Chronic obstructive pulmonary disease is a major cause of disability and mortality worldwide. There is level 1 evidence that exercise-based pulmonary rehabilitation improves exercise capacity, dyspnoea and quality of life. Telecommunication technology can be used to deliver exercise therapy. This systematic review aimed to estimate the effects of exercise therapy delivered using advanced telehealth technology compared to no exercise or inpatient or outpatient exercise therapy and home-based exercise therapy without telehealth on exercise capacity, quality of life, dyspnoea and costs in people with stable chronic obstructive pulmonary disease.
Guided by a prospectively registered protocol, sensitive searches were performed in 7 databases (including Medline and PEDro), hand searching of relevant conference proceedings and citation tracking. Randomised controlled trials involving people with stable chronic obstructive pulmonary disease were included if they compared exercise therapy delivered using advanced telehealth technology to: (1) no exercise, (2) inpatient or outpatient exercise therapy, or (3) home-based exercise therapy without telehealth. Exercise therapy delivered using advanced telehealth technology was defined as delivery of home-based exercise using any telehealth technology that was more advanced than phone contact alone (eg, real-time videoconferencing, web-based interactive platforms or smartphone applications providing either therapist or algorithm-mediated (automated) individualised feedback and goals). The primary outcomes were exercise capacity, quality of life, dyspnoea and costs in the short (1-4 months) and long (9-12 months) term. Two reviewers independently selected trials, extracted data, and evaluated trial quality and certainty of evidence, with any disagreements resolved by discussion or arbitration by a third reviewer. Trial quality was evaluated using the Cochrane risk of bias tool. Certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Meta-analysis was used to estimate the mean difference and 95% confidence interval (CI) for each outcome for each comparison.
34 articles reporting 15 trials (1,522 participants) were included in the analyses. Exercise therapy delivered using advanced telehealth technology was compared to no exercise in 7 trials, to inpatient or outpatient exercise therapy in 3 trials, and to home-based exercise therapy without telehealth in 6 trials (note, 1 trial compared exercise delivered with telehealth to both no exercise and home-based exercise without telehealth). The advanced telehealth technology consisted of real-time supervised/monitored exercise sessions (2 trials) and unsupervised training with telehealth feedback (13 trials). The dose of exercise training ranged from 3-7 sessions/week for 1-12 months.
Exercise therapy delivered using advanced telehealth technology increased the distance walked in 6 minutes (mean difference 15 m; 95% CI 5 to 24; 4 trials; 458 participants; low certainty) and improved quality of life measured using the St George Respiratory Questionnaire (mean difference -4%; 95% CI -7 to 0; 4 trials; 361 participants; low certainty) and dyspnoea measured using the Chronic Respiratory Questionnaire dyspnoea sub-score (mean difference 2 points; 95% CI 0 to 4; 2 trials; 120 participants; very low certainty) in the short term compared to no exercise therapy. Meta-analyses could not be performed for the long-term outcomes and there were no data available for cost-effectiveness.
Compared to inpatient or outpatient exercise therapy, exercise therapy delivered using advanced telehealth technology produced a similar distance walked in 6 minutes (mean difference 6 m; 95% CI -26 to 37; 2 trials; 224 participants; low certainty) and modified Medical Research Council dyspnoea scale score (mean difference 0 points; 95% CI 0 to 0; 2 trials; 152 participants; low certainty) but improved quality of life measured with the St George Respiratory Questionnaire score (mean difference -4%; 95% CI -9 to 0; 2 trials; 224 participants; low certainty) in the short-term. Again, meta-analyses could not be performed for the long-term outcomes and there were no data available for cost-effectiveness.
Exercise therapy delivered using advanced telehealth technology had a similar effect as home-based exercise therapy without technology on distance walked in 6 minutes (mean difference 2 m; 95% CI -16 to 19; 3 trials; 231 participants; low certainty) and St George Respiratory Questionnaire score (mean difference -14%; 95% CI -28 to 1; 3 trials; 171 participants; very low certainty) but improved the Chronic Respiratory Questionnaire dyspnoea sub-score (mean difference 2 points; 95% CI 0 to 4; 2 trials; 123 participants; very low certainty) in the short term. One trial (105 participants) reported cost-effectiveness, with no difference in total cost (mean difference EUR -288; 95% CI -3,998 to 3,424). Meta-analyses could not be performed for the long-term outcomes.
Exercise therapy delivered using advanced telehealth technology may improve exercise capacity, dyspnoea and quality of life compared with no exercise therapy, although some benefits may be small. Exercise therapy delivered using advanced telehealth technology is generally similar to inpatient or outpatient exercise therapy, and similar to or better than home-based exercise therapy without technology.
Bonnevie T, et al. Advanced telehealth technology improves home-based exercise therapy for people with stable chronic obstructive pulmonary disease: a systematic review. J Physiother 2021;67(1):27-40
