Long-term telerehabilitation and unsupervised home exercise training can reduce hospitalizations and emergency department (ED) presentations among patients with chronic obstructive pulmonary disease (COPD), according to study findings published in the American Journal of Respiratory and Critical Care Medicine.
Although pulmonary rehabilitation (PR) has proven effective for patients with COPD, the majority of patients with COPD do not benefit from PR due to low rates of referral, attendance, and completion. The iTrain study, an international randomized controlled trial, addressed unmet rehabilitation needs in COPD by assessing 2 alternative interventions: long-term telerehabilitation and unsupervised home exercise training.
Conducted in Norway, Australia, and Denmark, the iTrain study included 120 participants aged 40 to 80 years with COPD who were randomly assigned 1:1 to telerehabilitation, unsupervised training, or a control group receiving standard care.
The primary outcome was the combined number of hospitalizations and ED presentations during the 2-year trial period.
Participants in the 2 intervention groups had a supervised in-person training session on the treadmill with an experienced physiotherapist. Those in the telerehabilitation group were offered exercise training at home, telemonitoring, and self-management. Individuals in the unsupervised training group used a treadmill only for unsupervised exercise at home and received an exercise booklet, a paper exercise diary to record their training sessions, and an individualized training program. Participants in the control group received standard care.
The 3 groups studied had 40 participants each. The telerehabilitation group, which was 57.5% male, had a mean (SD) age of 64.9 (7.1) years; the unsupervised training group, which was 50% male, had a mean age of 64.0 (7.7) years; and the control group, which was 57.5% male, had a mean age of 63.5 (8.0 years).
In assessing the combined number of hospitalizations and ED presentations, investigators found lower incidence rates in the intervention groups, with a total of 84 events in 71.05 person years (1.18 events per person-year; 95% CI, 0.94-1.46; P = .0007) in the telerehabilitation group; 88 events in 76.93 person-years (1.14 events per person-year; 95% CI, 0.92-1.41; P = .0002) in the unsupervised training group; and 140 events per 74.59 person years (1.88 events per person-year; 95% CI, 1.58-2.21) in the control group.
Notably, the addition of smoking status and long-term oxygen therapy as covariates in the analysis did not affect the findings.
At 6 months, the telerehabilitation group had statistically significant changes in COPD Assessment Test (CAT) score (P =.037) and modified Medical Research Council (mMRC) scale (P =.037) compared with the control group. However, improvements in health status and dyspnea were not sustained after 2 years.
The unsupervised training group also had an improved CAT score (P =.002) and mMRC scale score (P =.027) at 6 months vs the control group. Dyspnea levels continued for 2 years, and the improvement in health status was maintained for 1 year.
No differences were observed among the groups regarding self-efficacy, anxiety, and depression. The mortality rate was 7.5% in the telerehabilitation group, 10% in the unsupervised training group, and 5% in the control group.
The researchers noted that rehabilitation interventions may have a greater effect in recently hospitalized patients, which could have affected the outcomes. In addition, the study was not powered for the secondary outcomes, and it was not possible to compare the benefits of the interventions with traditional center-based pulmonary rehabilitation or maintenance programs.
“The delivery of long-term telerehabilitation or unsupervised exercise training at home has the potential to broaden the availability of pulmonary rehabilitation programs and maintenance strategies, especially to those living in remote areas and with no access to center-based exercise programs,” concluded the study authors.
“Future research should focus on adapting PR and maintenance programs to the individual needs of the participants in order to maximize the benefits while making good use of healthcare resources,” they added.
Zanaboni P, Dinesen B, Hoaas H, et al. Long-term telerehabilitation or unsupervised training at home for patients with chronic obstructive pulmonary disease: a randomized controlled trial. Am J Respir Crit Care Med. Published online December 8, 2022. doi:10.1164/rccm.202204-0643OC