Review ArticleNarrative Review

Telerehabilitation in Subjects With Respiratory Disease: A Scoping Review

Shunsuke Taito, Kota Yamauchi and Yuki Kataoka
Respiratory Care April 2021, 66 (4) 686-698; DOI: https://doi.org/10.4187/respcare.08365

Abstract

Considering the current coronavirus disease (COVID-19) pandemic, telerehabilitation may be a viable first-line option for patients with respiratory tract disease. To date, there has been no systematic review on telerehabilitation for respiratory tract diseases, including COVID-19. Therefore, this scoping review aimed to determine what telerehabilitation for patients with respiratory tract diseases consists of, how safe telerehabilitation is for patients with respiratory tract diseases, and how feasible telerehabilitation is for hospitalized patients with COVID-19. In May 2020, we conducted a search of the following publication databases on the use of telerehabilitation in the treatment of respiratory tract diseases: Medical Literature Analysis and Retrieval System Online, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Literature, and Physiotherapy Evidence Database. Of the 208 articles identified, 23 studies were subsequently included in this scoping review. In 22 of the included studies, subjects had stable COPD and underwent telerehabilitation at home. The final included study was a case series of subjects with severe acute respiratory syndrome coronavirus 2 infection who underwent telerehabilitation in-hospital. Most telerehabilitation programs consisted of aerobic exercises using a cycle ergometer or a treadmill, walking, and muscle-strengthening exercises. The reported number of adverse events was low, and most studies reported that the average session adherence rate was > 70%. The majority of the telerehabilitation programs included a face-to-face rehabilitation assessment. Our findings indicate that, in its current state, telerehabilitation may be safe and feasible and may lead to reduced face-to-face rehabilitation therapy; in addition, remote rehabilitation assessment should be considered during the COVID-19 pandemic. Further research that targets a more diverse range of respiratory tract diseases and considers telerehabilitation in a hospital setting is required.

Introduction

Pulmonary rehabilitation (PR) is recognized as an important, standard treatment for individuals with chronic respiratory diseases. The goals of PR for chronic respiratory disease include minimizing symptom burden, maximizing exercise performance, and increasing participation in activities of daily living.1 PR is a first-line management strategy in patients with COPD, and it reduces dyspnea, increases exercise capacity, and improves health-related quality of life.2,3 It is beneficial to patients with diseases besides COPD such as interstitial lung disease, cystic fibrosis, bronchiectasis, and asthma.1 Depending on the disease, PR may become established in the acute phase, such as while a patient is still in the hospital after an exacerbation.4,5

Telerehabilitation refers to the delivery of therapeutic rehabilitation at a distance or in out-of-hospital settings using telecommunication technologies.6 Improving access to PR is one of the most pressing issues in the respiratory community.1,7 A recent systematic review including only stable subjects with COPD clarified that home-based telehealth care may lead to increased physical activity level.8 Although PR is provided for patients with other respiratory diseases except for stable COPD, telerehabilitation for respiratory tract disease has not been sufficiently investigated.

Due to the ongoing coronavirus disease (COVID-19) pandemic, redesigning rehabilitation services with the aim of minimizing face-to-face contact in both a timely and evidence-based manner has become important. Telerehabilitation has been suggested as the first-line option for patients with respiratory tract diseases, including those with COVID-19 in the post-acute phase.9 COVID-19 is a respiratory tract disease that has demonstrated rapid and widespread transmission.10 This has prompted the use of telerehabilitation systems in hospitals to mitigate the spread of the infection.11 It is, therefore, necessary to consider telerehabilitation during the acute phase for in-patients as well as during the post-acute phase from the perspective of infection prevention.

Therefore, this scoping review, conducted in the COVID-19 era, aimed to determine what telerehabilitation for patients with respiratory tract disease consists of, how safe telerehabilitation is for patients with respiratory tract diseases, and how feasible telerehabilitation is for hospitalized patients with COVID-19.

Review of the Literature

In accordance with the pre-defined protocol,12 we conducted a scoping review based on the 5-stage framework outlined by the Joanna Briggs Institute: identifying the research question; identifying relevant studies; study selection; data charting; and collating, summarizing, and reporting the results.13 This scoping review follows the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews statement14 (see the supplementary materials at http://www.rcjournal.com).

Eligibility Criteria and Search Strategy

We used the Population, Concept, and Context framework13 to define the inclusion criteria. All published studies conducted on subjects with respiratory tract diseases, including those with severe acute respiratory syndrome coronavirus 2 infection (SARS-Cov-2), Middle East respiratory syndrome, and coronavirus disease (COVID-19), were included. In this scoping review, the International Classification of Diseases, Tenth Revision, Clinical Modification codes of subjects included J00–J99 for diseases of the respiratory system; A15–16 for respiratory tuberculosis; U04 for SARS-Cov-2 infection; U07.1 for COVID-19, virus identified; and U07.2 for COVID-19, virus unidentified. We reviewed the existing literature on telerehabilitation in subjects with respiratory tract diseases regarding rehabilitation programs, feasibility, and safety. In this review, telerehabilitation was defined as delivery of therapeutic rehabilitation at a distance or offsite using telecommunication technologies.6 We also included studies on telerehabilitation, remote rehabilitation, and virtual rehabilitation as defined by each study’s authors. Studies were included regardless of the setting (including hospitals), phase, country, and follow-up duration. Studies were excluded if they did not fit the conceptual framework of the review.

Comprehensive searches of the following databases were conducted on May 9, 2020: Medical Literature Analysis and Retrieval System Online, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Literature, and Physiotherapy Evidence Database (see the supplementary materials at http://www.rcjournal.com). In addition, searches were conducted in the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov to identify ongoing clinical trials. We also identified additional relevant research by hand-searching the reference lists of the included studies and relevant reviews (based on the citation information from the Web of Science).

All published randomized controlled trials (RCTs), crossover trials, cluster-randomized trials, quasi-randomized trials, non-randomized trials, observational studies with controls, case reports, and case series were included. Studies in any language and from any country were accepted. Conference abstracts and review articles were excluded from this study, following the pre-defined protocol.12

Study Selection

The selection of studies was conducted independently by 2 researchers (ST and KY). The 2 researchers compared their lists, and any differences in opinion were resolved by discussion; where this failed, resolution was reached through arbitration by a third researcher (YK).

Data Extraction and Synthesis

Data extraction was conducted by 1 researcher (ST) using standard data-extraction forms including diagnosis, setting, study type, number of subjects, telerehabilitation program, control, outcomes, adverse events, and feasibility as in the pre-defined protocol.12 Another researcher (KY) confirmed the extracted data. Where necessary, we contacted the authors of the reviewed publications. We organized the extracted data described above as a qualitative synthesis.

Results

Of the 208 articles identified, 29 articles (23 studies) were included in this scoping review.11,15-42 The study selection process is shown in Figure 1. Fifteen studies were conducted in Europe, including Denmark,16,27,40,42 United Kingdom,31,32,39 Italy,26,30 the Netherlands,22,23 Norway,20,34 Germany,37 and Greece33 (see the supplementary materials at http://www.rcjournal.com). Regarding the study design, this review included 8 RCTs,16,22,28,30-33,42 6 case-control studies,15,23,25,26,38,39 and 9 case series.11,19-21,27,34,36,37,40

Fig. 1.
Fig. 1.

Flow chart.

Subjects in 22 of the 23 included studies (95.7%)15,16,19-23,25-28,30-34,36-40,42 had stable COPD who underwent telerehabilitation at home (Table 1). One case series11 reported subjects with SARS-CoV-2 infection in Japan who underwent telerehabilitation in the hospital. Although most ongoing studies and studies awaiting classification included subjects with COPD,43-52 2 RCTs in subjects with COVID-1953,54 were ongoing, and 2 studies including subjects with idiopathic pulmonary fibrosis55 and cystic fibrosis56 were awaiting classification (see the supplementary materials at http://www.rcjournal.com).

View this table:
Table 1.

Telerehabilitation for Subjects With Respiratory Diseases

Telerehabilitation programs in 14 of the studies consisted of both aerobic exercise, performed with a cycle ergometer or a treadmill or by walking, and muscle strength exercises (Table 1).15,18,19,23,25-28,30,32,34,36,38,40 The rehabilitation programs of 4 studies included stretching and breathing exercises.15,26,29,38 Thirteen studies used pulse oximetry to monitor oxyhemoglobin saturation and pulse rate.11,19,21,25-27,29,30,33,34,36,38,40 Sixteen studies11,15,16,19-21,23,25-28,34,38-40,42 used a web camera system and a laptop or tablet computer for video conferencing. Three studies used internet-based or smartphone applications to encourage subjects to exercise.32,36,39 The frequency of the programs varied from daily to twice per week. The duration of the majority of the programs was < 12 weeks15,19-23,25-28,30-32,36-39,42 without excluding 1- or 2-y programs.33,34

Seventeen studies11,15,16,20,21,25-28,30-32,36,38-40,42 reported that the number of adverse events was low (Table 2). The median ratio of subject withdrawal from the included studies was 5.0% (range 0–56.9%). The most reported average rate of adherence to telerehabilitation sessions was > 70% (Table 2).11,15,21,25,27,28,31,33,36,38,40,42 Most telerehabilitation programs did not include a face-to-face rehabilitation session but included a face-to-face rehabilitation assessment.15,19,21,25,26,28,30-32,34,36,38-40,42

View this table:
Table 2.

Safety and Feasibility of Telerehabilitation for Subjects With Respiratory Diseases

Summary

This study is the first scoping review of telerehabilitation for treating respiratory tract diseases. The review included 23 studies involving a total of 1,717 subjects. In this study, we clarified that the available evidence on the use of telerehabilitation for subjects with respiratory tract diseases is primarily based on PR for patients with stable COPD; that telerehabilitation for subjects with respiratory tract diseases is safe; and that telerehabilitation would reduce the need for face-to-face rehabilitation programs, although face-to-face assessments are still required. This scoping review is the first to clarify the lack of evidence for the telerehabilitation of patients with other respiratory tract diseases beyond stable COPD.

Studies included in this review focused on stable COPD, except for a case series on COVID-19. The exercise types included in these studies were in accordance with the PR guidelines shown in Table 1. Ongoing studies have tried to recruit subjects with other respiratory tract diseases, including those with COVID-19, idiopathic pulmonary fibrosis, and cystic fibrosis. No study, except the case series of subjects with COVID-19,11 reported telerehabilitation in a hospital setting. As optimal rehabilitation may vary with disease and setting, studies conducted on other diseases and in hospital settings are needed during the era of COVID-19.

For patients with respiratory tract diseases, telerehabilitation at home, using telemonitoring systems including measurements of Embedded Image and pulse rate, has been shown to be feasible and safe. The withdrawal rate of subjects from telerehabilitation was comparable to the reported rate in other studies (10–31.8%).57 In addition, no serious adverse events were reported for subjects with COPD58 and idiopathic pulmonary fibrosis,59 and resistance training can be successfully performed during PR without increasing adverse events.60 The number of adverse events was reported to be low in all included studies; thus, telerehabilitation is likely to be feasible and safe in patients with respiratory diseases such as stable COPD. As the majority of the studies did not specify the criteria for starting and discontinuing rehabilitation sessions, further studies are required to clarify whether the criteria used in telerehabilitation differ from those used in face-to-face rehabilitation.

Telerehabilitation for patients with COVID-19 in hospital settings may be feasible and help to reduce the need for face-to-face rehabilitation treatment. However, most evaluations determining the intensity of rehabilitation program before the implementation of telerehabilitation and the effectiveness of the program were conducted in a face-to-face manner. The guidelines for the field test to setting the exercise intensity state that the test should be performed in a location where a rapid and appropriate response to an emergency is possible.61 To prevent infection and transmission during the COVID-19 pandemic, remote assessment of telerehabilitation for hospitalized patients with COVID-19 is desirable.11 Further research is needed to determine how rehabilitation assessments can be conducted remotely to deliver effective interventions.

This review has several strengths and limitations. Regarding its strengths, the results of this review are based on the currently available evidence, following a comprehensive literature search. Furthermore, we employed a rigorous methodology that followed a written protocol that was developed a priori. A limitation is the limited extent to which the findings of the present review can be generalized beyond stable COPD. However, this scoping review is also the first report to clarify the lack of evidence for telerehabilitation in respiratory tract diseases besides stable COPD.

In conclusion, previous studies regarding telerehabilitation in patients with respiratory tract diseases primarily included stable patients with COPD. Current telerehabilitation is safe and feasible and helps reduce face-to-face rehabilitation treatment; remote rehabilitation assessment should be considered during the COVID-19 pandemic. Further research that targets in-hospital telerehabilitation and other respiratory tract diseases apart from stable COPD is needed.

Acknowledgments

The authors thank Editage (http://www.editage.jp) for English language editing.

Footnotes

  • Correspondence: Shunsuke Taito PhD PT, Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima, University Hospital, 1-2-3, Kasumi, Minami-ku, Hiroshima, 734-8551, Japan. E-mail: shutaitou{at}hiroshima-u.ac.jp

  • Supplementary material related to this paper is available at http://www.rcjournal.com.

  • The authors have disclosed no conflicts of interest.

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