Skip to main content

Main menu

  • Home
  • Current issue
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • COVID-19 submission information
    • Institutional open access agreements
    • Peer reviewer login
  • Alerts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • COVID-19 submission information
    • Institutional open access agreements
    • Peer reviewer login
  • Alerts
  • Subscriptions

Effectiveness of home-based pulmonary rehabilitation: systematic review and meta-analysis

Md. Nazim Uzzaman, Dhiraj Agarwal, Soo Chin Chan, Julia Patrick Engkasan, G.M. Monsur Habib, Nik Sherina Hanafi, Tracy Jackson, Paul Jebaraj, Ee Ming Khoo, Fatim Tahirah Mirza, Hilary Pinnock, Ranita Hisham Shunmugam, Roberto A. Rabinovich
European Respiratory Review 2022 31: 220076; DOI: 10.1183/16000617.0076-2022
Md. Nazim Uzzaman
1NIHR Global Health Research Unit on Respiratory Health (RESPIRE), The University of Edinburgh, Edinburgh, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Md. Nazim Uzzaman
Dhiraj Agarwal
2Vadu Rural Health Program, KEM Hospital and Research centre, Pune, India
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Soo Chin Chan
3Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Julia Patrick Engkasan
3Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Julia Patrick Engkasan
G.M. Monsur Habib
4Community Respiratory Centre, Bangladesh Primary Care Respiratory Society, Khulna, Bangladesh
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Nik Sherina Hanafi
3Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Tracy Jackson
1NIHR Global Health Research Unit on Respiratory Health (RESPIRE), The University of Edinburgh, Edinburgh, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Paul Jebaraj
5Rural Unit for Health and Social Affairs, Christian Medical College, Vellore, India
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Ee Ming Khoo
3Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Ee Ming Khoo
Fatim Tahirah Mirza
6Faculty of Health Sciences, Universiti Teknologi MARA, Selangor, Malaysia
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Hilary Pinnock
1NIHR Global Health Research Unit on Respiratory Health (RESPIRE), The University of Edinburgh, Edinburgh, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Hilary Pinnock
Ranita Hisham Shunmugam
7Library, University of Malaya, Kuala Lumpur, Malaysia
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Roberto A. Rabinovich
8MRC Centre for Information Research, University of Edinburgh, Edinburgh, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: roberto.rabinovich@ed.ac.uk
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

Abstract

Introduction Despite proven effectiveness for people with chronic respiratory diseases, practical barriers to attending centre-based pulmonary rehabilitation (centre-PR) limit accessibility. We aimed to review the clinical effectiveness, components and completion rates of home-based pulmonary rehabilitation (home-PR) compared to centre-PR or usual care.

Methods and analysis Using Cochrane methodology, we searched (January 1990 to August 2021) six electronic databases using a PICOS (population, intervention, comparison, outcome, study type) search strategy, assessed Cochrane risk of bias, performed meta-analysis and narrative synthesis to answer our objectives and used the Grading of Recommendations, Assessment, Development and Evaluations framework to rate certainty of evidence.

Results We identified 16 studies (1800 COPD patients; 11 countries). The effects of home-PR on exercise capacity and/or health-related quality of life (HRQoL) were compared to either centre-PR (n=7) or usual care (n=8); one study used both comparators. Compared to usual care, home-PR significantly improved exercise capacity (standardised mean difference (SMD) 0.88, 95% CI 0.32–1.44; p=0.002) and HRQoL (SMD −0.62, 95% CI −0.88–−0.36; p<0.001). Compared to centre-PR, home-PR showed no significant difference in exercise capacity (SMD −0.10, 95% CI −0.25–0.05; p=0.21) or HRQoL (SMD 0.01, 95% CI −0.15–0.17; p=0.87).

Conclusion Home-PR is as effective as centre-PR in improving functional exercise capacity and quality of life compared to usual care, and is an option to enable access to pulmonary rehabilitation.

Abstract

Home-based pulmonary rehabilitation is as effective as centre-based in improving exercise capacity and quality of life, and is an option for people with COPD whose access to pulmonary rehabilitation centres is difficult. https://bit.ly/39HkMm4

Introduction

An estimated 545 million people globally are affected by chronic respiratory diseases such as COPD, remodelled asthma, pulmonary impairment after tuberculosis, interstitial lung disease (ILD), bronchiectasis and cystic fibrosis [1]. Chronic respiratory diseases are associated with breathlessness, fatigue and muscle dysfunction, which contribute to reduced physical activity levels and functional exercise capacity [2], and impaired health-related quality of life (HRQoL) [3, 4].

Pulmonary rehabilitation is an individually tailored multifaceted intervention that improves the physical condition and psychological wellbeing of people with chronic respiratory diseases [5–7]. Despite proven effectiveness [8, 9] and guideline recommendations [10, 11], pulmonary rehabilitation is under-utilised. The reasons for poor attendance and completion rates are multifactorial, but inconvenient timing of programmes and geographical distance to pulmonary rehabilitation centres are commonly identified barriers [12–16]. While pertinent even in high-income countries [17–19], poor transport infrastructure in low- and middle-income countries (LMICs) exacerbates these barriers [20]. Typically, pulmonary rehabilitation is provided in hospital centres (centre-PR) [21], but community-based centres [22], home-based pulmonary rehabilitation (home-PR) with telephone mentoring [23], or telerehabilitation programmes [24], are attracting increasing interest. The ongoing coronavirus disease 2019 pandemic has necessitated remote delivery of the treatment for reasons of infection control [25].

Evidence of the effectiveness of these options varies. A subgroup analysis in a Cochrane review favoured centre-PR [8], while three systematic reviews concluded that home/community-PR could be as effective as centre-PR for people with COPD [26–29]. However, combining home and community services overlooks the distinction between a community-based group supervised in-person by a healthcare professional and a programme delivered to an individual in their own home. In addition, these reviews are limited by disease (COPD only), although there is evidence that pulmonary rehabilitation is of benefit in bronchiectasis and ILD [30–32]. More recently, a Cochrane review concluded that telerehabilitation for people with chronic respiratory diseases, achieved similar effectiveness and safety outcomes to centre-PR [33]. “Telerehabilitation” defines the intervention by the means of communication and the review included pulmonary rehabilitation delivered to individuals or groups (either physical or virtual) in any location, including in the patient's home or at a healthcare centre. In contrast, we defined home-PR as sessions undertaken by individuals by themselves (although a family member may be involved) and typically at home. Apart from baseline and post-PR assessments [32], the patient does not attend a centre (either a hospital centre or a local “satellite” community centre) and is not supervised face-to-face by a healthcare professional (though there may be remote communication from a healthcare professional for some or all of the sessions), is not part of an “in-person” group. In addition, to distinguish from “exercise training programmes” included in some reviews [26, 27, 32, 33], our definition of pulmonary rehabilitation comprised both exercise and at least one nonexercise component.

We aimed to systematically review the literature to assess the effectiveness, completion rates and components used in effective home-PR for people with chronic respiratory diseases. Our hypotheses were that 1) home-PR is superior to usual care, and 2) home-PR is noninferior to centre-PR. In people with chronic respiratory diseases, our objectives were to 1) assess the clinical effectiveness of home-PR compared to centre-PR or usual care at improving health outcomes (i.e. exercise capacity (primary outcome), HRQoL (primary outcome), dyspnoea, muscle fatigue, exacerbations and hospitalisations for chronic respiratory disease); 2) describe the components of home-PR that are associated with successful interventions (e.g. intensity of exercise, duration of the programme, education and/or other nonexercise components, frequency of supervision, information/resources, involvement of family members); and 3) compare the completion rate (defined as participating in ≥70% of pulmonary rehabilitation sessions) of home-PR with centre-PR.

Methods

We followed Cochrane methodology [34], and used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [35] to report our review findings. The review is registered at www.crd.york.ac.uk/PROSPERO (CRD42020220137) and the protocol has been published [36].

Search strategy

We developed a search strategy to identify randomised controlled trials (RCTs) and controlled clinical trials of “chronic respiratory disease” AND “pulmonary rehabilitation” AND “home-PR” from 1990 (when pulmonary rehabilitation was first recommended by global COPD guidelines [37]) to 12 October 2020, without any language restrictions. In addition, we checked reference lists and conducted forward citation on included studies and on Cochrane reviews of pulmonary rehabilitation [8]. We searched MEDLINE, the Cumulative Index to Nursing and Allied Health, Cochrane, Embase, PeDRO, and PsycInfo (see appendix 1 in the supplementary material). Table 1 describes the PICOS (population, intervention, comparison, outcome, study type) search strategy and our definition of home-PR and centre-PR. A pre-publication update was conducted in August 2021 using forward citation of the Cochrane review [8] and all the studies included in this review [38].

View this table:
  • View inline
  • View popup
TABLE 1

PICOS (population, intervention, comparison, outcome, study type) table for the search strategy

Selection process

Following the search, all identified records were loaded into EndNote X9 (Clarivate Analytics, Philadelphia, PA, USA) and duplicates were removed. Six trained reviewers (M.N. Uzzaman, T. Jackson, J.P. Engkasan, F.T. Mirza, D. Agarwal, P. Jebaraj) worked in pairs to independently screen titles and abstracts, followed by full-text papers using the inclusion and exclusion criteria, defined by our operational rules (table 1). Disagreements were resolved by discussion with the review team (H. Pinnock, R.A. Rabinovich, Su May Liew (University of Malaya, Kuala Lumpur, Malaysia), G.M.M. Habib, N.S. Hanafi and S.C. Chan) as necessary. The process is reported in a PRISMA flow diagram (figure 1).

FIGURE 1
  • Download figure
  • Open in new tab
  • Download powerpoint
FIGURE 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. CINAHL: Cumulative Index to Nursing and Allied Health; RCT: randomised controlled trial; CCT: clinical controlled trial; PR: pulmonary rehabilitation.

Outcome measurement

Our primary outcomes were functional exercise capacity and HRQoL: 1) functional exercise capacity measured with any validated tools such as the 6-min walk test (6MWT) [39], Incremental Shuttle Walking Test (ISWT) [40] or Endurance Shuttle Walking Test (ESWT) [41]; 2) HRQoL measured with any validated tools such as the St George's Respiratory Questionnaire (SGRQ) [42], Chronic Respiratory Questionnaire (CRQ) [43], COPD Assessment Test (CAT) [42] or Short Form (SF-36 or SF-12).

We were interested in between-group differences at the post-pulmonary rehabilitation assessment (or first follow-up assessment if post-pulmonary rehabilitation assessment was not reported). Where multiple assessment tools for an outcome (exercise capacity or HRQoL) were reported, we used the most frequently reported measure (e.g. 6MWT, SGRQ) in the meta-analysis.

Data extraction and risk-of-bias assessment

Data extraction was carried out by six reviewers (M.N. Uzzaman, T. Jackson, J.P. Engkasan, F.T. Mirza, D. Agarwal, P. Jebaraj) independently working in pairs, and checked by a third review author (H. Pinnock, R.A. Rabinovich). Data were extracted using a data extraction form in a Microsoft Excel spreadsheet and based on Cochrane Effective Practice and Organisation of Care guidance [44]. The following data were extracted from included studies: methods (study location, study design, duration of the intervention, duration of each pulmonary rehabilitation session, mode of supervision, follow-up period (if any)); participant characteristics (number, mean age, gender, diagnosis, severity of the condition); interventions (intervention, comparison); outcomes (primary and secondary outcomes specified and collected (at baseline and at the time of intervention completion) and follow-up measures at any other time point reported).

One review author (M.N. Uzzaman) transferred data into the Review Manager software (RevMan 2020, version 5.4.1) for conducting meta-analysis and another review author (R.A. Rabinovich) checked data accuracy. The six reviewers (M.N. Uzzaman, T. Jackson, J.P. Engkasan, F.T. Mirza, D. Agarwal, P. Jebaraj) also independently assessed methodological quality of all included studies using the Cochrane risk of bias tool for RCTs [45]. Discrepancies were resolved by discussion within the team. We assessed the risk of bias in the following domains: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective outcome reporting, other sources of bias and overall risk of bias. We assessed each potential source of bias as high, low or unclear and summarised the “risk of bias” judgements across different studies for each of the domains in a risk of bias table. We contacted the author(s) of included studies to obtain any incomplete or missing data, but did not perform any statistical calculation for missing data to include in the meta-analysis.

Heterogeneity and reporting bias

We assessed heterogeneity [46], and explored clinical and methodological reasons for substantial heterogeneity (I2 statistic >50%) in our primary outcome as defined in our a priori subgroups [34], and a sensitivity analyses for the effect of risk of bias. We were not able to pool >10 studies and therefore did not create a funnel plot to test for publication bias [47].

Subgroups and sensitivity analyses

Our a priori subgroups were high-/low-income countries, chronic respiratory disease diagnosis, severity, intensity of intervention and arrangements for supervision of the home-PR programme [36]. We undertook a sensitivity analysis of our primary outcomes for the home-PR versus centre-PR comparison excluding studies at high risk of bias (there were too few studies for a sensitivity analysis of the home-PR versus usual care analysis).

Data analysis to answer the three objectives

Effectiveness of home-PR

We performed meta-analysis using Review Manager software for the primary and secondary outcomes, comparing home-PR with centre-PR or usual care. For continuous data, we calculated the mean difference (MD) (for same scale metric) or standardised mean difference (SMD) (for different scale metrics) with 95% confidence intervals. We used an inverse variance method, and chose a random-effects model to account for between-study heterogeneity in the meta-analysis. At least two studies were needed to perform a meta-analysis and measure the effect size. We used pooled mean differences if the same measurement tool was used in the included RCTs, or if the measurement tool varied among trials, we used SMDs for our primary analysis, but reported pooled MDs for the most commonly used outcome as a sensitivity analysis. A p-value <0.05 was considered statistically significant for the overall effect. For comparison of home-PR and centre-PR, if sufficient studies used the same measure for functional exercise capacity or HRQoL, we defined the noninferiority margin as the minimum clinically important difference (MCID) (e.g. 30 m for the 6MWT).

Components of home-PR

We identified the components described in internationally recognised guidelines for pulmonary rehabilitation [5, 7, 11, 48] and constructed a matrix comparing components used in the included trials reporting effective interventions versus those reporting no effect.

Uptake, adherence and completion

We used a narrative approach to synthesise reported uptake, engagement, completion and attrition in home-PR and centre-PR groups using the following definitions. Uptake: number of patients who attended the initial/baseline assessment and at least one pulmonary rehabilitation session; engagement: the proportion of pulmonary rehabilitation sessions attended. This reflects the “dose” of the intervention received and may be reported as the number of patients who attended a pre-defined proportion of pulmonary rehabilitation sessions (e.g. 70% of sessions); completion: the number of patients who attended the pulmonary rehabilitation discharge assessment and are regarded as having “completed” the pulmonary rehabilitation programme (regardless of the proportion of sessions attended); trial attrition: the number of people who failed to attend for their post-pulmonary rehabilitaiton follow-up data collection in a trial. Trials of longer duration may have several follow-up assessments and thus several time points for recording attrition.

Assessment of the certainty of evidence

To assess the quality of evidence of included studies, we used the five GRADE (Grading of Recommendations, Assessment, Development and Evaluations) considerations (study design, risk of bias, inconsistency, imprecision and indirectness) for the primary outcomes. Using GRADEpro GDT software (gradepro.org), we followed the techniques and guidelines outlined in the Cochrane Handbook for Systematic Reviews of Interventions [49]. We provide footnotes to explain any decisions to downgrade the quality of evidence.

Results

Study selection

We identified a total of 6185 records from six databases (figure 1) and found 1133 records from forward citation. After removing duplicates, a total of 5857 titles and abstracts were screened, and 78 full-text articles were considered for inclusion by the pairs of reviewers. All disagreements and decisions were discussed within the multidisciplinary team and 62 articles were excluded (supplementary table S1). Thus, we included 16 articles in our review [50–65]. No additional papers were added from the pre-publication update.

Characteristics of included studies

Of the 16 included studies, 15 were individually randomised trials, and one was a cluster randomised implementation trial [59]. The latter, while relevant to our inclusion criteria, had a very different trial design informing the challenge of implementing home-PR within routine COPD care, rather than providing evidence of effectiveness, and we therefore did not include it in the meta-analysis. Eight studies compared home-PR versus usual care [50, 53, 58, 59, 61, 63–65] and seven studies compared home-PR versus centre-PR [51, 54–57, 60, 62]. One study compared home-PR against two different comparators (centre-PR and usual care) and is therefore included in both analyses [52] (supplementary table S2 presents key characteristics of included studies, main findings and interpretation).

The trials were conducted in Australia (n=3) [50, 56, 59], Brazil (n=2) [52, 63], Spain (n=2) [54, 65], the United Kingdom (n=2) [57, 58], Canada (n=1) [60], China (n=1) [51], Denmark (n=1) [55], Egypt (n=1) [53], India (n=1) [64], Iran (n=1) [61] and Turkey (n=1) [62]. Of these, nine were high-income countries [50, 54–60, 65], four were upper-middle-income countries [51, 52, 62, 63] and three were lower-middle-income countries [53, 61, 64].

All studies were in people with COPD. In total, 1800 people with a range of severities were recruited to the included trials (range 39–314 participants). Out of the 1733 participants with reported baseline demographic data, 1048 (62%) were male and the mean age ranged from 56 to 79 years.

All pulmonary rehabilitation programmes included either aerobic and/or resistance exercises (aerobic (n=15) [50, 52–65], resistance (n=13) [50–60, 62, 63], both (n=12) [50, 52–60, 62, 63]). Stretching exercises were included in two trials [52, 63] and inspiratory muscle training in one trial [53]. All studies except one [57] had 24 or more exercise sessions; five trials had more than 48 sessions of exercise [50, 53, 56, 58, 64]. All but two [55, 62] of the home-PR programmes included face-to-face training sessions either as inpatients [53, 61], outpatients [51, 52, 54, 57, 58, 60, 63–65] or home visits [50, 56, 59]. Most of the programmes described some form of supervision of the home-based sessions, most commonly telephone calls [52, 56–59, 61, 63, 65] although one used videoconferencing [55] and one study in housebound individuals provided repeated home visits. Other strategies included provision of a manual or written information [51, 57, 58, 61, 62] activity diaries [50, 52, 55, 56, 60, 62, 63, 65], pedometers [54, 56, 65] and heart rate monitors [52].

Risk-of-bias assessment

Only three studies were at overall low risk of bias [55–57]. Two were at unclear/moderate risk of bias [58, 60] and 11 were at high risk of bias [50–54, 59, 61–65] (supplementary figure S1). Blinding of participants and personnel is impossible due to the nature of the intervention, but only six studies ensured outcome assessors were blind to allocation [54–58, 60]. Computer-generated randomisation sequence was used in 10 studies [51, 52, 55–61] and allocation concealment was described in seven [50, 54–58, 60]; the remaining studies did not provide sufficient information on randomisation [53, 62–65]. We were able to compare reported outcomes with published protocols or trial registrations for six studies [51, 52, 55–57, 59], all of which were judged to be at low risk of selective reporting bias. Without a protocol for comparison, the remaining studies were designated as unclear risk of bias [50, 53, 54, 58, 60–65].

Effectiveness of home-PR (objective 1)

Primary outcome: functional exercise capacity

Home-PR versus usual care

Out of eight trials that compared home-PR with usual care, seven assessed at least one measure of functional exercise capacity [50, 52, 53, 58, 63–65]. Of these, five trials used the 6MWT [50, 52, 53, 63, 64], one trial used both ISWT and ESWT [58] and one trial used ESWT [65]. In one [52] of the seven studies, data were presented in a format that could not be retrieved for meta-analysis. Thus, we included six trials [50, 53, 58, 63–65] in the meta-analysis (figure 2). The pooled estimate showed a statistically significant increase in exercise capacity in home-PR compared with usual care (SMD 0.88, 95% CI 0.32–1.44; p=0.002). The only study not at high risk of bias showed no significant between-group differences [58].

FIGURE 2
  • Download figure
  • Open in new tab
  • Download powerpoint
FIGURE 2

Comparison of primary outcomes. a, b) Comparing home-pulmonary rehabilitation (PR) with usual care for a) functional exercise capacity and b) health-related quality of life; c, d) comparing home-PR with centre-PR for c) functional exercise capacity and d) health-related quality of life. 6MWT: 6-min walk test; ISWT: incremental shuttle walking test; ESWT: endurance shuttle walking test; IV: inverse variance; SMD: standardised mean difference; SGRQ: St George's Respiratory Questionnaire; CRQ: Chronic Respiratory Questionnaire; CAT: COPD Assessment Test.

In a subgroup meta-analysis of four RCTs [50, 53, 63, 64] with available data on 6MWT (supplementary figure S2), the pooled estimate showed a statistically significant increase in the mean difference in distance walked in home-PR compared with usual care (MD 61.58 m, 95% CI 45.88–77.29 m; p<0.01). Both the mean difference and the lower limit of the confidence interval exceeded the MCID for the 6-min walk distance (6MWD) of 30 m [66], indicating a clinically significant effect of home-PR.

Home-PR versus centre-PR

All the eight trials comparing home-PR with centre-PR assessed at least one measure of functional exercise capacity [51, 52, 54–57, 60, 62]. Of these, seven trials used the 6MWT [51, 52, 54–56, 60, 62], one trial used both ISWT and ESWT [57] and one trial used both cycle endurance test and 6MWT [60]. We included all eight trials [51, 52, 54–57, 60, 62] in the meta-analysis (figure 2). The pooled estimate showed no statistically significant difference in exercise capacity between home-PR and centre-PR (SMD −0.10, 95% CI −0.25–0.05; p=0.21). A sensitivity analysis including only the four studies at low/moderate risk of bias [55–57, 60] did not change the conclusion (SMD −0.02, 95% CI −0.18–0.15; I2=28%; p=0.85) (supplementary figure S3).

In the meta-analysis of the seven RCTs [51, 52, 54–56, 60, 62] that used 6MWT (supplementary figure S4), the pooled estimates showed no statistically significant difference in the mean difference in distance walked in home-PR compared with centre-PR (MD −6.26m, 95% CI −18.55–6.02; p=0.32). This is within the noninferiority margin of 30 m for the 6MWT, indicating that the clinical effect of home-PR is not inferior to centre-PR for people with COPD.

Primary outcome: health-related quality of life

Home-PR versus usual care

All the eight trials comparing home-PR with usual care assessed at least one measure of HRQoL [50, 53, 58, 59, 61, 63–65]. Of these, four trials used the SGRQ [50, 59, 63, 65], two trials used CRQ [58, 64], one trial used both SGRQ and CAT score [59], one trial used SF-36 [53] and one trial used SF-12 [61]. We excluded the cluster RCT [59] from the meta-analysis because it informed implementation (as opposed to effectiveness) of home-PR in routine primary care management of COPD and was thus not comparable with the other trials. Thus, we included seven trials [50, 53, 58, 61, 63–65] in the meta-analysis (figure 2) and the pooled estimate (SGRQ-total, CRQ-mastery, SF-36-physical, SF-12) showed statistically significant improvement in HRQoL in the home-PR group compared with usual care (SMD −0.62, 95% CI −0.88–−0.36; p<0.01). The only study not at high risk of bias showed no significant between group differences [58].

Meta-analysis of the three RCTs that used SGRQ [50, 63, 65] (supplementary figure S5) showed a statistically significant improvement that exceeded the MCID of 4.0 in all the domains except the “impact” domain. The effect on overall SGRQ in the home-PR group compared with usual care showed an MD −5.66 (95% CI −7.94–−3.39; p<0.01) that exceeded the MCID.

Meta-analysis of the two RCTs [58, 64] that used the CRQ (supplementary figure S6) showed a statistically significant improvement (p=0.010) that exceeded the MCID of 0.5 in all the domains (dyspnoea, emotion, fatigue, mastery).

Home-PR versus centre-PR

All seven trials comparing home-PR with centre-PR assessed at least one measure of HRQoL [51, 54–57, 60, 62]. Of these, four trials used the CRQ [54, 56, 57, 60] and three trials used the CAT score [51, 55, 62]. We included all seven trials [51, 54–57, 60, 62] in the meta-analysis (figure 2) and the pooled estimate (CRQ-mastery, CAT score) showed no statistically significant difference in the HRQoL in home-PR compared with centre-PR (SMD 0.01, 95% CI −0.15–0.17; p=0.87). A sensitivity analysis including only the four studies at low/moderate risk of bias [55–57, 60] did not change the conclusion (SMD −0.00, 95% CI −0.16–0.17; I2=30%; p=0.98) (supplementary figure S7).

Meta-analysis of the four RCTs [54, 56, 57, 60] that used CRQ (supplementary figure S8) showed no statistically significant between-group differences (p=0.21) in any of the domains of CRQ (dyspnoea, emotion, fatigue, mastery).

Meta-analysis of the three RCTs [51, 55, 62] that used the CAT score (supplementary figure S9) favoured home-PR compared with centre-PR (MD −1.53, 95% CI −2.81–−0.24; p=0.02).

Secondary outcome: dyspnoea

Home-PR versus usual care

Two trials [59, 65] assessed dyspnoea using the modified Medical Research Council (mMRC) scale and compared home-PR with usual care. The implementation cluster RCT [59] concluded that mMRC grades were not significantly different between groups. The other RCT also showed no statistically significant changes (p=0.22) in dyspnoea level associated with home-PR compared to usual care [65].

Home-PR versus centre-PR

Two trials [56, 62] assessed dyspnoea using mMRC and compared home-PR versus centre-PR. Meta-analysis showed no statistically significant changes between the groups in dyspnoea level (supplementary figure S10) between home-PR and centre-PR (MD −0.12, 95% CI −0.44–0.21; p=0.48).

Secondary outcome: anxiety and depression

Home-PR versus usual care

One trial [59] measured anxiety and depression using the Hospital Anxiety and Depression Scale (HADS) and compared the effect between home-PR and usual care. There was no statistically significant between-group difference in either anxiety (p=1.00) or depression (p=0.09).

Home-PR versus centre-PR

Two trials [55, 57] measured anxiety and depression using HADS and compared the effects between home-PR and centre-PR. Meta-analysis showed no statistically significant between-group difference in anxiety or depression (supplementary figures S11 and S12) (anxiety: MD −0.33, 95% CI −1.81–1.15; p=0.66; depression: MD −0.03, 95% CI −1.28–1.22; p=0.97).

Association of components of home-PR with effective interventions (objective 2)

Table 2 presents a matrix of components of home-PR mapped to effectiveness.

View this table:
  • View inline
  • View popup
TABLE 2

Matrix of the home-pulmonary rehabilitation (PR) components in the included studies

There were no obvious differences in the components of the home-PR between effective and ineffective studies or in the number of components included, supervision provided or duration of the course.

Uptake, engagement, completion and trial attrition (objective 3)

Table 3 shows details of recruitment, uptake, engagement, completion of pulmonary rehabilitation sessions and trial attrition.

View this table:
  • View inline
  • View popup
TABLE 3

Recruitment, uptake, engagement and completion of pulmonary rehabilitation (PR) sessions and trial attrition

Screening and eligibility for the trials

Nine studies [51, 52, 55–61] provided details of the eligibility screening process, reporting recruitment rates between 12% and 56%. Five trials cited the presence of comorbidity as a reason for excluding between 3% and 14% of screened participants [51, 55–58]. Three studies reported that approximately one in five (22.8%, 18.3% and 12.0% [55–57]) potentially eligible patients declined to participate because of a strong preference for centre-PR. In contrast, one trial comparing home-PR versus centre-PR excluded 55% because they definitely wanted home-PR [55]. Distance/travel was cited as a reason for nonparticipation in two trials [51, 60].

Uptake of pulmonary rehabilitation

The implementation cluster RCT reported an uptake of 66% among the 107 patients referred by their general practitioner [59]. Two trials reported that two patients did not attend any pulmonary rehabilitation sessions [50, 65].

Engagement with the programme

Only four studies defined “engagement” as a pre-determined proportion of pulmonary rehabilitation sessions attended [55, 56, 59, 60]. Using the widely cited 70% threshold [67], Holland et al. [56] showed that engagement with home-PR was nearly twice that of centre-PR (91% versus 49%; relative risk of nonengagement in centre-PR: 1.91, 95% CI 1.52–2.41). In contrast, two studies [55, 60] showed no between-group difference, although the latter used a lower threshold (≥60%) and reported that >90% of the participants in both groups achieved this threshold. The implementation cluster RCT reported 46% engaged with ≥70% of the pulmonary rehabilitation programme.

Completion of post-PR assessment and trial attrition

In the trial context, completion of the post-PR assessment was generally reported as attrition (i.e. loss to trial follow-up). Rates of attrition at the post-PR follow-up assessment ranged from 0% to 51%, but with no consistent pattern to suggest that mode of delivery affected follow-up.

Quality of evidence

Using GRADE, we judged primary outcomes (functional exercise capacity and HRQoL) of the review to provide low-certainty evidence when home-PR was compared with centre-PR and very low-certainty evidence when home-PR was compared with usual care. Downgrading for risk of bias was influenced by performance bias and some concerns in some or most of the domains of included studies. We additionally downgraded for imprecision because of use of SMD to assess the effect and/or small sample size, and for inconsistency due to heterogeneity in home-PR when compared with usual care (supplementary table S3).

Discussion

Summary of findings

Our systematic review identified 16 studies involving a total of 1800 COPD patients from 11 different countries. The effects of home-PR on exercise capacity and/or HRQoL in people with COPD were compared to either centre-PR (n=7) or usual care (n=8). One study had both comparators [52]. Overall, statistically significant improvement was found in functional exercise capacity and HRQoL in home-PR groups when compared with usual care, but no statistically significant differences were found in exercise capacity and HRQoL between home-PR and centre-PR groups. All studies that compared home-PR with usual care were at high risk of bias, except one which was at moderate risk of bias [58]. Conversely, among the studies that compared home-PR with centre-PR, three were at low risk of bias, one was at moderate risk of bias and four were at high risk of bias. No distinguishable patterns were found in exercise components, supervision and monitoring among the three trials [53, 63, 65] that had statistically significant between-group differences and exceeded MCIDs for both the primary outcomes when compared to other included studies. Rates of attrition at the post-PR follow-up assessment ranged from 0% to 51%, but with no consistent pattern to suggest that mode of delivery affected follow-up.

Strength and limitations

A strength of this systematic review is its comprehensive literature search constructed with the help of an expert librarian. We were open to including non-English language papers. We employed a rigorous methodology following a written protocol that has been published [36]. Although we searched for a wide range of chronic respiratory diseases, the included trials only recruited people with COPD, so the findings are not generalisable to people with other chronic respiratory diseases. We used generic terms for chronic respiratory diseases and named some of the commonest diseases, but our search might have missed some studies as all disease names were not explicitly included in the search strategy. Although we had low (home-PR versus centre-PR) or very low (home-PR versus usual care) confidence in our GRADE assessment for primary outcomes, this was influenced by multiple outcomes measures which we presented as an SMD in our meta-analysis. This emphasises the importance of agreed standardised outcomes for trials [68].

Six reviewers worked independently in pairs (as in the traditional model) and ensured that all titles and abstracts were duplicate-screened, and disagreements resolved in discussion involving the whole team as necessary. Involvement of six reviewers allowed us to complete the review in a timely manner and without overburdening any individual. The main limitation is the potential for inconsistency, so before starting screening, 100 articles were selected randomly from the total records by the study librarian and given to each pair to screen as a training exercise. Decisions were discussed within the study team and operational rules clarified and agreed.

Interpretation in the light of published literature

Effectiveness of home-PR

Our findings show that home-PR can be a clinically effective alternative to centre-PR for people with COPD in different settings [8, 27, 69] with the findings that both the MD and the lower limit of the confidence interval exceeded the MCID for the 6MWD [66] indicating a clinically significant effect in improving exercise capacity. This extends the findings of the recently published Cochrane review that assessed the effect of telerehabilitation (either delivered in local community centres or at home) in two ways [33]. Firstly, the home-based programme remained effective despite the lack of the face-to-face group support available in a traditional centre-based pulmonary rehabilitation. This is of particular value in the context of a pandemic when infection control is an important consideration and may preclude group settings. Secondly, most of the telerehabilitation interventions in the Cochrane review [33] used video-conferencing or web-based systems to create virtual groups whereas in our home-based studies over half relied on individual telephone calls, and only one study provided a group-based structured pulmonary rehabilitation programme via video-conferencing [55]. This extends the findings to LMIC countries (and indeed some rural areas of high-income countries) with limited access to reliable internet connections. In addition to improving functional exercise capacity and HRQoL, meta-analysis of secondary outcomes showed that home-PR improved dyspnoea, anxiety and depression. These findings hint that home-PR may reduce stress associated with accessing and participating in centre-PR [13], as well as helping to develop confidence in the ability to exercise unsupervised [70].

Components of home-PR

Less than 2% of all patients with COPD globally can be served by the existing centre-PR programmes [71], and increasing access to and benefit from remote pulmonary rehabilitation remains a significant clinical and research priority [72]. To do this with confidence, providers of pulmonary rehabilitation services will want to know which components they should include and how to adapt them to home-PR. Although our review did not provide consistent evidence of which components or models of care were associated with effective interventions, others have reported that the intensity of supervision and monitoring increase chances of success in comparison to unsupervised programmes [73, 74]. Most of the interventions in our included studies provided between 24 and 28 home-based sessions with a broad range of arrangements for supervision, but no one approach was associated with effective interventions.

Uptake, engagement, completion and trial attrition

The terms uptake, engagement and completion are often used interchangeably without clear definition. Data are rarely reported in full; a recent systematic review only identified one trial with comprehensive uptake and completion data [75]. Uptake, defined as the number of patients who attended the initial/baseline assessment and at least one pulmonary rehabilitation session, may be referred to as “enrolled” or in a trial context “recruited” [67]. In our review, uptake was not reported in any of the studies that compared home-PR to centre-PR. Engagement is the proportion of pulmonary rehabilitation sessions attended. This is often assessed as the number of patients who have attended a pre-defined proportion of pulmonary rehabilitation sessions (e.g. 70% of sessions) and is sometimes referred to as “completion rate” [55, 56], or “adherence” [60] or “compliance” [50]. Of the included studies, only four trials defined engagement [55, 56, 59, 60] and only three trials reported this clearly [55, 56, 60]. Engagement with defined sessions in home-PR varied from 73% to 98%, whereas in centre-PR engagement ranged from 49% to 93%. Completion can also be defined as the number of patients who attended the post-PR discharge assessment and are regarded as having “completed” the pulmonary rehabilitation programme (even if they attended very few of the sessions). Some trials referred to participants who did not complete as having “dropped out” of the pulmonary rehabilitation programme [67].

From a trial design perspective, attrition is the number of people who do not attend follow-up assessments and may be described as having “withdrawn” from the trial. Trials of longer duration may have several follow-up assessments and thus several time points for recording attrition. Attrition rates at the post-PR follow-up evaluation ranged from 0% to 51% in our review, but there was no consistent pattern to suggest that mode of delivery influenced follow-up.

Implications for clinical practice and research

This systematic review gives confidence that home-PR can be an effective option to the traditional models of centre-PR programmes which could extend access for people with COPD to this effective intervention, although the low certainty of the evidence warrants further high-quality evaluation. Specifically, there is evidence that pulmonary rehabilitation improves outcomes in bronchiectasis [30] and ILD [31], but our studies were COPD-specific, so further investigation is required to establish whether home-PR is suitable for chronic respiratory diseases other than COPD. This may be of particular importance in rural areas of LMICs where poor access to investigations mean that the diagnosis may not be clear and limited facilities and travel infrastructure make remote delivery an important option [21].

While we may not have been able to identify specific components that contributed to effectiveness, providers will note that almost all the interventions included aerobic training and resistance training along with a programme of education. Regular remote supervision varied, but did not have to be technologically complex; many used telephone calls often supplemented by maintaining an exercise diary. We recommend that future trials address issues of uptake, engagement, completion and attrition, and adopt standard terminology in order to provide clarity.

Conclusion

Our review concludes with low confidence that home-PR is as effective as centre-PR in improving functional exercise capacity and quality of life in people with COPD compared to usual care. Thus, home-PR is an option that could enable people whose lifestyles or geographical locations make attending a pulmonary rehabilitation centre difficult or who wish to socially distance to benefit from pulmonary rehabilitation.

Supplementary material

Supplementary Material

Please note: supplementary material is not edited by the Editorial Office, and is uploaded as it has been supplied by the author.

Supplementary material ERR-0076-2022.SUPPLEMENT

Acknowledgements

We acknowledge the contribution of Su May Liew (University of Malaya, Kuala Lumpur, Malaysia) who was a core member of the team until her untimely death in December 2021.

Footnotes

  • Provenance: Submitted article, peer reviewed.

  • Author contributions: R.A. Rabinovich and H. Pinnock led the team, who all contributed to the systematic review process. M.N. Uzzaman drafted the first version of the manuscript with support from R.A. Rabinovich and which was revised with contributions from all members of the team (D. Agarwal, S.C. Chan, J. Patrick Engkasan, G.M.M. Habib, N.S. Hanafi, T. Jackson, P. Jebaraj, E.M. Khoo, F.T. Mirza, H. Pinnock, R.H. Shunmugam). All authors have critically reviewed and approved the final manuscript.

  • Conflict of interest: M.N. Uzzaman has nothing to disclose.

  • Conflict of interest: D. Agarwal has nothing to disclose.

  • Conflict of interest: S.C. Chan has nothing to disclose.

  • Conflict of interest: J. Patrick Engkasan has nothing to disclose.

  • Conflict of interest: G.M.M. Habib owns a Pulmonary Rehabilitation clinic in Bangladesh.

  • Conflict of interest: N.S. Hanafi has nothing to disclose.

  • Conflict of interest: T. Jackson has nothing to disclose.

  • Conflict of interest: P. Jebaraj has nothing to disclose.

  • Conflict of interest: E.M. Khoo reports grants from UK National Institute for Health Research (NIHR) Global Health Research Unit, during the conduct of the study; personal fees from AstraZeneca, personal fees and non-financial support from GlaxoSmithKline plc, and grants from Seqirus UK Ltd, and is President of the International Primary Care Respiratory Group, UK, outside the submitted work.

  • Conflict of interest: F.T. Mirza has nothing to disclose.

  • Conflict of interest: H. Pinnock reports grants from National Institute of Health Research (16/136/109 (2017-2021), during the conduct of the study.

  • Conflict of interest: R.H. Shunmugam has nothing to disclose.

  • Conflict of interest: R.A. Rabinovich has nothing to disclose.

  • Support statement: This research was funded by the UK National Institute for Health Research (NIHR) (Global Health Research Unit on Respiratory Health (RESPIRE); 16/136/109) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK Government. The RESPIRE collaboration comprises the UK Grant holders, Partners and research teams as listed on the RESPIRE website (www.ed.ac.uk/usher/respire). T. Jackson is part-funded by the NIHR Global Health Research Unit on Respiratory Health (RESPIRE). G.M.M. Habib has a NIHR RESPIRE PhD studentship and M.N. Uzzaman holds a PhD studentship nested in the IMP2ART programme at the University of Edinburgh. D. Agarwal holds an NIHR RESPIRE Fellowship. H. Pinnock, R.A. Rabinovich, E.M. Khoo, S.C. Chan, J. Patrick Engkasan, N.S. Hanafi are co-investigators of NIHR RESPIRE-funded pulmonary rehabilitation feasibility studies in their respective centres.

  • Received April 27, 2022.
  • Accepted June 14, 2022.
  • Copyright ©The authors 2022
http://creativecommons.org/licenses/by-nc/4.0/

This version is distributed under the terms of the Creative Commons Attribution Non-Commercial Licence 4.0. For commercial reproduction rights and permissions contact permissions{at}ersnet.org

References

  1. ↵
    1. Soriano JB,
    2. Kendrick PJ,
    3. Paulson KR, et al.
    Prevalence and attributable health burden of chronic respiratory diseases, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet Respir Med 2020; 8: 585–596. doi:10.1016/S2213-2600(20)30105-3
    OpenUrlPubMed
  2. ↵
    1. Garcia-Aymerich J,
    2. Félez MA,
    3. Escarrabill J, et al.
    Physical activity and its determinants in severe chronic obstructive pulmonary disease. Med Sci Sports Exerc 2004; 36: 1667–1673. doi:10.1249/01.MSS.0000142378.98039.58
    OpenUrlCrossRefPubMed
  3. ↵
    1. Brien SB,
    2. Lewith GT,
    3. Thomas M
    . Patient coping strategies in COPD across disease severity and quality of life: a qualitative study. NPJ Prim Care Respir Med 2016; 26: 16051. doi:10.1038/npjpcrm.2016.51
    OpenUrl
  4. ↵
    1. Hesselink AE,
    2. van der Windt D,
    3. Penninx B, et al.
    What predicts change in pulmonary function and quality of life in asthma or COPD? J Asthma 2006; 43: 513–519. doi:10.1080/02770900600856954
    OpenUrlCrossRefPubMed
  5. ↵
    1. Spruit MA,
    2. Singh SJ,
    3. Garvey C, et al.
    An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 2013; 188: e13–e64. doi:10.1164/rccm.201309-1634ST
    OpenUrlCrossRefPubMed
    1. Singh D,
    2. Agusti A,
    3. Anzueto A, et al.
    Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease: the GOLD science committee report 2019. Eur Respir J 2019; 53: 1900164. doi:10.1183/13993003.00164-2019
    OpenUrlAbstract/FREE Full Text
  6. ↵
    1. Rochester C,
    2. Vogiatzis I,
    3. Holland A, et al.
    An official American Thoracic Society/European Respiratory Society policy statement: enhancing implementation, use, and delivery of pulmonary rehabilitation. Am J Respir Crit Care Med 2015; 192: 1373–1386. doi:10.1164/rccm.201510-1966ST
    OpenUrlCrossRefPubMed
  7. ↵
    1. McCarthy B,
    2. Casey D,
    3. Devane D, et al.
    Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2015; 2: CD003793. doi:10.1002/14651858.CD003793.pub3
    OpenUrlCrossRefPubMed
  8. ↵
    1. Puhan MA,
    2. Gimeno-Santos E,
    3. Cates CJ, et al.
    Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2016; 12: CD005305. doi:10.1002/14651858.CD005305.pub4
    OpenUrlCrossRefPubMed
  9. ↵
    1. National Institute for Health and Care Excellence
    . Chronic Obstructive Pulmonary Disease in Over 16s: Diagnosis and Management. https://www.nice.org.uk/guidance/ng115/ Date last accessed: 9 August 2022. Date last updated: 26 July 2019.
  10. ↵
    1. Bolton CE,
    2. Bevan-Smith EF,
    3. Blakey JD, et al.
    British Thoracic Society guideline on pulmonary rehabilitation in adults. Thorax 2013; 68: Suppl. 2, ii1–ii30. doi:10.1136/thoraxjnl-2013-203808
    OpenUrlFREE Full Text
  11. ↵
    1. Alsubaiei ME,
    2. Cafarella PA,
    3. Frith PA, et al.
    Barriers for setting up a pulmonary rehabilitation program in the Eastern Province of Saudi Arabia. Ann Thorac Med 2016; 11: 121–127. doi:10.4103/1817-1737.180028
    OpenUrlPubMed
  12. ↵
    1. Cox NS,
    2. Oliveira CC,
    3. Lahham A, et al.
    Pulmonary rehabilitation referral and participation are commonly influenced by environment, knowledge, and beliefs about consequences: a systematic review using the Theoretical Domains Framework. J Physiother 2017; 63: 84–93. doi:10.1016/j.jphys.2017.02.002
    OpenUrlPubMed
    1. Keating A,
    2. Lee A,
    3. Holland AE
    . What prevents people with chronic obstructive pulmonary disease from attending pulmonary rehabilitation? A systematic review. Chron Respir Dis 2011; 8: 89–99. doi:10.1177/1479972310393756
    OpenUrlCrossRefPubMed
    1. Romain D,
    2. Bernady A,
    3. Etchamendy E, et al.
    Coût des hospitalisations dues à une exacerbation de patients BPCO réhabilités à domicile. [Costs of hospitalisation for exacerbations of COPD in patients receiving domiciliary rehabilitation]. Rev Mal Respir 2011; 28: 864–872. doi:10.1016/j.rmr.2011.06.001
    OpenUrlPubMed
  13. ↵
    1. Trish E,
    2. Xu J,
    3. Joyce G
    . Medicare beneficiaries face growing out-of-pocket burden for specialty drugs while in catastrophic coverage phase. Health Aff 2016; 35: 1564–1571. doi:10.1377/hlthaff.2016.0418
    OpenUrlAbstract/FREE Full Text
  14. ↵
    1. Brooks D,
    2. Lacasse Y,
    3. Goldstein RS
    . Pulmonary rehabilitation programs in Canada: national survey. Can Respir J 1999; 6: 55–63.
    OpenUrlPubMed
    1. Wadell K,
    2. Ferreira TJ,
    3. Arne M, et al.
    Hospital-based pulmonary rehabilitation in patients with COPD in Sweden – a national survey. Respir Med 2013; 107: 1195–1200. doi:10.1016/j.rmed.2013.04.019
    OpenUrlCrossRefPubMed
  15. ↵
    1. Yohannes AM,
    2. Connolly MJ
    . Pulmonary rehabilitation programmes in the UK: a national representative survey. Clin Rehabil 2004; 18: 444–449. doi:10.1191/0269215504cr736oa
    OpenUrlCrossRefPubMed
  16. ↵
    1. Habib GM,
    2. Rabinovich R,
    3. Divgi K, et al.
    Systematic review of clinical effectiveness, components, and delivery of pulmonary rehabilitation in low-resource settings. NPJ Prim Care Respir Med 2020; 30: 32. doi:10.1038/s41533-020-00210-y
    OpenUrl
  17. ↵
    1. Man WD,
    2. Puhan MA,
    3. Harrison SL, et al.
    Pulmonary rehabilitation and severe exacerbations of COPD: solution or white elephant? ERJ Open Res 2015; 1: 00050-2015. doi:10.1183/23120541.00050-2015
    OpenUrlAbstract/FREE Full Text
  18. ↵
    1. Farias CC,
    2. Resqueti V,
    3. Dias FA, et al.
    Costs and benefits of pulmonary rehabilitation in chronic obstructive pulmonary disease: a randomized controlled trial. Braz J Phys Ther 2014; 18: 165–173. doi:10.1590/S1413-35552012005000151
    OpenUrlPubMed
  19. ↵
    1. Bove DG,
    2. Overgaard D,
    3. Lomborg K, et al.
    Efficacy of a minimal home-based psychoeducative intervention versus usual care for managing anxiety and dyspnoea in patients with severe chronic obstructive pulmonary disease: a randomised controlled trial protocol. BMJ Open 2015; 5: e008031.
    OpenUrlAbstract/FREE Full Text
  20. ↵
    1. Franke K-J,
    2. Domanski U,
    3. Schroeder M, et al.
    Telemonitoring of home exercise cycle training in patients with COPD. Int J Chron Obstruct Pulmon Dis 2016; 11: 2821–2829. doi:10.2147/COPD.S114181
    OpenUrlPubMed
  21. ↵
    1. Yang F,
    2. Liu N,
    3. Hu J, et al.
    [Pulmonary rehabilitation guidelines in the principle of 4S for patients infected with 2019 novel coronavirus (2019-nCoV)]. Zhonghua Jie He He Hu Xi Za Zhi 2020; 43: 180–182.
    OpenUrlPubMed
  22. ↵
    1. Xavier DM,
    2. Galvão EL,
    3. Fonseca AA, et al.
    Effects of home-based pulmonary rehabilitation on dyspnea, exercise capacity, quality of life and impact of the disease in COPD patients: a systematic review. COPD 2022; 19: 18–46. doi:10.1080/15412555.2021.2020234
    OpenUrl
  23. ↵
    1. Wuytack F,
    2. Devane D,
    3. Stovold E, et al.
    Comparison of outpatient and home-based exercise training programmes for COPD: a systematic review and meta-analysis. Respirology 2018; 23: 272–283. doi:10.1111/resp.13224
    OpenUrlCrossRefPubMed
    1. Neves LF,
    2. Reis M,
    3. Gonçalves TR
    . Home or community-based pulmonary rehabilitation for individuals with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Cad Saude Publica 2016; 32: S0102-311X2016000602001.
    OpenUrl
  24. ↵
    1. Chen Y-Y,
    2. Xiao-Xiao Y,
    3. Meng F-J
    . Home versus centre-based pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. TMR Integrative Med 2020; 4: 88888–e20012.10.12032/TMRIM202004012
    OpenUrl
  25. ↵
    1. Bradley JM,
    2. Moran F,
    3. Greenstone M
    . Physical training for bronchiectasis. Cochrane Database Syst Rev 2002; 3: CD002166. doi:10.1002/14651858.CD002166
    OpenUrlPubMed
  26. ↵
    1. Dowman L,
    2. Hill CJ,
    3. Holland AE
    . Pulmonary rehabilitation for interstitial lung disease. Cochrane Database Syst Rev 2014; 10: CD006322.
    OpenUrlPubMed
  27. ↵
    1. Taito S,
    2. Yamauchi K,
    3. Kataoka Y
    . Telerehabilitation in subjects with respiratory disease: a scoping review. Respir Care 2021; 66: 686–698. doi:10.4187/respcare.08365
    OpenUrlAbstract/FREE Full Text
  28. ↵
    1. Cox NS,
    2. Dal Corso S,
    3. Hansen H, et al.
    Telerehabilitation for chronic respiratory disease. Cochrane Database Syst Rev 2021; 1: CD013040. doi:10.1002/14651858.CD013040.pub2
    OpenUrlPubMed
  29. ↵
    1. Higgins J,
    2. Thomas J,
    3. Chandler J, et al.
    Cochrane Handbook for Systematic Reviews of Interventions Version 6.3. 2022. https://training.cochrane.org/handbook/current Date last accessed April 2022.
  30. ↵
    1. Page MJ,
    2. McKenzie JE,
    3. Bossuyt PM, et al.
    The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372: n71. doi:10.1136/bmj.n71
    OpenUrlFREE Full Text
  31. ↵
    1. Uzzaman MN,
    2. Chan SC,
    3. Shunmugam RH, et al.
    Clinical effectiveness and components of home-pulmonary rehabilitation for people with chronic respiratory diseases: a systematic review protocol. BMJ Open 2021; 11: e050362. doi:10.1136/bmjopen-2021-050362
    OpenUrl
  32. ↵
    1. Casaburi R
    . A brief history of pulmonary rehabilitation. Respir Care 2008; 53: 1185–1189.
    OpenUrlAbstract/FREE Full Text
  33. ↵
    1. Greenhalgh T,
    2. Peacock R
    . Effectiveness and efficiency of search methods in systematic reviews of complex evidence: audit of primary sources. BMJ 2005; 331: 1064–1065. doi:10.1136/bmj.38636.593461.68
    OpenUrlAbstract/FREE Full Text
  34. ↵
    1. Klein SR,
    2. Gulart AA,
    3. Venâncio RS, et al.
    Performance difference on the six-minute walk test on tracks of 20 and 30 meters for patients with chronic obstructive pulmonary disease: validity and reliability. Braz J Phys Ther 2021; 25: 40–47. doi:10.1016/j.bjpt.2020.01.001
    OpenUrl
  35. ↵
    1. Tej PS,
    2. Kumar SV,
    3. Vishnukanth G
    . Correlation of six minute walk test and incremental shuttle walk test with severity of airflow obstruction in patients with chronic obstructive pulmonary disease. J Assoc Chest Physicians 2021; 9: 22–28. doi:10.4103/jacp.jacp_13_20
    OpenUrl
  36. ↵
    1. Stoffels AA,
    2. van den Borst B,
    3. Peters JB, et al.
    Correlates of variability in endurance shuttle walk test time in patients with chronic obstructive pulmonary disease. PLoS One 2021; 16: e0249786. doi:10.1371/journal.pone.0249786
    OpenUrl
  37. ↵
    1. Jones P,
    2. Shukla S,
    3. Tombs L, et al.
    Uncovering the relationship between the COPD Assessment Test and St George's Respiratory Questionnaire in patients with chronic obstructive pulmonary disease: a post-hoc analysis of IMPACT, FULFIL, and EMAX Trials. Am J Respir Crit Care Med 2021; 203: Suppl., A4565. doi:10.1164/ajrccm-conference.2021.203.1_MeetingAbstracts.A4565
    OpenUrl
  38. ↵
    1. Moy ML,
    2. Wayne PM,
    3. Litrownik D, et al.
    Long-term Exercise After Pulmonary Rehabilitation (LEAP): a pilot randomised controlled trial of Tai Chi in COPD. ERJ Open Res 2021; 7: 00025-2021. doi:10.1183/23120541.00025-2021
    OpenUrl
  39. ↵
    1. Cochrane Effective Practice and Organisation of Care (EPOC)
    . Screening, Data Extraction and Management. Available from: https://epoc.cochrane.org/resources/epoc-resources-review-authors#conducting Date last accessed: September 2021.
  40. ↵
    1. Higgins JPT,
    2. Green S
    . Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. 2011. The Cochrane Collaboration. Available from: http://handbook-5-1.cochrane.org/
  41. ↵
    1. Higgins JP,
    2. Thompson SG,
    3. Deeks JJ, et al.
    Measuring inconsistency in meta-analyses. BMJ 2003; 327: 557–560. doi:10.1136/bmj.327.7414.557
    OpenUrlFREE Full Text
  42. ↵
    1. Egger M,
    2. Davey Smith G,
    3. Schneider M, et al.
    Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315: 629–634. doi:10.1136/bmj.315.7109.629
    OpenUrlAbstract/FREE Full Text
  43. ↵
    1. Alison JA,
    2. McKeough ZJ,
    3. Johnston K, et al.
    Australian and New Zealand pulmonary rehabilitation guidelines. Respirology 2017; 22: 800–819. doi:10.1111/resp.13025
    OpenUrlPubMed
  44. ↵
    1. Higgins JPT,
    2. Thomas J,
    3. Chandler J, et al.
    1. Schünemann HJ,
    2. Vist GE,
    3. Higgins JP, et al.
    Interpreting results and drawing conclusions. In: Higgins JPT, Thomas J, Chandler J, et al. Cochrane Handbook for Systematic Reviews of Interventions. Chichester, John Wiley & Sons, The Cochrane Collaboration, 2019; pp. 403–431. doi:10.1002/9781119536604.ch15
  45. ↵
    1. Boxall A-M,
    2. Barclay L,
    3. Sayers A, et al.
    Managing chronic obstructive pulmonary disease in the community. A randomized controlled trial of home-based pulmonary rehabilitation for elderly housebound patients. J Cardiopulm Rehabil 2005; 25: 378–385. doi:10.1097/00008483-200511000-00012
    OpenUrlCrossRefPubMed
  46. ↵
    1. Chen Y,
    2. Niu M,
    3. Zhang X, et al.
    Effects of home-based lower limb resistance training on muscle strength and functional status in stable chronic obstructive pulmonary disease patients. J Clin Nurs 2018; 27: e1022–e1037. doi:10.1111/jocn.14131
    OpenUrlPubMed
  47. ↵
    1. Mendes de Oliveira JC,
    2. Studart Leitão Filho FS,
    3. Malosa Sampaio LM, et al.
    Outpatient vs. home-based pulmonary rehabilitation in COPD: a randomized controlled trial. Multidiscip Respir Med 2010; 5: 401–408. doi:10.1186/2049-6958-5-6-401
    OpenUrlCrossRefPubMed
  48. ↵
    1. Ghanem M,
    2. Abd Elaal E,
    3. Mehany M, et al.
    Home-based pulmonary rehabilitation program: effect on exercise tolerance and quality of life in chronic obstructive pulmonary disease patients. Ann Thorac Med 2010; 5: 18–25. doi:10.4103/1817-1737.58955
    OpenUrlCrossRefPubMed
  49. ↵
    1. Güell MR,
    2. de Lucas P,
    3. Gáldiz JB, et al.
    Home vs hospital-based pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: a Spanish multicenter trial. Arch Bronconeumol 2008; 44: 512–518. doi:10.1016/S1579-2129(08)60096-8
    OpenUrlCrossRefPubMed
  50. ↵
    1. Hansen H,
    2. Bieler T,
    3. Beyer N, et al.
    Supervised pulmonary tele-rehabilitation versus pulmonary rehabilitation in severe COPD: a randomised multicentre trial. Thorax 2020; 75: 413–421. doi:10.1136/thoraxjnl-2019-214246
    OpenUrlAbstract/FREE Full Text
  51. ↵
    1. Holland AE,
    2. Mahal A,
    3. Hill CJ, et al.
    Home-based rehabilitation for COPD using minimal resources: a randomised, controlled equivalence trial. Thorax 2017; 72: 57–65. doi:10.1136/thoraxjnl-2016-208514
    OpenUrlAbstract/FREE Full Text
  52. ↵
    1. Horton EJ,
    2. Mitchell KE,
    3. Johnson-Warrington V, et al.
    Comparison of a structured home-based rehabilitation programme with conventional supervised pulmonary rehabilitation: a randomised non-inferiority trial. Thorax 2018; 73: 29–36. doi:10.1136/thoraxjnl-2016-208506
    OpenUrlAbstract/FREE Full Text
  53. ↵
    1. Johnson-Warrington V,
    2. Rees K,
    3. Gelder C, et al.
    Can a supported self-management program for COPD upon hospital discharge reduce readmissions? A randomized controlled trial. Int J Chron Obstruct Pulmon Dis 2016; 11: 1161–1169. doi:10.2147/COPD.S91253
    OpenUrl
  54. ↵
    1. Liang J,
    2. Abramson MJ,
    3. Russell G, et al.
    Interdisciplinary COPD intervention in primary care: a cluster randomised controlled trial. Eur Respir J 2019; 53: 1801530. doi:10.1183/13993003.01530-2018
    OpenUrlAbstract/FREE Full Text
  55. ↵
    1. Maltais F,
    2. Bourbeau J,
    3. Shapiro S, et al.
    Effects of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial. Ann Intern Med 2008; 149: 869–878. doi:10.7326/0003-4819-149-12-200812160-00006
    OpenUrlCrossRefPubMed
  56. ↵
    1. Mohammadi F,
    2. Jowkar Z,
    3. Reza Khankeh H, et al.
    Effect of home-based nursing pulmonary rehabilitation on patients with chronic obstructive pulmonary disease: a randomised clinical trial. Br J Community Nurs 2013; 18: 398–403. doi:10.12968/bjcn.2013.18.8.398
    OpenUrlCrossRefPubMed
  57. ↵
    1. Pehlivan E,
    2. Yazar E,
    3. Balcı A, et al.
    A comparative study of the effectiveness of hospital-based versus home-based pulmonary rehabilitation in candidates for bronchoscopic lung volume reduction. Heart Lung 2020; 49: 959–964. doi:10.1016/j.hrtlng.2020.06.011
    OpenUrl
  58. ↵
    1. Pradella CO,
    2. Belmonte GM,
    3. Maia MN, et al.
    Home-based pulmonary rehabilitation for subjects with COPD: a randomized study. Respir Care 2015; 60: 526–532. doi:10.4187/respcare.02994
    OpenUrlAbstract/FREE Full Text
  59. ↵
    1. Singh V,
    2. Khandelwal DC,
    3. Khandelwal R, et al.
    Pulmonary rehabilitation in patients with chronic obstructive pulmonary disease. Indian J Chest Dis Allied Sci 2003; 45: 13–17.
    OpenUrlPubMed
  60. ↵
    1. Varas AB,
    2. Córdoba S,
    3. Rodríguez-Andonaegui I, et al.
    Effectiveness of a community-based exercise training programme to increase physical activity level in patients with chronic obstructive pulmonary disease: a randomized controlled trial. Physiother Res Int 2018; 23: e1740. doi:10.1002/pri.1740
    OpenUrlPubMed
  61. ↵
    1. Holland AE,
    2. Spruit MA,
    3. Troosters T, et al.
    An official European Respiratory Society/American Thoracic Society technical standard: field walking tests in chronic respiratory disease. Eur Respir J 2014; 44: 1428–1446. doi:10.1183/09031936.00150314
    OpenUrlAbstract/FREE Full Text
  62. ↵
    1. National Asthma and Chronic Obstructive Pulmonary Disease Audit Programme (NACAP)
    1. Royal College of Physicians
    , National Asthma and Chronic Obstructive Pulmonary Disease Audit Programme (NACAP). Pulmonary Rehabilitation Clinical and Organisational Audits 2019. Available from: www.nacap.org.uk/nacap/welcome.nsf/reportsPR.html Date last accessed: 19 July 2021.
  63. ↵
    1. Williamson PR,
    2. Altman DG,
    3. Bagley H, et al.
    The COMET Handbook: version 1.0. Trials 2017; 18: 280. doi:10.1186/s13063-017-1978-4.
    OpenUrlCrossRefPubMed
  64. ↵
    1. Hwang R,
    2. Bruning J,
    3. Morris N, et al.
    A systematic review of the effects of telerehabilitation in patients with cardiopulmonary diseases. J Cardiopulm Rehabil Prev 2015; 35: 380–389. doi:10.1097/HCR.0000000000000121
    OpenUrlCrossRefPubMed
  65. ↵
    1. Hoaas H,
    2. Andreassen HK,
    3. Lien LA, et al.
    Adherence and factors affecting satisfaction in long-term telerehabilitation for patients with chronic obstructive pulmonary disease: a mixed methods study. BMC Med Inform Decis Mak 2016; 16: 26. doi:10.1186/s12911-016-0264-9
    OpenUrlPubMed
  66. ↵
    1. Desveaux L,
    2. Janaudis-Ferreira T,
    3. Goldstein R, et al.
    An international comparison of pulmonary rehabilitation: a systematic review. COPD 2015; 12: 144–153. doi:10.3109/15412555.2014.922066
    OpenUrlCrossRefPubMed
  67. ↵
    1. Rochester CL,
    2. Vogiatzis I,
    3. Holland AE, et al.
    An official American Thoracic Society/European Respiratory Society policy statement: enhancing implementation, use, and delivery of pulmonary rehabilitation. Am J Respir Crit Care Med 2015; 192: 1373–1386. doi:10.1164/rccm.201510-1966ST
    OpenUrlCrossRefPubMed
  68. ↵
    1. Bourbeau J
    . Making pulmonary rehabilitation a success in COPD. Swiss Med Wkly 2010; 140: w1306710.4414/smw.2010.13067
    OpenUrlPubMed
  69. ↵
    1. Puente-Maestu L,
    2. Sánz M,
    3. Sánz P, et al.
    Comparison of effects of supervised versus self-monitored training programmes in patients with chronic obstructive pulmonary disease. Eur Respir J 2000; 15: 517–525. doi:10.1034/j.1399-3003.2000.15.15.x
    OpenUrlAbstract
  70. ↵
    1. Jones AW,
    2. Taylor A,
    3. Gowler H, et al.
    Systematic review of interventions to improve patient uptake and completion of pulmonary rehabilitation in COPD. ERJ Open Res 2017; 3: 00089-2016. doi:10.1183/23120541.00089-2016
    OpenUrlAbstract/FREE Full Text
PreviousNext
Back to top
View this article with LENS
Vol 31 Issue 165 Table of Contents
European Respiratory Review: 31 (165)
  • Table of Contents
  • Index by author
Email

Thank you for your interest in spreading the word on European Respiratory Society .

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Effectiveness of home-based pulmonary rehabilitation: systematic review and meta-analysis
(Your Name) has sent you a message from European Respiratory Society
(Your Name) thought you would like to see the European Respiratory Society web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Print
Citation Tools
Effectiveness of home-based pulmonary rehabilitation: systematic review and meta-analysis
Md. Nazim Uzzaman, Dhiraj Agarwal, Soo Chin Chan, Julia Patrick Engkasan, G.M. Monsur Habib, Nik Sherina Hanafi, Tracy Jackson, Paul Jebaraj, Ee Ming Khoo, Fatim Tahirah Mirza, Hilary Pinnock, Ranita Hisham Shunmugam, Roberto A. Rabinovich
European Respiratory Review Sep 2022, 31 (165) 220076; DOI: 10.1183/16000617.0076-2022

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Effectiveness of home-based pulmonary rehabilitation: systematic review and meta-analysis
Md. Nazim Uzzaman, Dhiraj Agarwal, Soo Chin Chan, Julia Patrick Engkasan, G.M. Monsur Habib, Nik Sherina Hanafi, Tracy Jackson, Paul Jebaraj, Ee Ming Khoo, Fatim Tahirah Mirza, Hilary Pinnock, Ranita Hisham Shunmugam, Roberto A. Rabinovich
European Respiratory Review Sep 2022, 31 (165) 220076; DOI: 10.1183/16000617.0076-2022
Reddit logo Technorati logo Twitter logo Connotea logo Facebook logo Mendeley logo
Full Text (PDF)

Jump To

  • Article
    • Abstract
    • Abstract
    • Introduction
    • Methods
    • Results
    • Discussion
    • Implications for clinical practice and research
    • Conclusion
    • Supplementary material
    • Acknowledgements
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • PDF

Subjects

  • Respiratory clinical practice
  • Tweet Widget
  • Facebook Like
  • Google Plus One

More in this TOC Section

  • Forbearance with endobronchial stenting: cognisance before conviction
  • Prevalence, imaging patterns, and risk factors of ILD in CTD
  • Strength of association between comorbidities and asthma
Show more Reviews

Related Articles

Navigate

  • Home
  • Current issue
  • Archive

About the ERR

  • Journal information
  • Editorial board
  • Press
  • Permissions and reprints
  • Advertising
  • Sponsorship

The European Respiratory Society

  • Society home
  • myERS
  • Privacy policy
  • Accessibility

ERS publications

  • European Respiratory Journal
  • ERJ Open Research
  • European Respiratory Review
  • Breathe
  • ERS books online
  • ERS Bookshop

Help

  • Feedback

For authors

  • Instructions for authors
  • Publication ethics and malpractice
  • Submit a manuscript

For readers

  • Alerts
  • Subjects
  • RSS

Subscriptions

  • Accessing the ERS publications

Contact us

European Respiratory Society
442 Glossop Road
Sheffield S10 2PX
United Kingdom
Tel: +44 114 2672860
Email: journals@ersnet.org

ISSN

Print ISSN: 0905-9180
Online ISSN: 1600-0617

Copyright © 2023 by the European Respiratory Society