significant increase in the lower-limb muscle strengthening. Therefore, a pulmonary rehabilitation program using multimedia at home can lessen symptoms and improve exercise performance in COPD patients.

Development features and study characteristics of mobile health apps in the management of chronic conditions: a systematic review of randomised trials

COVID-19 pandemic challenges have accelerated the reliance on digital health fuelling the expanded incorporation of mobile apps into healthcare services, particularly for the management of long-term conditions such as chronic diseases (CDs). However, the impact of health apps on outcomes for CD remains unclear, potentially owing to both the poor adoption of formal development standards in the design process and the methodological quality of studies. A systematic search of randomised trials was performed on Medline, ScienceDirect, the Cochrane Library and Scopus to provide a comprehensive outlook and review the impact of health apps on CD. We identified 69 studies on diabetes (n = 29), cardiovascular diseases (n = 13), chronic respiratory diseases (n = 13), cancer (n = 10) or their combinations (n = 4). The apps rarely adopted developmental factors in the design stage, with only around one-third of studies reporting user or healthcare professional engagement. Apps differed significantly in content, with a median of eight behaviour change techniques adopted, most frequently pertaining to the ‘Feedback and monitoring’ (91%) and ‘Shaping knowledge’ (72%) categories. As for the study methodologies, all studies adopted a traditional randomised control trial (RCT) design, with relatively short follow-ups and limited sample sizes. Findings were not significant for the majority of studies across all CD, with most RCTs revealing a high risk of bias. To support the adoption of apps for CD management, this review reinforces the need for more robust development and appropriate study characteristics to sustain evidence generation and elucidate whether study results reflect the true benefits of apps or a biased estimate due to unsuitable designs.

Self-Efficacy of Older People Using Technology to Self-Manage COPD, Hypertension, Heart Failure, or Dementia at Home: An Overview of Systematic Reviews

BACKGROUND AND OBJECTIVES

Although telehealth research among the general population is voluminous, the quality of studies is low and results are mixed. Little is known specifically concerning older people and their self-efficacy to engage with and benefit from such technologies. This article reviews the evidence for which self-care telehealth technology supports the self-efficacy of older people with long-term conditions (LTCs) living at home.

RESEARCH DESIGN AND METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement (PRISMA) guidelines, this overview of systematic reviews focused on four LTCs and the concept of "self-efficacy." Quality was appraised using R-AMSTAR and study evaluation was guided by the PRISMS taxonomy for reporting of self-management support. Heterogeneous data evidencing technology-enhanced self-efficacy were narratively synthesized.

RESULTS

Five included articles contained 74 primary studies involving 9,004 participants with chronic obstructive pulmonary disease, hypertension, heart failure, or dementia. Evidence for self-care telehealth technology supporting the self-efficacy of older people with LTCs living at home was limited. Self-efficacy was rarely an outcome, also attrition and dropout rates and mediators of support or education. The pathway from telehealth to self-efficacy depended on telehealth modes and techniques promoting healthy lifestyles. Increased self-care and self-monitoring empowered self-efficacy, patient activation, or mastery.

DISCUSSION AND IMPLICATIONS

Future research needs to focus on the process by which the intervention works and the effects of mediating variables and mechanisms through which self-management is achieved. Self-efficacy, patient activation, and motivation are critical components to telehealth's adoption by the patient and hence to the success of self-care in self-management of LTCs. Their invisibility as outcomes is a limitation.

Actigraphy informs distinct patient-centered outcomes in Pre-COPD

BACKGROUND

Actigraphy can provide useful patient-centered outcomes for quantification of physical activity in the "real-world" setting.

METHODS

To characterize the relationship of actigraphy outputs with "in-laboratory" measures of cardiopulmonary function and respiratory symptoms in pre-COPD, we obtained actigraphy data for 8 h/day for 5 consecutive days a week before in-laboratory administration of respiratory questionnaires, PFT, and CPET to a subgroup of subjects participating in the larger study of the health effects of exposure to secondhand tobacco smoke who had air trapping but no spirometric obstruction (pre-COPD). Using machine learning approaches, we identified the most relevant actigraphy predictors and examined their associations with symptoms, lung function, and exercise outcomes.

RESULTS

Sixty-one subjects (age = 66±7 years; BMI = 24±3 kg/m²; FEV₁/FVC = 0.75 ± 0.05; FEV₁ = 103 ± 17 %predicted) completed the nested study. In the hierarchical cluster analysis, the activity, distance, and energy domains of actigraphy, including moderate to vigorous physical activity, were closely correlated with each other, but were only loosely associated with spirometric and peak exercise measures of oxygen consumption, ventilation, oxygen-pulse, and anaerobic threshold (VO_2AT), and were divergent from symptom measures. Conversely, the sedentary domain clustered with respiratory symptoms, air trapping, airflow indices, and ventilatory efficiency. In Regression modeling, sedentary domain was inversely associated with baseline lung volumes and tidal breathing at peak exercise, while the activity domains were associated with VO_2AT. Respiratory symptoms and PFT data were not associated with actigraphy outcomes.

DISCUSSION

Outpatient actigraphy can provide information for "real-world" patient-centered outcomes that are not captured by standardized respiratory questionnaires, lung function, or exercise testing. Actigraphy activity and sedentary domains inform of distinct outcomes.

Systematic review of context-aware digital behavior change interventions to improve health

Health risk behaviors are leading contributors to morbidity, premature mortality associated with chronic diseases, and escalating health costs. However, traditional interventions to change health behaviors often have modest effects, and limited applicability and scale. To better support health improvement goals across the care continuum, new approaches incorporating various smart technologies are being utilized to create more individualized digital behavior change interventions (DBCIs). The purpose of this study is to identify context-aware DBCIs that provide individualized interventions to improve health. A systematic review of published literature (2013-2020) was conducted from multiple databases and manual searches. All included DBCIs were context-aware, automated digital health technologies, whereby user input, activity, or location influenced the intervention. Included studies addressed explicit health behaviors and reported data of behavior change outcomes. Data extracted from studies included study design, type of intervention, including its functions and technologies used, behavior change techniques, and target health behavior and outcomes data. Thirty-three articles were included, comprising mobile health (mHealth) applications, Internet of Things wearables/sensors, and internet-based web applications. The most frequently adopted behavior change techniques were in the groupings of feedback and monitoring, shaping knowledge, associations, and goals and planning. Technologies used to apply these in a context-aware, automated fashion included analytic and artificial intelligence (e.g., machine learning and symbolic reasoning) methods requiring various degrees of access to data. Studies demonstrated improvements in physical activity, dietary behaviors, medication adherence, and sun protection practices. Context-aware DBCIs effectively supported behavior change to improve users' health behaviors.

Objectively measured physical activity as a COPD clinical trial outcome

BACKGROUND

Reduced physical activity is common in COPD and is associated with poor outcomes. Physical activity is therefore a worthy target for intervention in clinical trials, however, trials evaluating physical activity have used heterogeneous methodologies.

RESEARCH QUESTION

What is the available evidence on the efficacy and/or effectiveness of various interventions to enhance objectively measured physical activity in patients with COPD, taking into account minimal preferred methodological quality of physical activity assessment?

STUDY DESIGN AND METHODS

In this narrative review, the COPD Biomarker Qualification Consortium (CBQC) task force searched three scientific databases for articles that reported the effect of an intervention on objectively-measured physical activity in COPD. Based on scientific literature and expert consensus, only studies with ≥7 measurement days and ≥4 valid days of ≥8 hours of monitoring were included in the primary analysis.

RESULTS

37 of 110 (34%) identified studies fulfilled the criteria, investigating the efficacy and/or effectiveness of physical activity behavior change programs (n=7), mobile health or eHealth interventions (n=9), rehabilitative exercise (n=9), bronchodilation (n=6), lung volume reduction procedures (n=3) and other interventions (n=3). Results are generally variable, reflecting the large variation in study characteristics and outcomes. Few studies show an increase beyond the proposed minimal important change of 600-1100 daily steps, indicating that enhancing physical activity levels is a challenge.

INTERPRETATION

Only a third of clinical trials measuring objective physical activity in people with COPD fulfilled the pre-set criteria regarding physical activity assessment. Studies showed variable effects on physical activity even when investigating similar interventions.

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.

Long-term Effectiveness of mHealth Physical Activity Interventions: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Mobile health (mHealth) interventions can increase physical activity (PA); however, their long-term impact is not well understood.

OBJECTIVE

The primary aim of this study is to understand the immediate and long-term effects of mHealth interventions on PA. The secondary aim is to explore potential effect moderators.

METHODS

We performed this study according to the Cochrane and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched PubMed, the Cochrane Library, SCOPUS, and PsycINFO in July 2020. Eligible studies included randomized controlled trials of mHealth interventions targeting PA as a primary outcome in adults. Eligible outcome measures were walking, moderate-to-vigorous physical activity (MVPA), total physical activity (TPA), and energy expenditure. Where reported, we extracted data for 3 time points (ie, end of intervention, follow-up ≤6 months, and follow-up >6 months). To explore effect moderators, we performed subgroup analyses by population, intervention design, and control group type. Results were summarized using random effects meta-analysis. Risk of bias was assessed using the Cochrane Collaboration tool.

RESULTS

Of the 2828 identified studies, 117 were included. These studies reported on 21,118 participants with a mean age of 52.03 (SD 14.14) years, of whom 58.99% (n=12,459) were female. mHealth interventions significantly increased PA across all the 4 outcome measures at the end of intervention (walking standardized mean difference [SMD] 0.46, 95% CI 0.36-0.55; P<.001; MVPA SMD 0.28, 95% CI 0.21-0.35; P<.001; TPA SMD 0.34, 95% CI 0.20-0.47; P<.001; energy expenditure SMD 0.44, 95% CI 0.13-0.75; P=.01). Only 33 studies reported short-term follow-up measurements, and 8 studies reported long-term follow-up measurements in addition to end-of-intervention results. In the short term, effects were sustained for walking (SMD 0.26, 95% CI 0.09-0.42; P=.002), MVPA (SMD 0.20, 95% CI 0.05-0.35; P=.008), and TPA (SMD 0.53, 95% CI 0.13-0.93; P=.009). In the long term, effects were also sustained for walking (SMD 0.25, 95% CI 0.10-0.39; P=.001) and MVPA (SMD 0.19, 95% CI 0.11-0.27; P<.001). We found the study population to be an effect moderator, with higher effect scores in sick and at-risk populations. PA was increased both in scalable and nonscalable mHealth intervention designs and regardless of the control group type. The risk of bias was rated high in 80.3% (94/117) of the studies. Heterogeneity was significant, resulting in low to very low quality of evidence.

CONCLUSIONS

mHealth interventions can foster small to moderate increases in PA. The effects are maintained long term; however, the effect size decreases over time. The results encourage using mHealth interventions in at-risk and sick populations and support the use of scalable mHealth intervention designs to affordably reach large populations. However, given the low evidence quality, further methodologically rigorous studies are warranted to evaluate the long-term effects.

Pulmonary Rehabilitation in a Post-COVID-19 World: Telerehabilitation as a New Standard in Patients with COPD

Pulmonary rehabilitation (PR) is effective in reducing symptoms and improving health status, and exercise tolerance of patients with chronic obstructive pulmonary disease (COPD). The coronavirus disease 19 (COVID-19) pandemic has greatly impacted PR programs and their delivery to patients. Owing to fears of viral transmission and resultant outbreaks of COVID-19, institution-based PR programs have been forced to significantly reduce enrolment or in some cases completely shut down during the pandemic. As a majority of COPD patients are elderly and have multiple co-morbidities including cardiovascular disease and diabetes, they are notably susceptible to severe complications of COVID-19. As such, patients have been advised to stay at home and avoid social contact to the maximum extent possible. This has increased patients’ vulnerability to physical deconditioning, depression, and social isolation. To address this major gap in care, some traditional hospital or clinic-centered PR programs have converted some or all of their learning contents to home-based telerehabilitation during the pandemic. There are, however, some significant barriers to this approach that have impeded its implementation in the community. These include variable access and use of technology (by patients), a lack of standardization of methods and tools for evaluation of the program, and inadequate training and resources for health professionals in optimally delivering telerehabilitation to patients. There is a pressing need for high-quality studies on these modalities of PR to enable the successful implementation of PR at home and via teleconferencing technologies. Here, we highlight the importance of telerehabilitation of patients with COPD in the post-COVID world and discuss various strategies for clinical implementation.

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.

A Co-Designed Active Video Game for Physical Activity Promotion in People With Chronic Obstructive Pulmonary Disease: Pilot Trial

BACKGROUND

People with chronic obstructive pulmonary disease (COPD) who are less active have lower quality of life, greater risk of exacerbations, and greater mortality than those who are more active. The effectiveness of physical activity interventions may facilitate the addition of game elements to improve engagement. The use of a co-design approach with people with COPD and clinicians as co-designers may also improve the effectiveness of the intervention.

OBJECTIVE

The primary aim of this study is to evaluate the feasibility of a co-designed mobile game by examining the usage of the game, subjective measures of game engagement, and adherence to wearing activity trackers. The secondary aim of this study is to estimate the effect of the game on daily steps and daily moderate-to-vigorous physical activity (MVPA).

METHODS

Participants with COPD who were taking part in the co-design of the active video game (n=9) acted as the experiment group, spending 3 weeks testing the game they helped to develop. Daily steps and MVPA were compared with a control group (n=9) of participants who did not co-design or test the game.

RESULTS

Most participants (8/9, 89%) engaged with the game after downloading it. Participants used the game to record physical activity on 58.6% (82/141) of the days the game was available. The highest scores on the Intrinsic Motivation Inventory were seen for the value and usefulness subscale, with a mean of 6.38 (SD 0.6). Adherence to wearing Fitbit was high, with participants in both groups recording steps on >80% of days. Usage of the game was positively correlated with changes in daily steps but not with MVPA.

CONCLUSIONS

The co-designed mobile app shows promise as an intervention and should be evaluated in a larger-scale trial in this population.

Effect of Internet-Based Rehabilitation Programs on Improvement of Pain and Physical Function in Patients with Knee Osteoarthritis: Systematic Review and Meta-analysis of Randomized Controlled Trials

Background

Osteoarthritis (OA) is a chronic, debilitating, and degenerative joint disease. However, it is difficult for patients with knee OA to access conventional rehabilitation when discharging from the hospital. Internet-based rehabilitation is one of the promising telemedicine strategies to provide a means combining monitoring, guidance, and treatment for patients with knee OA.

Objective

The aim of this study was to conduct a systematic review and meta-analysis for assessing the effect of internet-based rehabilitation programs on pain and physical function in patients with knee OA.

Methods

Keywords related to knee OA and internet-based rehabilitation were systematically searched in the Web of Science, MEDLINE, EMBASE, CENTRAL, Scopus, PEDro (Physiotherapy Evidence Database), CNKI, SinoMed, and WANFANG databases from January 2000 to April 2020. Only randomized controlled trials were included. The authors independently screened the literature. The main outcome measures were focused on pain and physical function. A meta-analysis was performed on the collected data. Review Manager (RevMan, version 5.3) was used for all analyses.

Results

The systematic review identified 6 randomized controlled trials, 4 of which were included in the meta-analysis, comprising a total of 791 patients with knee OA. The meta-analysis with the fixed-effects model showed that the internet-based rehabilitation programs could significantly alleviate the osteoarthritic pain for patients compared with conventional rehabilitation (standardized mean difference [SMD] –0.21, 95% CI  −0.4 to –0.01, P=.04). No significant difference was found in the improvement of physical function in patients with knee OA compared with conventional rehabilitation within 2 to 12 months (SMD –0.08, 95% CI −0.27 to 0.12, P=.43).

Conclusions

This systematic review shows that internet-based rehabilitation programs could improve the pain but not physical function for patients with knee OA. However, there was a very small number of studies that could be included in the review and meta-analysis. Thus, further studies with large sample sizes are warranted to promote the effectiveness of internet-based rehabilitation and to develop its personalized design.

Advanced telehealth technology improves home-based exercise therapy for people with stable chronic obstructive pulmonary disease: a systematic review

QUESTIONS

How effective is home-based exercise therapy delivered using advanced telehealth technology (ATT-ET) for people with chronic obstructive pulmonary disease (COPD) compared with: no exercise therapy (ET), in/outpatient ET, and home-based ET without ATT?

DESIGN

Systematic review and meta-analysis of randomised trials.

PARTICIPANTS

People with stable COPD referred for ET.

INTERVENTION

ATT-ET.

OUTCOME MEASURES

Exercise capacity, quality of life, functional dyspnoea, cost-effectiveness and various secondary outcomes.

RESULTS

Fifteen eligible trials involved 1,522 participants. Compared with no ET, ATT-ET improved exercise capacity (four studies, 6-minute walk test MD 15 m, 95% CI 5 to 24) and probably improved quality of life (four studies, SMD 0.22, 95% CI 0.00 to 0.43) and functional dyspnoea (two studies, Chronic Respiratory Questionnaire-Dyspnoea MD 2, 95% CI 0 to 4). ATT-ET had a similar effect as in/outpatient ET on functional dyspnoea (two studies, SMD -0.05, 95% CI -0.39 to 0.29) and a similar or better effect on quality of life (two studies, SMD 0.23, 95% CI -0.04 to 0.50) but its relative effect on exercise capacity was very uncertain (three studies, 6-minute walk test MD 6 m, 95% CI -26 to 37). ATT-ET had a similar effect as home-based ET without ATT on exercise capacity (three studies, 6-minute walk test MD 2 m, 95% CI -16 to 19) and similar or better effects on quality of life (three studies, SMD 0.79, 95% CI -0.04 to 1.62) and functional dyspnoea (two studies, Chronic Respiratory Questionnaire-Dyspnoea MD 2, 95% CI 0 to 4). ATT-ET had effects on most secondary outcomes that were similar to or better than each comparator.

CONCLUSION

ATT-ET improves exercise capacity, functional dyspnoea and quality of life compared with no ET, although some benefits may be small. Its benefits are generally similar to in/outpatient ET and similar to or better than home-based ET without ATT.

REGISTRATION

PROSPERO CRD42020165773.

Going digital: a narrative overview of the effects, quality and utility of mobile apps in chronic disease self-management

Objective Smartphone health applications (apps) are being increasingly used to assist patients in chronic disease self-management. The effects of such apps on patient outcomes are uncertain, as are design features that maximise usability and efficacy, and the best methods for evaluating app quality and utility. Methods In assessing efficacy, PubMed, Cochrane Library and EMBASE were searched for systematic reviews (and single studies if no systematic review was available) published between January 2007 and January 2018 using search terms (and synonyms) of 'smartphone' and 'mobile applications', and terms for each of 11 chronic diseases: asthma, chronic obstructive lung disease (COPD), diabetes, chronic pain, serious mental health disorders, alcohol and substance addiction, heart failure, ischaemic heart disease, cancer, cognitive impairment, chronic kidney disease (CKD). With regard to design features and evaluation methods, additional reviews were sought using search terms 'design', 'quality,' 'usability', 'functionality,' 'adherence', 'evaluation' and related synonyms. Results Of 13 reviews and six single studies assessing efficacy, consistent evidence of benefit was seen only with apps for diabetes, as measured by decreased glycosylated haemoglobin levels (HbA1c). Some, but not all, studies showed benefit in asthma, low back pain, alcohol addiction, heart failure, ischaemic heart disease and cancer. There was no evidence of benefit in COPD, cognitive impairment or CKD. In all studies, benefits were clinically marginal and none related to morbid events or hospitalisation. Twelve design features were identified as enhancing usability. An evaluation framework comprising 32 items was formulated. Conclusion Evidence of clinical benefit of most available apps is very limited. Design features that enhance usability and maximise efficacy were identified. A provisional 'first-pass' evaluation framework is proposed that can help decide which apps should be endorsed by government agencies following more detailed technical assessments and which could then be recommended with confidence by clinicians to their patients. What is known about the topic? Smartphone health apps have attracted considerable interest from patients and health managers as a means of promoting more effective self-management of chronic diseases, which leads to better health outcomes. However, most commercially available apps have never been evaluated for benefits or harms in clinical trials, and there are currently no agreed quality criteria, standards or regulations to ensure health apps are user-friendly, accurate in content, evidence based or efficacious. What does this paper add? This paper presents a comprehensive review of evidence relating to the efficacy, usability and evaluation of apps for 11 common diseases aimed at assisting patients in self-management. Consistent evidence of benefit was only seen for diabetes apps; there was absent or conflicting evidence of benefit for apps for the remaining 10 diseases. Benefits that were detected were of marginal clinical importance, with no reporting of hard clinical end-points, such as mortality or hospitalisations. Only a minority of studies explicitly reported using behaviour change theories to underpin the app intervention. Many apps lacked design features that the literature identified as enhancing usability and potential to confer benefit. Despite a plethora of published evaluation tools, there is no universal framework that covers all relevant clinical and technical attributes. An inclusive list of evaluation criteria is proposed that may overcome this shortcoming. What are the implications for practitioners? The number of smartphone apps will continue to grow, as will the appetite for patients and clinicians to use them in chronic disease self-management. However, the evidence to date of clinical benefit of most apps already available is very limited. Design features that enhance usability and clinical efficacy need to be considered. In making decisions about which apps should be endorsed by government agencies and recommended with confidence by clinicians to their patients, a comprehensive but workable evaluation framework needs to be used by bodies assuming the roles of setting and applying standards.

A mobile health application to support self-management in patients with chronic obstructive pulmonary disease: a randomised controlled trial

OBJECTIVE

To investigate the effects of a mobile health smartphone application to support self-management programmes on quality of life, self-management behaviour and exercise and smoking cessation behaviour in patients with chronic obstructive pulmonary disease (COPD).

DESIGN

A randomised controlled, single-blind trial, was carried out from November 2017 to February 2019, which included 78 participants admitted with COPD to the Affiliated Hospital of Zunyi Medical University in Guizhou. The study participants were randomised into intervention (n = 39) and control groups (n = 39).

METHODS

Participants in the intervention group undertook a mobile medical application-based programme in addition to routine care, and participants in the control group received only routine care. The outcome measures were health-related quality of life evaluated by the COPD Assessment-Test, self-management behaviour using the COPD Self-Management Scale and physical activity and smoking behaviour were measured using a self-designed questionnaire. Data collection was conducted at baseline, third month, sixth month and 12th months.

RESULTS

Thirty-five participants in the intervention group and 33 in the control group completed the study. Compared to the control group, participants in the intervention group showed statistically significant improvement in the COPD -Assessment -Test scores (P < 0.01) and in all domains of the COPD Self-Management Scale scores (P < 0.01) at 12th 12 months. Improvements in the COPD -Assessment -Test scores by 4.3 and 0.3 units, and in the total scores of the COPD Self-Management Scale total score by 23.01 and 2.28 units, respectively, were observed in the intervention and control groups, respectively over the 12-month study period. Meanwhile, the mobile health application programme also improved participants' exercise and smoking cessation behaviour.

CONCLUSIONS

The mobile health smartphone application to support self-management programmes was effective in improving health-related quality of life and self-management behaviour in patients with COPD.

TRIAL REGISTRATION

This study was registered in Chinese clinicaltrials.gov.

Coaching Through Technology: A Systematic Review into Efficacy and Effectiveness for the Ageing Population

Background: Despite the evidence on the positive role of self-management, the adoption of health coaching strategies for older people is still limited. To address these gaps, recent efforts have been made in the ICT sector in order to develop systems for delivering coaching and overcoming barriers relating to scarcity of resources. The aim of this review is to examine the efficacy of personal health coaching systems for older adults using digital virtual agents. Methods: A systematic review of the literature was conducted in December 2019 analyzing manuscripts from four databases over the last 10 years. Nine papers were included. Results: Despite the low number of studies, there was evidence that technology-integrated interventions can deliver benefits for health over usual care. However, the review raises important questions about how to maintain benefits and permanence of behavior change produced by short-term interventions. Conclusion: These systems offer a potential tool to reduce costs, minimize therapist burden and training, and expand the range of clients who can benefit from them. It is desirable that in the future the number of studies will grow, considering other aspects such as the role of the virtual coaches’ characteristics, social-presence, empathy, usability, and health literacy.

A Virtual Reality-Supported Intervention for Pulmonary Rehabilitation of Patients With Chronic Obstructive Pulmonary Disease: Mixed Methods Study

BACKGROUND

The uptake of traditional pulmonary rehabilitation classes by patients with chronic obstructive pulmonary disease (COPD) is poor because of personal factors that prevent accessibility to the venue. Therefore, there is a need for innovative methods of pulmonary rehabilitation, and virtual reality (VR) could be a promising technology for patients with COPD to access services remotely.

OBJECTIVE

This study aimed to investigate whether VR improves compliance with pulmonary rehabilitation among patients with COPD, a particularly vulnerable patient group (Medical Research Council [MRC] 4 or 5), and whether VR provides a credible alternative to traditional pulmonary rehabilitation programs.

METHODS

This was an 8-week patient trial using an innovative VR pulmonary rehabilitation program. A purposive sample of 10 patients with COPD graded MRC 4 or 5 and registered at a selected health care center and a hospital in Cumbria, United Kingdom, were included. Qualitative (focus groups and interviews) data were collected, and to further support the qualitative findings, quantitative data (self-report patient surveys) were gathered before and after the 8-week trial. The 5 self-reported surveys included the Patient Activation Measure, Generalized Anxiety Disorder-7, Patient Health Questionnaire-9, Short Physical Performance Battery, and the Edmonton Frail Scale.

RESULTS

In a thematic analysis of the qualitative data, 11 themes emerged specific to delivering pulmonary rehabilitation using VR. The quantitative data further support the qualitative findings by revealing significant improvements in all physical measures.

CONCLUSIONS

Overall, this study demonstrates how remotely supervised VR-based pulmonary rehabilitation could help to overcome current issues and limitations associated with providing this service to patients with COPD at scale.

A Systematic Review of the Effectiveness of Telerehabilitation Interventions for Therapeutic Purposes in the Elderly

BACKGROUND

Many elderly people suffer from chronic health conditions and mobility limitations. Therefore, they may benefit from traditional rehabilitation or telerehabilitation interventions as an alternative for this type of services.

OBJECTIVE

The purpose of this study was to compare the effectiveness of telerehabilitation interventions with traditional rehabilitation services for therapeutic purposes in the elderly.

METHODS

This systematic review was conducted in 2018. The searched databases were Cochrane Library, PubMed, Scopus, Web of Science, Embase, and ProQuest. The search was conducted with no time or language limitation. The selected papers included the randomized clinical trial studies in which elderly people aged 60 and over used telerehabilitation services for treatment purposes. The quality of the studies was evaluated by using the physiotherapy evidence database (PEDro) scale. Data were extracted by using a data extraction form and findings were narratively synthesized.

RESULTS

After screening the retrieved papers, eight articles were selected to be included in the study. According to the findings, telerehabilitation was used for the elderly after stroke, chronic obstructive pulmonary disease (COPD), total knee replacement, and in patients with the comorbidity of COPD and chronic heart failure. Overall, in most studies, there was no significant difference between the intervention and control groups and the level of improvements was similar for most outcomes.

CONCLUSION

Telerehabilitation services can be regarded as an alternative to traditional rehabilitation approaches to reduce outpatient resource utilization and improve quality of life. However, more rigorous studies are suggested to investigate the effectiveness of telerehabilitation services for specific diseases or health conditions.

Telerehabilitation Programme as a Maintenance Strategy for COPD Patients: A 12-Month Randomized Clinical Trial

BACKGROUND

There is uncertainty regarding efficacy of telehealth-based approaches in COPD patients for sustaining benefits achieved with intensive pulmonary rehabilitation (PR).

RESEARCH QUESTION

To determine whether a maintenance pulmonary telerehabilitation (TelePR) programme, after intensive initial PR, is superior to usual care in sustaining over time benefits achieved by intensive PR.

STUDY DESIGN AND METHODS

A multicentre open-label pragmatic parallel-group randomized clinical trial was conducted. Two groups were created at completion of an 8-week intensive outpatient hospital PR programme. Intervention group (IG) patients were given appropriate training equipment and instructed to perform three weekly training sessions and send performance data through an app to a web-based platform. Patients in the control group (CG) were advised to exercise regularly (usual care).

RESULTS

Ninety-four patients (46 IG, 48 CG) were randomized. The analysis of covariance showed non-significant improvements in 6-min walk distance [19.9m (95% CI -4.1/+43.8)] and Chronic Respiratory Disease Questionnaire - Emotion score [0.4 points (0-0.8)] in the IG. Secondary linear mixed models showed improvements in the IG in Short Form-36 mental component summary [9.7, (4.0-15.4)] and Chronic Respiratory Disease Questionnaire - Emotion [0.5, (0.2-0.9)] scores, but there was no association between compliance and outcomes. Acute exacerbations were associated with a marginally significant decrease in 6-minute walk distance of 15.8m (-32.3/0.8) in linear models.

CONCLUSIONS

The TelePR maintenance strategy was both feasible and safe but failed to show superiority over usual care, despite improvements in some HRQoL domains. Acute exacerbations may have an important negative influence on long-term physical function. CLINICALTRIALS.

GOV IDENTIFIER

NCT03247933.

The effect of e-health interventions promoting physical activity in older people: a systematic review and meta-analysis

INTRODUCTION

The objectives of this review paper were to synthesize the data from randomized controlled trials in the literature to come to a conclusion on the effects of e-health interventions on promoting physical activity in older people.

METHODS

The Medline, CINAHL, Embase, PsycINFO, and SportDiscus databases were searched for articles about studies that 1) recruited subjects with a mean age of > 50 years, 2) tested e-health interventions, 3) employed control groups with no or less advanced e-health strategies, 4) measured physical activity as an outcome, 5) were published between 1st January 2008 and 31st May 2019, and 6) employed randomized controlled trials. The risk of bias in individual studies was assessed using the Physiotherapy Evidence Database scale. To examine the effects of the interventions, variables quantifying the amount of physical activity were extracted. The within-group effects of individual studies were summarized using Hedges g and 95% confidence intervals. Between-group effects were summarized by meta-analyses using RevMan 5.0 with a random effect model.

RESULTS

Of the 2810 identified studies, 38 were eligible, 25 were included in the meta-analyses. The within-group effect sizes (Hedges g) of physical activity in the intervention group at T1 ranged from small to large: physical activity time (0.12 to 0.84), step counts (- 0.01 to 11.19), energy expenditure (- 0.05 to 0.86), walking time (0.13 to 3.33), and sedentary time (- 0.12 to - 0.28). The delayed effects as observed in T2 and T3 also ranged from small to large: physical activity time (0.24 to 1.24) and energy expenditure (0.15 to 1.32). In the meta-analysis, the between-group effect of the e-health intervention on physical activity time measured by questionnaires, physical activity time measured by objective wearable devices, energy expenditure, and step counts were all significant with minimal heterogeneity.

CONCLUSION

E-health interventions are effective at increasing the time spent on physical activity, energy expenditure in physical activity, and the number of walking steps. It is recommended that e-health interventions be included in guidelines to enhance physical activity in older people. Further studies should be conducted to determine the most effective e-health strategies.

Interventions for promoting physical activity in people with chronic obstructive pulmonary disease (COPD)

BACKGROUND

Escalating awareness of the magnitude of the challenge posed by low levels of physical activity in people with chronic obstructive pulmonary disease (COPD) highlights the need for interventions to increase physical activity participation. The widely-accepted benefits of physical activity, coupled with the increasing availability of wearable monitoring devices to objectively measure participation, has led to a dramatic rise in the number and variety of studies that aimed to improve the physical activity of people with COPD. However, little was known about the relative efficacy of interventions tested so far.

OBJECTIVES

In people with COPD, which interventions are effective at improving objectively-assessed physical activity?

SEARCH METHODS

We identified trials from the Cochrane Airways Trials Register Register, which contains records identified from bibliographic databases including the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, AMED, and PsycINFO. We also searched PEDro, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform portal and the Australian New Zealand Clinical Trials Registry (from inception to June 2019). We checked reference lists of all primary studies and review articles for additional references, as well as respiratory journals and respiratory meeting abstracts, to identify relevant studies.

SELECTION CRITERIA

We included randomised controlled trials of interventions that used objective measures for the assessment of physical activity in people with COPD. Trials compared an intervention with no intervention or a sham/placebo intervention, an intervention in addition to another standard intervention common to both groups, or two different interventions.

DATA COLLECTION AND ANALYSIS

We used standard methods recommended by Cochrane. Subgroup analyses were possible for supervised compared to unsupervised pulmonary rehabilitation programmes in clinically-stable COPD for a range of physical activity outcomes. Secondary outcomes were health-related quality of life, exercise capacity, adverse events and adherence. Insufficient data were available to perform prespecified subgroup analyses by duration of intervention or disease severity. We undertook sensitivity analyses by removing studies that were at high or unclear risk of bias for the domains of blinding and incomplete outcome data.

MAIN RESULTS

We included 76 studies with 8018 participants. Most studies were funded by government bodies, although some were sponsored by equipment or drug manufacturers. Only 38 studies had physical activity as a primary outcome. A diverse range of interventions have been assessed, primarily in single studies, but improvements have not been systematically demonstrated following any particular interventions. Where improvements were demonstrated, results were confined to single studies, or data for maintained improvement were not provided. Step count was the most frequently reported outcome, but it was commonly assessed using devices with documented inaccuracy for this variable. Compared to no intervention, the mean difference (MD) in time in moderate- to vigorous-intensity physical activity (MVPA) following pulmonary rehabilitation was four minutes per day (95% confidence interval (CI) -2 to 9; 3 studies, 190 participants; low-certainty evidence). An improvement was demonstrated following high-intensity interval exercise training (6 minutes per day, 95% CI 4 to 8; 2 studies, 275 participants; moderate-certainty evidence). One study demonstrated an improvement following six months of physical activity counselling (MD 11 minutes per day, 95% CI 7 to 15; 1 study, 280 participants; moderate-certainty evidence), but we found mixed results for the addition of physical activity counselling to pulmonary rehabilitation. There was an improvement following three to four weeks of pharmacological treatment with long-acting muscarinic antagonist and long-acting beta2-agonist (LAMA/LABA) compared to placebo (MD 10 minutes per day, 95% CI 4 to 15; 2 studies, 423 participants; high-certainty evidence). These interventions also demonstrated improvements in other measures of physical activity. Other interventions included self-management strategies, nutritional supplementation, supplemental oxygen, endobronchial valve surgery, non-invasive ventilation, neuromuscular electrical stimulation and inspiratory muscle training.

AUTHORS' CONCLUSIONS

A diverse range of interventions have been assessed, primarily in single studies. Improvements in physical activity have not been systematically demonstrated following any particular intervention. There was limited evidence for improvement in physical activity with strategies including exercise training, physical activity counselling and pharmacological management. The optimal timing, components, duration and models for interventions are still unclear. Assessment of quality was limited by a lack of methodological detail. There was scant evidence for a continued effect over time following completion of interventions, a likely requirement for meaningful health benefits for people with COPD.

Are COPD self-management mobile applications effective? A systematic review and meta-analysis

The burden of chronic obstructive pulmonary disease (COPD) to patients and health services is steadily increasing. Self-management supported by mobile device applications could improve outcomes for people with COPD. Our aim was to synthesize evidence on the effectiveness of mobile health applications compared with usual care. A systematic review was conducted to identify randomized controlled trials. Outcomes of interest included exacerbations, physical function, and Quality of Life (QoL). Where possible, outcome data were pooled for meta-analyses. Of 1709 citations returned, 13 were eligible trials. Number of exacerbations, quality of life, physical function, dyspnea, physical activity, and self-efficacy were reported. Evidence for effectiveness was inconsistent between studies, and the pooled effect size for physical function and QoL was not significant. There was notable variation in outcome measures used across trials. Developing a standardized outcome-reporting framework for digital health interventions in COPD self-management may help standardize future research.

Effectiveness of Mobile Applications Running on Smartphones to Promote Physical Activity: A Systematic Review with Meta-Analysis

Mobile applications reach a high number of individuals at low costs. This systematic review investigated the effectiveness of mobile application-based interventions to increase physical activity (PA) and self-efficacy and to decrease sedentarism. Randomized controlled trials (RCTs) and quasi-RCTs investigating the effect of PA interventions using an app compared to no intervention or traditional interventions were included. Pooled effects using the standardized mean difference (SMD) or the weighted mean difference (WMD) were calculated and the overall quality of the evidence was rated using the GRADE. Eleven studies were included. In the short term, pooled estimates showed a small and positive effect in the number of steps favoring interventions using a mobile app when compared with no interventions (WMD = 1579.04, 95%CI 454.04 to 2703.38) and with traditional interventions (WMD = 665.96, 95%CI 167.92 to 1164.00). For self-efficacy and at follow-up, results favoured traditional interventions (WMD = −8.20, 95%CI −14.25 to −2.15). Non-significant results were found for the remaining comparisons. The quality of the evidence ranged from very low to low. There is very low to low quality evidence that interventions using mobile apps running on smartphones, when combined with traditional interventions, are superior to traditional interventions in the short term. Further high-quality studies are required.