August 24, 2023

4 min read

Zanaboni reports receiving study funding from the Research Council of Norway and Northern Norway Regional Health Authority. Please see the study for all other authors’ relevant financial disclosures. Bourbeau reports receiving support/grants/contracts to his institution from AstraZeneca Canada, Boehringer Ingelheim Canada, the Canadian Institute of Heath Research (CIHR), GlaxoSmithKline Canada, Grifols, McGill University, McGill University Health Centre Foundation, Novartis, Réseau en santé respiratoire du FRQS, Sanofi and Trudell Canada; and receiving payment/honoraria for lectures from AstraZeneca Canada, Boehringer Ingelheim Canada, COVIS Pharma Canada, GlaxoSmithKline Canada, Pfizer Canada and Trudell Canada. Bhatt reports receiving support from the NIH; grants/contracts from Nuvaira and Sanofi; royalties/licenses from Elsevier; consulting fees from Boehringer Ingelheim and Sanofi/Regeneron; and payment/honoraria for lectures from IntegrityCE.

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Key takeaways:

  • Compared with standard care, remote pulmonary rehabilitation reduced hospitalization and ED events.
  • Improvement in 6-minute walk distance also occurred with this form of rehab.

Telerehabilitation and unsupervised remote training for COPD over 2 years resulted in fewer hospitalizations and ED visits vs. standard care, according to results published in American Journal of Respiratory and Critical Care Medicine.

“These interventions have the potential to improve uptake and access to pulmonary rehabilitation and support long-term exercise maintenance strategies,” Paolo Zanaboni, PhD, professor in telemedicine and e-health at Norwegian Centre for E-health Research, University Hospital of North Norway, and colleagues wrote. “Unsupervised training at home could be offered to patients with COPD who do not access pulmonary rehabilitation or maintenance programs. Telerehabilitation may be useful for patients who are unsuitable for unsupervised training and need a closer follow-up.”

Infographic showing incidence rate of hospitalizations plus ED visits per person-year

Data were derived from Zanaboni P, et al. Am J Respir Crit Care Med. 2023;doi:10.1164/rccm.202204-0643OC.

In a randomized controlled trial, Zanaboni and colleagues analyzed 120 patients with COPD in Norway, Australia or Denmark to see if participation in telerehabilitation or unsupervised remote exercise training for 2 years resulted in comparable or reduced rates of hospitalizations and ED visits to standard care.

Patients in the telerehabilitation group (n = 40; mean age, 64.9 years; 57.5% men) were self-managed but supervised by a physiotherapist through videoconferencing when completing treadmill training, whereas the other treatment group (n = 40; mean age, 64 years; 50% men) was not supervised. The remaining 40 patients (mean age, 63.5 years; 57.5% men) made up the group that received standard care.

In addition to hospital admissions and ED visits, researchers evaluated exercise capacity (6-minute walk distance [6MWD]), dyspnea (modified Medical Research Council [mMRC] scale), health status (COPD Assessment test [CAT]), quality of life (EuroQol 5 dimensions [EQ-5D] questionnaire), anxiety and depression (Hospital Anxiety and Depression Scale), self-efficacy (Generalized Self-Efficacy Scale) and subjective impression of change (Patient Global Impression of Change scale) between groups.

Hospitalizations, ED visits

When evaluating a total of 312 combined hospitalizations and ED visits, researchers found most events occurred among patients in the standard care group (140 events), followed by 88 events from the unsupervised remote training group and 84 events from the telerehabilitation group.

Compared with patients receiving standard care with an incidence rate of 1.88 (95% CI, 1.58-2.21) hospitalizations plus ED visits per person-year, researchers found fewer events among those participating in telerehabilitation (1.18; 95% CI, 0.94-1.46) and those participating in unsupervised remote training (1.14; 95% CI, 0.92-1.41).

This result continued when researchers looked at hospitalizations and ED visits separately, with 1.69 (95% CI, 1.41-2.01) hospitalizations per person-year in the standard care group compared with 0.96 (95% CI, 0.74-1.21) in the telerehabilitation group and 0.96 (95% CI, 0.76-1.21) in the unsupervised remote training group. Further, the incidence rate of ED visits per person-year was one (95% CI, 0.78-1.26) in the telerehabilitation group and 0.97 (95% CI, 0.77-1.22) in the unsupervised training group, both of which were lower than the incidence rate observed in the standard care group (1.58; 95% CI, 1.31-1.89).

Researchers noted similar finding when they included smoking status and long-term oxygen therapy as covariates.

Health status, 6MWD, quality of life

Compared with patients receiving standard care, patients participating in telerehabilitation and unsupervised remote training saw significant improvement in several assessed outcomes.

Health status and dyspnea measures both significantly improved at 6 months in the telerehabilitation group (CAT and mMRC, P = .037 for both) and the unsupervised training group (CAT, P = .002; mMRC, P = .027), with sustained changes in CAT scores at 1 year and mMRC scores at 2 years in patients participating in unsupervised training.

In terms of 6MWD, both groups achieved greater than the minimal important difference over the 2-year study period.

At 6 months, researchers found an improved and significant change on the Patients Global Impression of Change scale among 53.1% of patients participating in telerehabilitation, compared with 24.2% of patients participating in unsupervised training and 13.3% of patients receiving standard care (P = .001).

Patients participating in unsupervised training showed more sustained quality-of-life scores on the EQ-5D utility index at 6 months (P = .036) and EQ-VAS at 2 years (P = .04) than those receiving standard care.

When comparing each treatment group to standard care, self-efficacy, anxiety, depression and mortality rate did not differ, according to researchers.

Researchers noted none of the patients experienced a treadmill-related injury.

Future studies

This study contributes to growing literature on the positive impact of more accessible forms of pulmonary rehabilitation, but factors other than a patient’s COPD severity level must be considered in future studies, according to an accompanying editorial by Jean Bourbeau, MD, MSc, FRCPC, FCAHS, professor in the department of medicine at McGill University, and Surya P. Bhatt, MD, MSPH, associate professor of medicine in the division of pulmonary, allergy and critical care medicine at The University of Alabama at Birmingham.

“Reasons for noninclusion included comorbidities (14%), home environment (19%), and reasons such as a lack of interest or feeling too sick or too healthy (22%),” Bourbeau and Bhatt wrote. “The presence of comorbidities and the safety of the home environment are important aspects to consider, as are patient comfort and a patient’s confidence in being able to exercise on their own. The optimal candidate for such programs is therefore not clear, and there may be additional barriers unique to telerehabilitation, including digital access outside of a research study, as well as digital competency.”


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