Why would programs be undertaken at home instead of at a hospital or other centre?

Pulmonary rehabilitation (PR) and other forms of exercise therapy are effective therapeutic options to manage symptoms in people with chronic obstructive pulmonary disease.

Paradoxically, as little as five per cent of people who would benefit from PR undertake it.

Obviously, there are many factors to explain this low participation.

Some of these are highlighted in other studies in the Journal of Physiotherapy (Keating et al 2011 and Cox et al 2017), where the limited availability of PR centres and transport issues are identified as likely major contributors.

This is particularly important in very large countries with localised urban centres, such as Australia.

Therefore, delivering PR in the home environment instead of at the hospital or other centre may address these difficulties.

How are such programs normally supervised and progressed?

Usually home-based exercise therapy necessitates in-home visits of the physiotherapist to initiate the program.

Thereafter, the use of non-advanced telehealth technology, such as regular phone call, is used to follow-up participants. Alternatively, some of these programs are simply unsupervised.

What are advanced telehealth technologies and what do they offer?

The term telerehabilitation is often used to describe home-based PR or exercise therapy that uses telecommunication technologies to follow-up participants.

However, this definition is unhelpfully broad because it includes a wide range of interventions ranging from real-time supervised and monitored exercise sessions to unsupervised training with telephone calls as a way to follow-up participants, the latter of which overlaps with many home-based exercise therapy programs, as we previously discussed.

Therefore, the term advanced telehealth technology describes any more advanced telehealth technology than phone contact alone.

Using advanced telehealth technologies to deliver exercise therapy could take the form of real-time videoconferencing, web-based interactive platforms or smartphone applications providing either therapist or algorithm-mediated individualised feedback and goals.

This approach enables support that phone follow-up or unsupervised programs do not allow.

This includes peer support; direct, prompt or automated feedback to individualise training; and monitoring for safety, adherence and early signs of exacerbations.

So, to the first of your three questions: how effective is home-based exercise therapy delivered using advanced telehealth technology compared with no exercise therapy?

Seven studies with 787 participants addressed this first question.

It was reassuring to see that home-based exercise therapy delivered using advanced telehealth technology improved exercise capacity and objective physical activity, and also probably improved quality of life, functional dyspnoea, self-efficacy and anxiety/depression.

However, due to the imprecision of the estimates, it is still unclear whether these benefits are clinically worthwhile.

What about when it is compared to centre-based exercise therapy, like a pulmonary rehabilitation program?

Home-based exercise therapy delivered using advanced telehealth technology was compared with centre-based programs in three studies with 327 participants.

Overall, it has a similar effect on functional dyspnoea and similar or better effects on quality of life, health status, objective physical activity and anxiety/depression.

Again, these estimates came with some uncertainty so that any further benefit may be trivial. It should be acknowledged that the similarity between these interventions was not confirmed for their ability in improving exercise  capacity. 

What  should we make of all  these results?

We consider that unless future studies clarify an important difference in their effects, using advanced telehealth technologies to deliver exercise therapy programs may be a valuable alternative for those people who cannot attend centre-based programs.

And what about comparisons of home-based exercise therapy with or without the advanced telehealth technologies—did any studies in your review make that comparison?

Actually, six studies with 451 participants addressed this question.

Because using advanced telehealth technologies may incur an additional burden and cost compared with other home-based on exercise capacity and similar or better effects on quality of life, objective physical activity, functional dyspnoea, health status and self-efficacy.

However, due to the width of the estimates, we were not able to show that any further benefit provided by using advanced telehealth technology was systematically clinically worthwhile.

In this context, the cost-effectiveness and the cost-utility of adding telehealth technology to home-based exercise therapy warrant further investigation.

Where else should research in this area be heading?

In addition to assessing the cost-effectiveness of advanced telehealth technology to deliver exercise therapy, future research should also directly compare these interventions (real-time videoconferencing, smartphone applications and so on).

Finally, most trials did not blind participants and outcome assessors.

Blinding of outcome assessors should be implemented where possible in future trials to strengthen the quality of evidence supporting the findings.

Click here to check out the animation based on this paper.

>> Tristan Bonnevie, PhD, undertakes research in the field of pulmonary rehabilitation. Tristan has 10 years’ experience in respiratory physiotherapy, including intensive care unit patient management (Rouen University Hospital, France) and pulmonary rehabilitation (ADIR Association, Rouen University Hospital, France).