Figures
- 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.
- 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.
Tables
- TABLE 1
PICOS (population, intervention, comparison, outcome, study type) table for the search strategy
Description, inclusion Exclusion criteria Operational rules Population Adults with primary diagnosis of CRDs
Age >18 years
Comorbidity will not be an exclusion criterionPregnant women and paediatric population
Rehabilitation provided to predominant condition is nonrespiratory conditions
Recovery from acute infections or injury (e.g. immediately post-COVID-19) until the condition has been stable for 6 months
Conference abstract
Lung cancer
Pulmonary hypertensionPR delivered to people with CRDs such as COPD, remodelled asthma, PIAT, bronchiectasis, ILD, CF, stable post-COVID-19 (but excluding post-ICU rehabilitation) will be studied. We will also include PR delivered to people with more than one CRD, or undifferentiated chronic respiratory conditions
Conference abstracts will be excluded, but will prompt a search for a subsequent published paperIntervention Home-PR that comprises both exercise and at least one nonexercise component for a duration not less than 4 weeks Formal hospital or community medical centre-based programmes Home-PR: the key criterion is that the sessions are undertaken by individuals by themselves (although a family member may be involved) and typically at home. Apart from baseline and post-PR assessments, the patient does not attend a centre (either a hospital centre or a local “satellite” centre) and is not supervised face-to-face by a healthcare professional (although there may be remote communication from a healthcare professional for some or all of the session), and is not part of an “in-person” group
Exercise sessions typically include aerobic, endurance, resistance and reconditioning exercises, although local resources and preferences may include other exercise modalities. Nonexercise components commonly include patient education, energy conservation training, smoking cessation, psychological support, self-management skill development or other recognised PR interventions, along with optimisation of pharmacotherapyComparison Either population receiving centre-PR or receiving usual care No control group Centre-PR: the key criterion is that the sessions are under direct healthcare professional's supervision. The “centre” can be in a hospital, community setting or remote facility. Centre-based sessions are normally group-based (although it is recognised that this may be modified in the context of a pandemic). Telehealth services where patients attend a supervised satellite centre would be considered as centre-PR
Usual care: the standard care received by individuals with CRD in the relevant healthcare system, but excluding the exercise components of PROutcomes Either one of the following outcome measures:
HRQoL
Functional exercise capacity
±
Additional outcome(s):
Uptake of the service, completion rates
Assessment of motivation/other intermediate outcome
Activities of daily living
Physical activity level
Symptom control
Psychological status
Healthcare burden, e.g. exacerbation rates, hospitalisation, etc.
Adverse effectNot including HRQoL or any measurement of exercise capacity as outcome Any validated instruments will be considered:
HRQoL: e.g. SGRQ, CRQ, EQ-5D
Functional exercise capacity: e.g. 6MWT, ISWT, ESWT. We will also include step tests and sit-to-stand tests that are sometimes used in home-PR assessments
Symptom control: e.g. mMRC, CCQ, Borg scale
Psychological status: e.g. HADS, PHQ-9, STAI, Beck's inventory testsSetting Any settings Low- or high-resource settings, irrespective of level of economies of the countries Study designs RCTs, CCTs Cohort study, case series, case report We will exclude studies that do not have a control group. We will consider RCTs to answer all of the three research questions (i.e. effectiveness, components and completion rate of home-PR), and consider CCTs to answer research questions 2 and 3 Language No language restriction CRD: chronic respiratory disease; COVID-19: coronavirus disease 2019; PR: pulmonary rehabilitation; PIAT: pulmonary impairment after tuberculosis; ILD: interstitial lung disease; CF: cystic fibrosis; ICU: intensive care unit; HRQoL: health-related quality of life; SGRQ: St George's Respiratory Questionnaire; CRQ: Chronic Respiratory Questionnaire; EQ-5D: EuroQol Five Dimension; 6MWT: 6-min walk test; ISWT: incremental shuttle walking test; ESWT: endurance shuttle walking test; mMRC: modified Medical Research Council dyspnoea scale; CCQ: Clinical COPD Questionnaire; HADS: Hospital Anxiety and Depression Scale; PHQ-9: Patient Health Questionnaire-9; STAI: State-Trait Anxiety Inventory; RCT: randomised controlled trial; CCT: clinical controlled trial. Reproduced from [36] with permission.
- TABLE 2
Matrix of the home-pulmonary rehabilitation (PR) components in the included studies
Author, year [reference] Exercise type Edu PR frequency; duration Total sessions Training, supervision and monitoring in the home-PR group FEC HRQoL AE RT Flex RMT <24 24–48 ≥48 Home-PR versus usual care (n=9) Ghanem, 2010 [53] ✓ ✓ X ✓ ✓ 2× per week; 8 weeks X ✓ X 1 inpatient training session, then unsupervised home exercise S# S# Pradella, 2015 [63] ✓ ✓ ✓ X ✓ 3× per week; 8 weeks X ✓ X Outpatient training (first week), then diary + weekly TC to encourage home exercises S# S# Varas, 2018 [65] ✓ X X X ✓ 5× per week; 8 weeks X ✓ X 5 outpatient training sessions, then diary + pedometer + weekly TC S# S# Singh, 2003 [64] ✓ X X X X 2× per day; 4 weeks X ✓ X Outpatient training sessions, then weekly supervision (mode not described) ns# S# Boxall, 2005 [50] ✓ ✓ X X X Daily; 12 weeks X X ✓ Weekly home visits for 6 weeks + diary, then fortnightly home visits ns# ns# Johnson-Warrington, 2016 [58] ✓ ✓ X X ✓ 3× per week; 12 weeks X X ✓ 1 face-to-face introductory session and given manual, then fortnightly TC ns ns# Liang, 2019 [59] ✓ ✓ X X ✓ NR; 8 weeks ✓ X X 1 home visit, then weekly TC ns ns Mendes de Oliveira, 2010 [52] ✓ ✓ ✓ X ✓ 3× per week; 12 weeks X ✓ X 1 outpatient education + exercise training session, then diary + heart rate monitor + TC NR ns Mohammadi, 2013 [61] ✓ X X X ✓ 3× per week; 8 weeks X ✓ X 3 inpatient training sessions, then manual + TC (alternate days) NR ns Home-PR versus centre-PR (n=8) Pehlivan, 2020 [62] ✓ ✓ X X ✓ 2–7× per week; 8 weeks X ✓ X Exercise sessions + daily walking + diary + manual
Supervision NRS ns# Chen, 2018 [51] X ✓ X X ✓ 3× per week; 12 weeks X ✓ X 1 outpatient education and training session, then home exercise + manual
Supervision NRns# ns# Güell, 2008 [54] ✓ ✓ X ✓ ✓ 3× per week; 9 weeks X ✓ X 4 outpatient education and training sessions, then home exercise/walking sessions + pedometer
Supervision NRns# ns Hansen, 2020 [55] ✓ ✓ X X ✓ 3× per week; 10 weeks X ✓ X 3× per week exercise and education sessions, supervised by video-conference + diary ns ns Holland, 2017 [56] ✓ ✓ X X ✓ Most days; 8 weeks X X ✓ 1 home visit, then home exercise sessions supervised by weekly TC + diary + pedometer ns ns# Horton, 2018 [57] ✓ ✓ X X ✓ 3× per week; 7 weeks X ✓ X 1 outpatient training session, then home exercise supervised by TC (×2) + manual ns ns Maltais, 2008 [60] ✓ ✓ X X ✓ 3× per week; 8 weeks X ✓ X Outpatient education and training sessions, then home-based exercise + diary ns ns Mendes de Oliveira, 2010 [52] ✓ ✓ ✓ X ✓ 3× per week; 12 weeks X ✓ X 1 outpatient education + exercise training session, then diary + heart rate monitor + TC ns# NR AE: aerobic training; RT: resistance training; flex: flexibility training; RMT: respiratory muscle training; Edu: education; FEC: functional exercise capacity; HRQoL: health-related quality of life; S: significant between-group difference; TC: telephone call; ns: nonsignificant between-group difference; NR: not reported. #: improved above minimal clinically important difference.
- TABLE 3
Recruitment, uptake, engagement and completion of pulmonary rehabilitation (PR) sessions and trial attrition
Author, year [reference] Screened (reasons for ineligibility) Recruited: randomised Uptake of PR/usual care (reasons for nonstart) Dose of PR and definition of engagement Engaged with defined number of sessions (reasons for non-engagement) Completed PR programme (reasons for dropout) Trial attrition rate (reason for attrition) Home-PR versus usual care Boxall, 2005 [50]
RoB: highEligibility screening not reported
60 recruited: home-PR n=30, usual care n=30Uptake of PR: home-PR 28/30 (93%) (2 ill-health) Home-PR: 11 sessions (12 weeks: 11 visits + daily unsupervised exercise)
Engagement not definedEngagement not reported Home-PR: 23/30 (77%) (3 withdrew, 1 died, 1 ill-health) Post-PR
Home-PR: 7/30 (23%) (3 withdrew, 1 died, 3 ill-health)
Control: 7/30 (23%) (2 withdrew, 2 died, 1 ill-health, 2 moved)Chen, 2018 [51]
RoB: high265 screened for eligibility
(77 lost to contact, 44 distances >44 km, 53 declined, 36 comorbidity, 38 other)
55 (21%) recruited: home-PR n=29, usual care n=26Uptake not reported Home-PR: 36 sessions (12 weeks: 3× per week unsupervised exercise)
Engagement not definedEngagement not reported Home-PR: 25/29 (86%) (3 ill-health, 1 moved)
Usual care: 22/26 (85%) (1 ill-health, 3 not serious enough)Post-PR
Home-PR: 4/29 (14%) (1 moved, 3 ill-health)
Usual care: 4/26 (15%) (1 not serious, 1 ill-health)Ghanem, 2010 [53]
RoB: highEligibility screening not reported
39 recruited: home-PR n=25, usual care n=14Uptake not reported Home-PR: 48 sessions (8 weeks: alternate days unsupervised exercise)
Engagement not definedEngagement not reported Completion not reported Post-PR
Home-PR: 0/25 (0%)
Usual care: 0/14 (0%)Johnson-Warrington, 2016 [58]
RoB: moderate464 screened for eligibility
175 declined, 76 not eligible, 49 comorbidity, 90 lost to contact
78 (17%) recruited: home-PR n=39, usual care n=39Uptake not reported Home-PR: 42 sessions (12 weeks 6 TCs + 3× per week unsupervised exercise)
Engagement not definedEngagement not reported Home-PR: 35/39 (90%) (2 ill-health, 1 preferred centre-PR, 1 not COPD)
Usual care: 36/39 (92%) (3 died)Post-PR
Home-PR: 4/39 (10%)
(1 wanted centre-PR; 2 ill-health; 1 not COPD)
Usual care: 3/39 (8%)
(3 died)Mohammadi, 2013 [61]
RoB: high106 assessed for eligibility
40 (38%) recruited: home-PR n=20, usual care n=20Uptake not reported Home-PR: 24 sessions
(8 weeks: 3 sessions then daily TCs + unsupervised sessions 3× per week)
Engagement not definedCompletion not reported Not reported
No attrition reportedPradella, 2015 [63]
RoB: highEligibility screening not reported
50 recruited: home-PR n=32, usual care n=18Uptake not reported Home-PR: 24 sessions (8 weeks: weekly TCs + 3 unsupervised sessions per week)
Engagement not definedEngagement not reported Home-PR: 29/32 (91%) (1 withdrew; 1 died, 1 AECOPD) Post-PR
Home-PR: 3/32 (9%) (1 died, 1 withdrew, 1 AECOPD)
Usual care: 3/18 (17%) (2 withdrew, 1 AECOPD)Singh, 2003 [64]
RoB: highEligibility screening not reported
40 recruited: home-PR n=20, usual care n=20Uptake not reported Home-PR: 4 sessions (4 weeks: weekly visits + daily unsupervised exercise)
Engagement not definedEngagement not reported Engagement not reported Post-PR
Home-PR: 0/20 (0%)
Control: 0/20 (0%)Varas, 2018 [65]
RoB: highEligibility screening not reported
40 recruited: home-PR n=21, usual care n=19Uptake of PR:
home-PR 19/21 (90%) (2 withdrew)Home-PR: 8 sessions (1× per week + unsupervised exercise ×8 weeks)
Engagement not definedEngagement not reported Home-PR: 17/21 (81%)
(2 did not complete)Post-PR
Home-PR: 4/21 (19%) (4 withdrew)
Usual care: 3/19 (16%) (3 withdrew)
3 months and 12 months
Home-PR: 4/21 (19%)
Usual care: 3/19 (16%)Cluster randomised implementation trial: home-PR versus usual care Liang, 2019 [59]
RoB: highCluster RCT: 21 practices/group
1050 screened for eligibility
272 (26%) recruited: home-PR n=157, control n=115GP referred for PR: home-PR 107/157 (68%)
Uptake of PR: home-PR 71/107 (66%)Home-PR: 8 sessions (8 weeks: 1 session + weekly TC unsupervised exercise)
Engagement defined as ≥70% sessions attendedEngaged ≥70%
Home-PR: 49/107 (46%)Completion not reported 6 months
Home-PR: 39/157 (25%)
Usual care: 21/115 (18%)
12 months
Home-PR: 44/157 (28%) (27 lost to follow-up, 15 withdrew, 2 died)
Usual care: 38/115 (33%) (29 lost to follow-up, 7 withdrew, 1 moved, 1 died)Home-PR versus centre-PR Güell, 2008 [54]
RoB: highEligibility screening not reported
57 recruited: home-PR n=28, centre-PR n=29Uptake not reported Home-PR: 27 sessions (9 weeks: 4 sessions + 3× per week unsupervised
Centre-PR: 27 sessions (9 weeks: 3× per week)
Engagement not definedEngagement not reported Home-PR: 23/28 (82%) (4 dropped out, 1 chest pain)
Centre-PR: 28/29 (96%) (1 dropped out)Post-PR
Home-PR: 5/28 (18%)
Centre-PR: 1/29 (4%)
6 months
Home-PR: 8/28 (29%) (4 withdrew, 1 ill-health, 3 lost to follow-up)
Centre-PR: 6/29 (21%) (1 dropped out, 5 lost to follow-up)Hansen, 2020 [55]
RoB: low1099 assessed for eligibility:
(608 declined centre-PR, 251 declined home-PR, 40 comorbidity, 66 other)
134 (12%) recruited: home-PR n=67, centre-PR n=67Uptake not reported Home-PR: 30 sessions (10 weeks: 3 sessions per week)
Centre-PR: 20 sessions (10 weeks: 2 sessions per week)
Engagement defined as ≥70% sessions attended
Attendance defined as participating in the whole sessionEngaged ≥70%
Home-PR: 49/67 (73%)
Centre-PR: 42/67 (63%)
Median (IQR) number sessions attended
Home-PR: 25/30 (20–28)
Centre-PR 16/20 (8/19)
Home-PR >70% engagement: OR 1.68, 95% CI 0.78–3.37; p<0.27Home-PR: 57/67 (85%) (6 dropped out, 2 ill-health, 1 died, 1 AECOPD)
Centre-PR: 43/67 (64%) (10 dropped out, 8 ill-health, 2 died, 4 AECOPD)
Home-PR completing: OR 3.18, 95% CI 1.37–7.35; p<0.01Post-PR
Home-PR: 20/67 (30%)
Centre-PR: 26/67 (39%)
3-month follow-up
Home-PR: 29/67 (43%)
Centre-PR: 26/67 (39%)Holland, 2017 [56]
RoB: low295 assessed for eligibility
(27 recent PR, 10 comorbidities, 5 recent AECOPD, 67 declined (54 wanted centre-PR), 120 other)
166 (56%) recruited: home-PR n=80, centre-PR n=86Uptake not reported Home-PR: 8 sessions (8 weeks: visit then weekly TCs + unsupervised sessions)
Centre-PR: 16 sessions (8 weeks: twice weekly)
Engagement defined as ≥70% sessions attendedMean/total sessions attended (range)
Home-PR: 7.4/8 (0–8)
Centre-PR 8.3/16 (0–16)
Engaged ≥70%
Home-PR: 73/80 (91%)
Centre-PR: 42/86 (49%)
Relative risk of noncompletion in centre-PR 1.91 (95% CI 1.52–2.41)Home-PR: 73/80 (91%) (1 died, 1 lost to follow-up, 5 declined)
Centre-PR: 77/86 (89%) (1 died, 1 lost to follow-up, 7 declined)Post-PR
Home-PR: 7/80 (9%)
Centre-PR: 9/86 (11%)
12-month follow-up
Home-PR: 18/80 (24%) (4 lost to follow-up, 9 declined follow-up, 5 died)
Centre-PR: 24/86 (28%) (10 lost to follow-up, 10 declined follow-up, 4 died)Horton, 2018 [57]
RoB: low1162 assessed for eligibility
(185 DNA, 32 comorbidities, 606 not eligible, 140 wanted centre-PR, 100 declined, 199 other)
287 (25%) recruited: home-PR n=145, centre-PR n=142Uptake not reported Home-PR: 21 sessions (7 weeks: 3 unsupervised sessions a week)
Centre-PR: 14 sessions (7 weeks: twice weekly)
Engagement not definedEngagement not reported Home-PR: 94/145 (85%) (16 lost to follow-up, 16 comorbidities, 2 died, 2 wanted centre-PR, 17 other)
Centre-PR: 84/142 (59%) (30 lost to follow-up, 12 comorbidities, 1 died, 3 wanted home-PR, 12 others)Post-PR
Home-PR: 51/145 (35%)
Centre-PR: 58/142 (41%)
6 months
Home-PR: 70/145 (48%) (7 lost to follow-up, 3 DNA, 3 declined, 13 comorbidities, 3 other)
Centre-PR: 72/142 (51%) (8 lost to follow-up, 1 comorbidity, 3 died, 2 others)Maltais, 2008 [60]
RoB: moderate631 assessed for eligibility (214 declined, 27 transport problems, 1 died, 29 others)
252 (40%) recruited: home-PR n=126, centre-PR n=126Uptake not reported Home-PR: 24 sessions (8 weeks: 3 unsupervised sessions per week)
Centre-PR: 24 sessions (4× 8 weeks: 3 sessions per week)
Engagement defined as ≥60% sessions attendedEngaged ≥60%
Home-PR: 123/126 (98%)
Centre-PR:117/126 (93%)Completion not reported Post-PR
Home-PR: 7/126 (6%)
Centre-PR: 12/126 (10%)
12 months
Home-PR: 19/126 (15%) (2 lost to follow-up, 16 withdrew, 1 died)
Centre-PR: 17/126 (13%) (2 lost to follow-up, 14 withdrew, 1 died)Pehlivan, 2020 [62]
RoB: high71 assessed for eligibility
71 recruited: home-PR n=39, centre-PR n=32Uptake not reported Home-PR: 32 sessions (8 weeks: 4 unsupervised sessions per week)
Centre-PR: 16 sessions (8 weeks: 2 sessions per week)
Engagement not definedEngagement not reported
4 home-PR patients were excluded for “noncompliance”Home-PR: 35/39 (4 discontinued)
Centre-PR: 32/32Post-PR
Home-PR: 4/39 (10%) (4 withdrew)
Centre-PR: 0/32 (0%)Three-arm trial (home-PR versus centre PR versus usual care Mendes de Oliveira, 2010 [52]
RoB: high216 assessed for eligibility (65 declined, 32 ineligible, 2 died)
117 (54%) recruited: home-PR n=42, centre-PR n=46, usual care n=29Uptake not reported Home-PR: 36 sessions (12 weeks: TCs + 3 unsupervised sessions per week)
Centre-PR: 36 sessions (12 weeks: 3 sessions per week)
Engagement not definedEngagement not reported Home-PR: 35/42 (83%) (7 “abandoned” the programme)
Centre-PR: 27/46 (59%) (7 “abandoned” the programme)Post-PR
Home-PR: 9/42 (21%) (2 lost to follow-up)
Centre-PR: 22/45 (50%) (4 lost to follow-up)
Usual care: 0/29 (0%)Home-PR: home-based pulmonary rehabilitation; RoB: risk of bias; centre-PR: centre-based pulmonary rehabilitation; TC: telephone contact; AECOPD: acute exacerbation of COPD; RCT: randomised controlled trial; GP: general practitioner; IQR: interquartile range; DNA: did not attend.
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
Vol 31 Issue 165
Table of Contents
Effectiveness of home-based pulmonary rehabilitation: systematic review and meta-analysis
