Expanding Implementation of Tele-Pulmonary Rehabilitation: The New Frontier

Implementation of virtual pulmonary rehabilitation during the COVID-19 pandemic: Experiences and perceptions of patients and healthcare providers

BACKGROUND

Pulmonary rehabilitation (PR) plays an important role in the management of symptomatic patients with chronic respiratory diseases (CRD). While studies have investigated the feasibility and efficacy of virtual PR (VPR), it is important to understand the experiences of patients and healthcare providers (HCPs) during the rapid digital health transformation that occurred in the COVID-19 pandemic.

OBJECTIVES

To explore the experiences and perspectives of patients and HCPs who participated in VPR during the pandemic.

METHODS

Semi-structured interviews were conducted with CRD patients and HCPs. This study used a qualitative descriptive approach and a team-based inductive thematic analysis.

RESULTS

Participants included 11 HCPs (7 female; 29-55 years) and 19 CRD patients (11 male; 62-83 years; 15 COPD, 4 COPD/ILD). Three major themes and 10 subthemes were identified: i) the pandemic response: a 'trial by fire' (navigating uncertainty, emotional impact of change, shifting practice amid complexity); ii) beyond the emergency: navigating a 'new normal' (eligibility and assessment for VPR, virtual exercise, virtual education and resources, clinical supervision and patient safety); and iii) care beyond boundaries: the implications of using technology for PR (benefits and limitations of technology, psychosocial implications, VPR in the future).

CONCLUSION

The pivot to VPR was acknowledged as positive by both patients and HCPs although both groups were mindful of the implementation challenges. These findings provide insight into the experience of HCPs and patients in introducing VPR in response to the pandemic and will inform future implementation of VPR for individuals with CRD.

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.

Telehealth Services: Improving Equity in Pulmonary Health Outcomes

Expansion of telehealth services has the potential to attenuate health inequities in pulmonary medicine, by improving access to care and health outcomes in patients with lung disease. These telehealth services include remote patient monitoring, synchronous telemedicine, and remote pulmonary rehabilitation. Currently, patients who are White, well-educated, wealthy, and from urban areas are the most likely to benefit from telehealth services. Without clear policy decisions and planning to overcome the "Digital Divide," telehealth services will only exacerbate existing disparities within the pulmonary disease. We describe the benefits and limitations of these new technologies and their impact on improving equity in pulmonary medicine.

Role of digital health in pulmonary rehabilitation and beyond: shaping the future

Pulmonary rehabilitation (PR) is a cost-effective intervention with well-known benefits to exercise capacity, symptoms and quality of life in patients with chronic respiratory diseases. Despite the compelling evidence of its benefits, PR implementation is still suboptimal, and maintenance of PR benefits is challenging. To overcome these pitfalls, there has been a growing interest in developing novel models for PR delivery. Digital health is a promising solution, as it has the potential to address some of the most reported barriers to PR uptake and adherence (such as accessibility issues), help maintain the positive results following a PR programme and promote patients' adherence to a more active lifestyle through physical activity (tele)coaching. Despite the accelerated use of digital health to deliver PR during the coronavirus disease 2019 pandemic, there are still several factors that contribute to the resistance to the adoption of digital health, such as the lack of evidence on its effectiveness, low acceptability by patients and healthcare professionals, concerns about implementation and maintenance costs, inequalities in access to the internet and technological devices, and data protection issues. Nevertheless, the trend towards reducing technology costs and the higher availability of digital devices, as well as the greater ease and simplicity of use of devices, enhance the opportunities for future development of digitally enabled PR interventions. This narrative review aims to examine the current evidence on the role of digital health in the context of PR, including strengths and weaknesses, and to determine possible threats and opportunities, as well as areas for future work.

Does Telemedicine Promote Physical Activity?

Exercise capacity and physical activity are different concepts: the former refers to what an individual is capable of performing, while the latter refers to what the individual does in daily life. Low levels of physical activity (PA), which are very common in individuals with COPD, are associated with poor health outcomes, including increased symptoms, a more rapid decline in lung function, increased health care utilization and increased mortality risk. Because of these pervasive negative outcomes, attempts have been made to increase physical activity in individuals with COPD, hoping that success in this area will mitigate the negative effects of inactivity. Based on its ability to increase exercise capacity and reduce dyspnea in COPD and other chronic respiratory diseases, pulmonary rehabilitation (PR) would be expected also increase physical activity in these patients. However, accessibility to pulmonary rehabilitation programs is problematic in some areas, and studies testing its effectiveness in this outcome area have had inconsistent results. Using telehealth interventions using technology to provide medical care conveniently over a distance would have the benefit of reaching a larger proportion of individuals with COPD. A systematic review of clinical trials testing telehealth to promote physical activity had mixed results and low-certainty evidence, resulting in the inability to recommend any single type of intervention. Thus, using telehealth interventions to promote physical activity for individuals with chronic respiratory diseases, while promising, remains an area where future investigations are needed to identify its optimal modalities and clarify its benefits.