4.1. Summary of Evidence
This systematic review reveals a growing interest in telemedicine-driven pulmonary rehabilitation following the acute phase of COVID-19, although, as the pandemic reaches an end, it will be interesting to observe this trend in the upcoming years. The studies included in this review were conducted across diverse geographical settings, further supporting the potential global applicability of telemedicine interventions in post-acute COVID-19 management. It seems that regardless of the study design, the integration of telerehabilitation in post-acute care significantly improved several health outcomes among COVID-19 patients. These improvements were observed in physical and mental health, quality of life, and pulmonary function, albeit with variations across different studies.
In terms of rehabilitation protocols, a significant amount of heterogeneity was observed among the studies. This could be reflective of the individualized approach necessary for addressing the distinct needs of post-acute COVID-19 patients, as well as the absence of a unified protocol for telerehabilitation in this setting. The protocols were designed to incorporate a balance of aerobic and resistance training, breathing exercises, and functional activities, often accompanied by counseling or motivational measures to promote adherence. The intensity, duration, and frequency of the sessions varied widely, suggesting the need for further studies to identify optimal parameters for telerehabilitation programs in this population.
Different rehabilitation protocols emphasize various exercises, including deep breathing, inspiratory muscle training, and breathing control techniques, although the majority were performed in a hospital or institutional setting, contrary to our study [28
]. These protocols often also incorporate physical exercises for strength and endurance, which help in functional improvement and disability reduction [32
]. However, the question that arises is what degree of change and disability reduction is dependent on the PR setting. A holistic approach, encouraged by the American Thoracic Society (ATS) and the European Respiratory Society (ERS), expands beyond mere physical exercises, embracing comprehensive patient evaluation and lifestyle modifications [34
]. Some studies have combined their rehabilitation protocols with educational sessions to address such issues as dyspnea, cough, fatigue, anxiety, memory, and daily activity management [35
]. These integrative approaches have demonstrated significant improvements in functional abilities, patient’s quality of life, and reintroduction into professional life.
Around 90% of COVID-19 patients in hospitals deal with debilitating lung effects, indicating the importance of physical and respiratory rehabilitation [37
]. The most common symptoms include dyspnea, fatigue, and exercise intolerance. Thus, telerehabilitation, offering physiotherapy remotely, is a suitable option to address these issues, particularly during social distancing, while its convenience also encourages patient adherence [39
]. Improvements in physical health outcomes, such as fatigue, pain, and exercise capacity, suggest that telerehabilitation can be an effective modality to enhance recovery and function after acute COVID-19. The improvements in mental health outcomes further support the potential of telerehabilitation in addressing the psychological impact of the disease, an aspect that is often overlooked in physical rehabilitation programs. The positive effect on quality-of-life measures is particularly encouraging, given the significant impact COVID-19 can have on overall well-being.
The pandemic added challenges for research and trial participation due to strict control measures and economic struggles. Randomized trials showcased a variety of participant details, disease stage, telerehabilitation methods, and the varying telemonitoring options that could have impacted outcomes, such as smartphones, video conferences, and messaging applications [40
]. The rush to introduce remote interventions often came with inadequate implementation guidance and professional training, which was evident in some of our included studies and other trials for acute COVID-19 [25
]. Despite the variability in the measures used to assess pulmonary function, some significant improvements were reported. It is important to highlight that the effects on pulmonary function seem to depend on the severity of the disease, with the less severe cases showing more significant improvements. Thus, one hypothesis that this study suggests is that telerehabilitation might be more effective when initiated in the early post-acute phase before severe pulmonary sequelae develop.
Moreover, further research is needed to examine the aspects of physical abilities and lung function that better represent changes during PR post-COVID-19. Notably, these parameters encompass Forced Vital Capacity (FVC), Forced Expiratory Volume in 1 s (FEV1), and Diffusing Capacity for Carbon Monoxide (DLCO), as used in other PR programs for COPD and ILD [43
]. Furthermore, not only do these traditional lung function tests show improvement following a physical rehabilitation program, but the severity of dyspnea, or shortness of breath, also significantly decreased among adult survivors of COVID-19. This provides another practical measurement of improved respiratory function, as reducing the feeling of breathlessness is a critical component of the recovery process. In addition to the aforementioned tests, it may also be beneficial to consider other tests, such as the Total Lung Capacity (TLC) and the Peak Expiratory Flow (PEF), that may provide a more nuanced understanding of the impact of physical rehabilitation programs on lung function among COVID-19 survivors.
The quality of the studies included in this review was generally good or excellent, suggesting reliable findings. However, it is worth noting that the higher-quality studies were all randomized trials conducted in 2022, indicating that the quality of research in this area is improving. Additionally, the higher-quality studies tended to have larger sample sizes, suggesting that they may provide more reliable evidence for the effectiveness of telerehabilitation in this setting.
While the findings of this review are encouraging, it is important to acknowledge its limitations. The diversity of the rehabilitation programs, their duration, intensity, and the measures used to assess outcomes across studies make it challenging to draw definitive conclusions. There was also a wide age range among the participants, which might influence the outcomes of the rehabilitation programs. The gender distribution was not balanced across studies, and the severity of COVID-19 varied, factors that might also affect the response to rehabilitation. Furthermore, many studies did not provide detailed data about the length of hospitalization, making it difficult to explore its potential impact on outcomes. Moreover, the number of included studies was relatively small, indicating a need for more high-quality research in this field.
By limiting the search to studies published in English, there may have been inadvertently introduced language bias, potentially excluding relevant studies published in other languages. In addition, this review did not include the gray literature, such as conference papers or technical reports, possibly leading to publication bias. Despite the robust measures used to assess this, the possibility of missing some relevant information cannot be entirely negated. Finally, our quality assessment was based on the National Heart, Lung, and Blood Institute (NHLBI) tool. Despite its wide acceptance and use, it possesses inherent limitations and subjectivity, which could potentially influence the conclusions drawn from this review. Future studies should strive for uniformity in their protocols and measures to allow for more direct comparisons and, potentially, meta-analyses.