Telerehabilitation for People with Chronic Obstructive Pulmonary Disease: Feasibility of a Simple,Real Time Model of Supervised Exercise Training

Abstract

We evaluated the safety and feasibility of home telerehabilitation for people with chronic obstructive pulmonary disease (COPD). Eight patients with mean age of 66 years and moderately impaired lung function took part. The telerehabilitation equipment in the participant's home included an exercise bicycle, a tablet computer with webcam for low bandwidth videoconferencing, and a pulse oximeter positioned so that the display was visible while videoconferencing. Participants undertook supervised aerobic training twice a week for eight weeks, with two participants and a physiotherapist attending each class via videoconferencing from separate locations. Primary outcomes were adverse events, sessions attended and system usability. Secondary outcomes were the 6-minute walk distance (6MWD) and Chronic Respiratory Questionnaire (CRQ). No significant adverse events occurred during the study. Participants attended 76% of possible sessions. System usability ratings were excellent when sessions were delivered via the university network (mean 94 out of 100) but lower when using the hospital network (mean 59 out of 100), with 67% of technical problems related to data network capability. Five participants completed the programme, with clinically significant improvements in 6MWD (mean 27 m, SD 40) and CRQ dyspnoea (4 units, SD 4). Simple home-based telerehabilitation using readily available equipment is safe and feasible for people with COPD. Effective delivery of telerehabilitation requires an adequate data network.

Introduction

Chronic obstructive pulmonary disease (COPD) is a disabling condition characterised by shortness of breath on exertion, marked disability and frequent hospitalisation. The World Health Organization estimates that 65 million people have moderate to severe COPD and the prevalence is rising.¹ COPD is a leading cause of morbidity and mortality around the world,¹ with significant impact on both individuals and communities.

There is Level 1 evidence that pulmonary rehabilitation improves exercise capacity, reduces shortness of breath (dyspnoea) and improves quality of life in people with COPD, regardless of disease severity.² Rehabilitation typically involves eight weeks of twice-weekly supervised exercise training in a group setting, as well as education regarding COPD self-management. Despite the compelling evidence for its benefits, only about 1-2% of people with COPD receive pulmonary rehabilitation each year.³ The reasons include a lack of programmes, a shortage of qualified health professionals and poor patient access to existing programmes, due to disabling symptoms, poor mobility and lack of transport to rehabilitation centres. New programme models that improve access and uptake are required.

Telehealth has a growing role in the management of people with COPD. Home-based monitoring has been used to effectively monitor lung function, oxygenation and symptoms in people with stable disease⁴ and in those undergoing treatment for acute exacerbations.⁵ However, the use of telehealth strategies in pulmonary rehabilitation is in its infancy, despite its growing use in the rehabilitation of other patient groups.⁶ One study has reported the success of a centre-based telerehabilitation model for COPD, linking one expert centre with smaller regional centres.⁷ However this model does not overcome access difficulties for disabled patients who cannot travel to a centre for treatment. A recent study reported the feasibility of a home telerehabilitation programme for three participants, using a bespoke system that is not clinically available.⁸ We hypothesised that existing, widely available technology could be used to provide safe and effective telerehabilitation for people with COPD. The aim of the present study was to establish the feasibility and acceptability of real time, home-based telerehabilitation for people with COPD using existing technology.

Methods

Eight patients with COPD were recruited from a large teaching hospital in Melbourne. Participants had the diagnosis of COPD confirmed on spirometry⁹ and were in a stable clinical state, with no evidence of an acute exacerbation of COPD within the previous four weeks. Participants also fulfilled the usual inclusion criteria for centre-based pulmonary rehabilitation, which include breathlessness on exertion and absence of comorbidities that preclude exercise (severe cardiac, neurological or orthopaedic problems). Patients were excluded if they were unable to follow verbal instructions, suffered cognitive impairment or had language difficulties. Participants were recruited by a researcher who was not involved in their clinical care. As there were no data available on which to perform a power calculation, a sample size of eight was chosen to ensure that we included at least two participants in each of the categories of mild, moderate and severe pulmonary impairment⁹ as well as participants with a range of ages and a range of experience using the Internet. The study was approved by the appropriate ethics committees.

Assessments

All participants underwent an initial assessment of exercise capacity, health-related quality of life and dyspnoea, in accordance with usual practice in pulmonary rehabilitation.¹⁰ This assessment took place at the hospital and was performed by a researcher who was not involved in delivery of the telerehabilitation programme. The 6-minute walk test (6MWT) is a standardised and well validated measure of functional exercise capacity for people with chronic lung disease.¹¹ Any participants who exhibit an abnormal exercise response during this test (oxyhaemoglobin saturation, SpO₂ less than 85% despite supplemental oxygen, or failure of heart rate to rise appropriately with exercise) were excluded from further participation. The Chronic Respiratory Disease Questionnaire (CRQ) is a well validated disease-specific measure of health related quality of life. Dyspnoea was measured using the Modified Medical Research Council (mMRC) scale.¹³

Equipment

Telerehabilitation was conducted in the patients’ homes using a cycle ergometer. A pulse oximeter was used to monitor oxyhaemoglobin saturation and heart rate. A tablet computer was used for videoconferencing. The cycle ergometer (Insight B890P) had a step-through design, which improved safety as participants were not required to lift their legs over a central bar in order to mount and dismount. The pulse oximeter (Nonin Palmsat 2500A) measured SpO₂ and heart rate via a fingerclip. The oximeter was fixed to the exercise bicycle with the display positioned so that its output was visible to the videoconferencing camera (Figure 1). The pulse oximeter's audible alarms were programmed to sound if SpO₂ fell below 88% or heart rate exceeded 150 beats per minute. A tablet computer (TEGA 3G Touch Tablet PC with Win7 Pro) with a built-in web camera was used, with an external speaker to improve sound quality (Logitech Laptop Speaker Z205). The videocollaboration software (VSee. See http://vsee.com) was used to provide low bandwidth videoconferencing, with centralized per-user constraints on bandwidth usage and capabilities. Only invited users could participate in, view or hear the videoconferences, which were encrypted. All participants were provided with a wireless 3G modem to connect to the Internet. For two of the groups (4 participants) the physiotherapy clinician was located in the university and connected via the university data network, and for two groups (4 participants) the physiotherapy clinician was located in the hospital, and connected via the hospital data network.

Figure 1

Telerehabilitation in a participant's home

A research assistant visited the participants in their homes to provide instruction in how to switch on and off the system, how to position the fingerclip pulse oximeter and how to use the touch screen to commence the videoconferencing. The participant was also shown how to mount and dismount the exercise bike safely.

Pulmonary rehabilitation

Supervised exercise training was provided twice weekly for eight weeks. An experienced physiotherapist remotely supervised the exercise training sessions for two participants at a time. Participants could see and talk to each other, as well as seeing and talking to the supervising physiotherapist. Prior to commencing each session, each participant reported any change in their symptoms, then checked their resting oxyhaemoglobin saturation levels and heart rate to ensure clinical stability. The exercise programme involved cycling at an intensity of 60% of peak work estimated from the initial 6MWT, using a previously published algorithm for cycle exercise prescription in pulmonary rehabilitation.¹⁴ Duration was increased up to 30 min, and then intensity was increased according to standardised criteria.¹⁵ Participants were asked to monitor their symptoms of breathlessness and fatigue using the Borg scale.¹⁶ Participants were encouraged to exercise at a dyspnoea score of 3 (moderate dyspnoea).¹⁵ Heart rate and SpO₂ were monitored during training by the physiotherapist. The intensity of exercise was reduced or stopped if SpO₂ dropped below 88%, heart rate rose above 150 beats per minute, dyspnoea scores were greater than 4 (somewhat severe) or participants exhibited signs of discomfort or distress. This is consistent with procedures in a centre-based programme.¹⁵

The physiotherapist led informal discussions about aspects of self management relevant to healthy living with COPD, as would be typical in a centre-based programme. These discussions included management of acute exacerbations, dealing with breathlessness, guidelines for physical exercise, correct use of medications, healthy eating and coping with chronic lung disease.¹⁵ Participants were also provided with written material on these topics¹⁷ and referred to other members of the multi-disciplinary team if additional consultation was required.

Outcomes

The primary outcomes were adverse events, feasibility and acceptability. These were defined as participant-related major adverse events such as dizziness or chest pain during exercise, or minor adverse events. The minor events were failure to complete the prescribed exercise session or failure to achieve the set exercise intensity, SpO₂ <88% or heart rate >150 beats per minute during exercise, or failure to progress the exercise prescription in subsequent sessions according to the protocol. To assess feasibility, the number of sessions attended and completion rate were recorded. Completion was denned as undertaking at least 70% of planned sessions.¹⁸ To assess acceptability participants were invited to report their experiences at the end of the trial using the System Usability Scale, an instrument designed to document users’ experiences of technology which has good internal consistency.¹⁹ Physiotherapists kept a log of technical problems that occurred during their sessions.

Secondary outcomes were the clinical outcomes that are routinely collected in pulmonary rehabilitation programmes. The impact of telerehabilitation on functional exercise capacity was measured by the change in distance in the 6MWT. Health-related quality of life was evaluated by the change in the CRQ total score and the domains of dyspnoea, fatigue, mastery and emotional function. Effects on dyspnoea were evaluated with the change in mMRC.

Results

Eight people with COPD (three men) took part in the programme, in four groups of two participants. They were aged 56–83 years. The forced expiratory volume in one second (FEV₁) was 49–90% predicted, with a mean of 66% predicted (SD 18). Two participants had mild COPD, four had moderate COPD and two had severe COPD.²⁰ The mMRC dyspnoea scores ranged from 1 (breathless while walking up hill) to 4 (breathless whilst dressing) and the 6-minute walk distance was 274–550 m (mean 428 m, SD 104). No participant required supplementary oxygen, either at rest or during training. Comorbidities included hypertension (n = 5), depression (n = 3), gastroesophageal reflux disease (n = 3), diabetes mellitus (n = 1), ulcerative colitis (n = 1), chronic renal disease (n = 1), obstructive sleep apnea (n = 1), previous knee replacement (n = 1) and hearing impairment (n = 1). Three participants had previously completed a conventional centre-based pulmonary rehabilitation programme and two participants were regular Internet users.

No major adverse events were recorded (Table 1). Minor adverse events were desaturation to less than 88% (1 session) and heart rate greater than 150 beats per minute (6 sessions in one person). These changes resolved with a small reduction in exercise intensity and no changes to the subsequent exercise prescription were required.

Table 1

Programme outcomes. The values shown are the number and percentage of sessions, or the number and percentage of participants

Primary outcomes	No (%)
Major adverse events	0(0)
Minor adverse events	7(7)
SpO₂< 88%	1(1%)
Heart rate >150/min	6(6)
Failure to progress exercise prescription	0(0)
Failure to complete session	0(0)
Sessions attended	97(76)
Participants who completed programme	5(67)

Secondary outcomes	Mean (SD)
6-minute walk distance (m)	27 (40)^*
CRQ dyspnoea	4(4)^*
CRQ fatigue	2(6)^*
CRQ mastery	0(3)
CRQ emotional function	2(6)
mMRC dyspnoea	–0.6(1)

SpO₂ – oxyhaemoglobin saturation; CRQ – Chronic Respiratory Disease Questionnaire; mMRC – modified Medical Research Council Scale

mean change exceeds minimum important difference for this outcome

Participants attended 76% of planned sessions. Five of the eight participants completed the programme. Reasons for non-completion were related to exacerbations of underlying medical conditions. Two participants were admitted to hospital with acute infective exacerbations of COPD, whilst one participant with diabetes developed unstable blood glucose levels that required changes in medication. For these participants, the physiotherapists identified these intercurrent illnesses based on changes in symptoms and monitoring prior to the start of a telerehabilitation session, and advised the participants to seek medical attention.

The system usability scale ratings are shown in Table 2. System usability scores were high (94 out of 100) for the groups where the physiotherapist used the university data network, but were much lower (59 out of 100) when the physiotherapist used the hospital data network. The physiotherapists reported a total of 38 technical problems, of which 27 (71%) were related to network connectivity, specifically problems with video (50%) and/or sound (21%). The remaining technical problems were minor participant difficulties with the tablet (13%), cycle ergometer (10%) or pulse oximeter (5%).

Table 2

System usability scale values (0 = not usable to 100 = highly usable) and technical problems

All sessions	SUS median (range)
All participants	81 (43–100)
Clinician at university	94(88–100)
Clinician at hospital	60 (43–75)

Sessions with technical problems	No of sessions (%)
All participants	32 (36)
Clinician at university	8(16)
Clinician at hospital	24 (52)

In participants who completed the programme, the mean improvements in secondary outcomes were clinically significant for 6-minute walk distance, CRQ dyspnoea and CRQ fatigue, with smaller improvements in other outcomes (Table 2).

Discussion

The present pilot study shows that simple, real time telerehabilitation is safe and feasible in people with COPD. We used equipment that is commonly available, either commercially (tablet computers), for free (videoconferencing software) or in existing pulmonary rehabilitation programmes (pulse oximeters and cycle ergometers). The equipment and supervision model was acceptable to participants with a wide range of ages and disease severity. However, the study identified significant challenges to the routine adoption of telerehabilitation, related to the limited capacity of hospital data networks.

The telerehabilitation programme was safe, with no important adverse events. The minor adverse events recorded were of little clinical significance and would probably have required no action in a centre-based pulmonary rehabilitation programme.¹⁵ Our experience suggests that the monitoring provided using pulse oximetry and an experienced physiotherapist, was sufficient to allow safe and effective exercise training for people with COPD at home.

Session attendance and programme completion rate were very similar to those reported in the literature. For those who completed the programme, improvements that exceeded the minimum important difference were evident for functional exercise capacity, fatigue and dyspnoea. The outcomes of our standard, hospital outpatient pulmonary rehabilitation programme have been documented in other studies,^21,22 and it was interesting to note that there were smaller improvements in mastery and emotional function than we have seen in these previous centre-based trials. It is possible that this was related to the relative absence of group support, as participants had only one training partner, or to our lesser focus on education and self management than is common in centre-based programmes.¹⁰ These factors deserve examination in future trials. Similarly, although the improvements in 6-minute walk distance were clinically important, they were smaller than previously documented.² It is possible that because our trial was focussed on safety and feasibility, participants trained at a lower intensity than they would have done in a centre-based programme. In addition, because the effects of exercise training are specific to the training modality, it is likely that the beneficial effects of exercise training on a cycle ergometer are not well captured by an exercise test involving walking.²³ These factors have implications for choice of interventions and outcomes in future studies.

There are limited data on the feasibility and outcomes of telerehabilitation for people with COPD. One large controlled trial has shown that a centre-based model of telerehabilitation, where videoconferencing was used to connect one large, expert centre with nine regional centres, results in equivalent clinical outcomes to traditional pulmonary rehabilitation.⁷ This model improves access for people with COPD in regional areas, but does not overcome the travel and transport barriers faced by many disabled people with COPD, even in metropolitan areas.³ One recent study, by Tousignant and others, used a bespoke system to provide telerehabilitation to three people with COPD in their own homes.⁸ Clinical outcomes were similar to those seen in our study, although there were no data on attendance and usability. In contrast to the telerehabilitation platform used in the trial by Tousignant et al., we used equipment that is readily available, and this proved to be feasible and acceptable to patients.

Our model of telerehabilitation used videoconferencing to allow direct supervision of participants by physiotherapists, in a manner similar to conventional pulmonary rehabilitation. The pilot study clearly illustrates the dependency of this model on a satisfactory data network. There is growing interest in telerehabilitation for conditions as diverse as cardiac disease, stroke, spinal cord injury and joint replacement.⁶ However there has been little attention to the health system infrastructure that would be required to run such programmes. Although telerehabilitation has demonstrated potential to improve access to services and reduce costs,⁶ this cannot be realised without the appropriate infrastructure.

In conclusion, our pilot study has shown that a simple model of telerehabilitation using readily available equipment is safe and feasible in patients with COPD. The benefits of telerehabilitation in this small sample provide a rationale for future testing in large randomised controlled trials.

Footnotes

Acknowledgements

We acknowledge the late Professor Rob Pierce, whose commitment to treatment equity and access for people with chronic lung disease was instrumental in the development of this study. The study was funded by research grants from the Windermere Foundation, Telstra and La Trobe University.

References

World Health Organization. The Global Burden of Disease: 2004 update. Geneva: WHO, 2008. Available from http://www.who.int/healthinfo/global_burden_disease/en/ (last checked 25 March 2013)

Lacasse

, Goldstein

, Lasserson

, Martin

Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2006: CD003793

Keating

, Lee

, Holland

AE.

What prevents people with chronic obstructive pulmonary disease from attending pulmonary rehabilitation? A systematic review. Chron Respir Dis 2011; 8: 89–99.

Antoniades

, Rochford

, Pretto

JJ.

Pilot study of remote telemonitoring in COPD. Telemed J E Health 2012; 18: 634–40.

Mair

, Goldstein

, May

Patient and provider perspectives on home telecare: preliminary results from a randomized controlled trial. J Telemed Telecare 2005; 11 (Suppl. 1): 95–7.

Kairy

, Lehoux

, Vincent

, Visintin

A systematic review of clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation. Disabil Rehabil 2009; 31: 427–47.

Stickland

, Jourdain

, Wong

, Rodgers

, Jendzjowsky

, Macdonald

GF.

Using telehealth technology to deliver pulmonary rehabilitation in chronic obstructive pulmonary disease patients. Can Respir J 2011; 18: 216–20.

Tousignant

, Marquis

, Page

In-home telerehabilitation for older persons with chronic obstructive pulmonary disease: a pilot study. International Journal of Telerehabilitation 2012; 4: 7–13.

Abramson

, Crockett

, Frith

, McDonald

CF.

COPDX: an update of guidelines for the management of chronic obstructive pulmonary disease with a review of recent evidence. Med J Aust 2006; 184: 342–5.

10.

Nici

, Donner

, Wouters

American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med 2006; 173: 1390–413.

11.

American Thoracic Society. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med 2002; 166: 111–7.

12.

Guyatt

, Berman

, Townsend

, Pugsley

, Chambers

LW.

A measure of quality of life for clinical trials in chronic lung disease. Thorax 1987; 42: 773–8.

13.

Bestall

, Paul

, Garrod

, Garnham

, Jones

, Wedzicha

JA.

Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax 1999; 54: 581–6.

14.

Hill

, Jenkins

, Cecins

, Philippe

, Hillman

, Eastwood

PR.

Estimating maximum work rate during incremental cycle ergometry testing from six-minute walk distance in patients with chronic obstructive pulmonary disease. Arch Phys Med Rehabil 2008; 89: 1782–7.

15.

Australian Lung Foundation/Australian Physiotherapy Association. Pulmonary Rehabilitation Toolkit. See http://www.pulmonaryrehab.com.au (last checked 20 March 2013)

16.

Borg

Psycho physical bases of perceived exertion. Med Sci Sports Exerc 1982; 14: 377–81.

17.

Lung Foundation Australia. Better Living with Chronic Obstructive Pulmonary Disease - A Patient Guide, 2008. Available from: http://lungfoundation.com.au/ (last checked 25 March 2013)

18.

Garrod

, Marshall

, Barley

, Jones

PW.

Predictors of success and failure in pulmonary rehabilitation. Eur Respir J 2006; 27: 788–94.

19.

Brooke

SUS: a ‘quick and dirty’ usability scale. In: Jordan

, Thomas

, Weerdmeeter

, McClelland

, eds. Usability Evaluation in Industry. London: Taylor and Francis, 1996: 189–94.

20.

Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management and Prevention of COPD. Available from http://www.goldcopd.org (last checked 20 March 2013)

21.

Holland

, Hill

, Rasekaba

, Lee

, Naughton

, McDonald

CF.

Updating the minimal important difference for six-minute walk distance in patients with chronic obstructive pulmonary disease. Arch Phys Med Rehabil 2010; 91: 221–5.

22.

Holland

, Hill

, Nehez

, Ntoumenopoulos

Does unsupported upper limb exercise training improve symptoms and quality of life for patients with chronic obstructive pulmonary disease?

J Cardiopulm Rehabil 2004; 24: 422–7.

23.

Leung

, Alison

, McKeough

, Peters

MJ.

Ground walk training improves functional exercise capacity more than cycle training in people with chronic obstructive pulmonary disease (COPD): a randomised trial. J Physiother 2010; 56: 105–12.