Anne, a cardiopulmonary physiotherapist whose work has shaped 40 clinical practice guidelines and who has produced more than 500 publications, spoke about the longstanding strength of the evidence for pulmonary rehabilitation and the ongoing failure to deliver it equitably.

Pulmonary rehabilitation, she said, is one of the highest value interventions physiotherapists can offer people with COPD. 

‘It improves exercise capacity, breathlessness and quality of life.’ 

Anne noted that pulmonary rehabilitation also decreases hospitalisations and outperforms many commonly prescribed COPD medications on cost-effectiveness. 

The evidence is so robust, she said, that Cochrane formally closed its pulmonary rehabilitation review in 2015, concluding that no further trials against usual care were needed.

Yet access remains very low. Anne said that in Australia, fewer than 10 per cent of eligible patients receive pulmonary rehabilitation each year, with even lower rates globally.

Geography remains a major barrier, especially in rural and remote areas. 

However, Anne stressed that it is only one part of a much more complex picture. 

As she noted, even in major cities in the US, less than two per cent of individuals who would benefit receive the program.

Her team’s 2017 systematic review mapped access and barriers to pulmonary rehabilitation against the Theoretical Domains
Framework, identifying issues across knowledge, resources, beliefs about consequences and social influences—and across clinicians, systems and patients. 

With so many competing barriers, the question became: where to start?

The answer, Anne said, came from the patients themselves. In early work published in Journal of Physiotherapy, Anne’s group found that many people declined pulmonary rehabilitation because the travel burden was simply too great. 

One comment stayed with her: ‘If I could do this at home, it’d be golden.’ 

That insight catalysed more than a decade of research into home-based and telerehabilitation models of pulmonary rehabilitation.

Anne presented findings from two major NHMRC-funded trials. 

The first compared a low-cost, telephone-supported, home-based model—featuring one home visit, goal setting and motivational interviewing—with traditional centre-based pulmonary rehabilitation. 

The results, she said, demonstrated equivalent outcomes in exercise capacity and quality of life, along with significantly higher completion rates. 

Completion mattered, Anne said, because ‘if you complete a program you are less likely to be admitted to hospital.’

The second trial tested a virtual group telerehabilitation model using simple off-the-shelf equipment—no bluetooth, no custom technology. 

Again, outcomes were broadly similar to centre-based pulmonary rehabilitation and patients reported feeling supported and motivated.

Travel distances fell sharply, although Anne noted that the travel burden shifted partly to the service delivering equipment.

Cost-effectiveness analysis reinforced the message that both home-based and telerehabilitation models delivered downstream savings by reducing hospitalisations, with home-based pulmonary rehabilitation showing particularly strong value.

However, Anne was clear that scaling access cannot come at the expense of quality. 

Reviewing telerehabilitation trials within a recent Cochrane review, Anne highlighted inconsistent delivery of pulmonary rehabilitation’s essential components including centre-based assessment, exercise testing and individually prescribed aerobic and resistance training. 

‘We have a little more work to do,’ Anne said, emphasising the need for physiotherapists to protect fidelity while innovating.

Anne concluded by returning to the patient voices that sparked this program of work. Partnering with consumers, she said, is essential to designing models of care that are meaningful and effective. 

As physiotherapists move into an era of expanded pulmonary rehabilitation delivery options, Anne’s message was that the profession has the tools, and now the responsibility, to close the gap between evidence and access.