Home-based pulmonary tele-

rehabilitation: An acceptable and

feasible way of rehabilitation for COPD
patients?

R.J. Schuinder, s2302136

Supervisor: J. W van den Berg
Institution: Isala hospital Zwolle, department of pulmonology
Table of contents
Table of contents .......................................................................................... 1

Summary ...................................................................................................... 2

Samenvatting ................................................................................................ 3

Introduction .................................................................................................. 4

Hypothesis and research question ................................................................. 6

Materials and methods ................................................................................. 7

Results ........................................................................................................ 10

Discussion ................................................................................................... 13

Conclusion .................................................................................................. 16

Bibliography................................................................................................ 17

1
Summary
Introduction
Chronic obstructive pulmonary disease (COPD) is a chronic and highly prevalent disease with
a high economic and social healthcare burden. Rehabilitation programs play a vital role in the
treatment of COPD, as they improve quality of life and decrease hospital admissions in patients.
Although rehabilitation is a very important therapeutic option, only 10% of all COPD patients
eligible for rehabilitation undergo a rehabilitation program. To reach the other 90%, new
strategies must be explored. Home-based pulmonary tele-rehabilitation has shown promising
results in other disciplines like cardiology, therefore we investigated if a home-based tele-
monitoring program is an acceptable and feasible method of pulmonary rehabilitation in COPD
patients from Isala hospital.
Materials and methods
A total of 16 patients with moderate to severe COPD took part in this single-centre, prospective
acceptability and feasibility study. Participants took part in a 12-week intervention of home
based tele-rehabilitation. Monitoring and coaching was performed through an electronic portal
and based on heart rate, duration and quantity of the performed activities.
All patients were assessed at baseline and after 12 weeks. Both the initial and the last assessment
included a 6-minute walking test and an assessment of the quality of life using the St. George's
Respiratory Questionnaire, the COPD Assessment Test and the clinical COPD questionnaire.
In the last assessment patients also received an additional questionnaire with an emphasis on
acceptability and feasibility.
Results
Regarding acceptability and feasibility of home-based pulmonary rehabilitation, we have
shown a high participation rate of 73% with 18.7% dropout. The average satisfaction was 7.54
out of 10 and ease of use had a mean of 6.85 out of 10. All participants would recommend the
program to others. There were no significant improvements in exercise capacity and the quality
of life but there was a trend towards improvement of both exercise capacity and quality of life.
When taking adherence into account the increase of quality of life was statistically significant.
Conclusion
Home-based pulmonary tele-rehabilitation is an acceptable and feasible way of rehabilitation
and shows promising results regarding exercise capacity and quality of life. In regards to
technology there is still room for improvement.

2
Samenvatting
Introductie
Chronische obstructieve longziekte (COPD) is een chronisch een veel voorkomende ziekte en
vormt een hoge economische en sociale last voor de gezondheidzorg. Revalidatieprogramma’s
hebben vanwege hun positieve invloed op ziekenhuisopnames en kwaliteit van leven een
centrale rol binnen de behandeling van COPD. Hoewel revalidatieprogramma’s deze centrale
rol hebben, participeert slechts 10% van de patiënten die in aanmerking komen voor revalidatie,
een revalidatieprogramma. Om de overige 90% te bereiken moeten er nieuwe strategieën
worden onderzocht. Pulmonale telerevalidatie in de thuissituatie heeft veelbelovende resultaten
laten zien in andere disciplines zoals de cardiologie, daarom hopen we nu ook te kunnen
aantonen dat het een acceptabele en haalbare methode van pulmonale revalidatie is binnen het
Isala ziekenhuis.
Materiaal en methode
Een totaal van 16 patiënten met middelmatige tot ernstige COPD heeft deelgenomen aan deze
single-centre, prospectieve acceptability en feasibility studie. Deelnemers ondergingen een 12-
weken durend telerevalidatie programma. Monitoring en het coachen verliep via een
elektronische portaal en was gebaseerd op het aantal activiteiten, de duur en de hartslag
passende bij de activiteit.
Alle patiënten werden op het begin en op het einde van de studie geëvalueerd. Zowel de eerste
als de laatste evaluatie bestond uit een 6 minuten wandeltest en een evaluatie van de kwaliteit
van leven middels de St. George’s Respiratory Questionnaire, de COPD Assessment test en de
klinische COPD questionnaire. Gedurende de laatste evaluatie kregen patiënten ook een
additionele questionnaire waarin in het bijzonder de haalbaarheid en de acceptatie van het
telemonitoring traject werd geëvalueerd.
Resultaten
Met betrekking tot de haalbaarheid en acceptatie van mobiele pulmonale telerevalidatie hebben
we een hoge deelname van 73% met 18.7% uitval gedurende de studie. De gemiddelde
tevredenheid was een 7.54 van de 10 en het gebruikersgemak kreeg een cijfer van 6.85 van de
10. Alle deelnemers zouden het revalidatieprogramma aanraden aan andere patiënten. Er was
geen sprake van een significante verbetering in inspanningscapaciteit en kwaliteit van leven
maar er was wel een duidelijke verbeterende trend. Wanneer therapietrouw werd meegenomen
in de analyse was er wel een significante verbetering in kwaliteit van leven.
Conclusie
Pulmonale telerevalidatie in de thuissituatie is een acceptabele en haalbare manier van
revalidatie en laat veelbelovende resultaten zien op het gebied van inspanningscapaciteit en
kwaliteit van leven. Met betrekking tot de technologie betrokken is er nog ruimte voor
verbetering.

3
Introduction
Chronic obstructive pulmonary disease (COPD) is defined as a common, preventable and
treatable disease that is characterized by persistent respiratory symptoms such as shortness of
breath, mucus production, cough and airflow limitation. These symptoms lead to exercise
intolerance and a decreased quality of life (1). COPD affects more than 5% of the global
population and in 2002 it was the fifth leading cause of death worldwide. In the coming years
the prevalence of COPD is estimated to increase to 8% of all worldwide deaths, and thus also
increasing the global burden of COPD. This increase is expected to be disproportionately in
lower income countries (2,3).
Since COPD is a highly prevalent disease which requires long-term medical treatment, it forms
a large economic burden for western healthcare systems. COPD often leads to frequent general
practitioner visits, frequent hospitalizations due to exacerbations and a need for chronic
pharmaceutical treatment (4).
Most studies indicate that patients who undergo rehabilitation programs have an increased
quality of life and a decreased rate of readmission to hospital following exacerbations. This
decrease in hospital admissions is a start in improving quality of life and decreasing the
healthcare costs associated with COPD (5).

Pulmonary rehabilitation
In recent years it has been shown that pulmonary rehabilitation is one of the most effective ways
to prevent COPD exacerbations and increase quality of life. Pulmonary rehabilitation is a
multidisciplinary intervention which involves supervised exercise training, usually in a group
setting, combined with education and instruction in self-management (6).
Rehabilitation in the Isala hospital in the Netherlands, consists of two modules, an info-module
and a fit-module. The info-module focuses on information given through multiple disciplinaries
such as nurses, psychologists and dieticians working together to improve patients understanding
of the disease and to make them better at self-management. The fit-module consists of an
intensive training program, with an emphasis on improving condition and posture. Furthermore,
patients are taught cough- and breathing techniques and relaxation exercises (7). Both modules
contribute to patients learning their own boundaries and respecting those boundaries. By
respecting their boundaries patients have more energy to participate in day to day life, be more
autonomous and perceive a better quality of life (8).
A problem with current rehabilitation programs is that only about 10% of the targeted
population takes part in a rehabilitation program. Most common reasons for not participating in
rehabilitation programs, are transport difficulties and a lack of perceived benefits (9). Of the
participating patients, between 8.3-49.6% drops out of rehabilitation, an acute exacerbation of
their COPD or another disease being the most common reason (14-66%). Other factors that are
negatively associated with completion of rehabilitation include current smoking habits and
depression (9).

Previous studies
To eliminate the problem outlined above, our study is targeted on providing rehabilitation
without the necessity to travel and focus on informing the patients of the benefits of
rehabilitation. There have been previous studies that tried to improve patient participation in
rehabilitation through home-based rehabilitation. Methods that have been tried include; video
conferencing once to twice a week, mobile phone applications that monitor exercise and
distribution of a 5 day a week exercise program without monitoring. The aforementioned
methods showed a significant increase in perceived quality of life. This was measured using the

4
St. George respiratory questionnaire and the chronic respiratory disease questionnaire. Most of
these methods also increased the exercise capacity of participating patients, which was in
general measured by a 6-minute walking test. There is a great variety between the methods, but
the goal of rehabilitation is the same.(10) After showing that rehabilitation at home is effective,
another question remained; is rehabilitation at home as effective as rehabilitation in a hospital
setting. To answer this a 2016 British non-inferiority study used weekly phone calls by a
physiotherapist to rehabilitate at home and compared this to a centre-based rehabilitation
program. In this study they showed non-inferiority of home-based rehabilitation compared to a
center-based rehabilitation program, regarding 6-minute walking distance and quality of life.
Although this was a non-inferiority study, promising completion rates were also seen.(11)

Current study
As there has not been a previous study focused on home-based rehabilitation for COPD patients
in the Netherlands, we primarily want to study the feasibility and acceptability of a home-based
tele monitoring guided pulmonary rehabilitation program in the Netherlands, specifically within
patients from Isala hospital in Zwolle. Although an attempt will be made to evaluate the
effectiveness of home-based pulmonary rehabilitation, this is not the main objective of this
study as it has previously been evaluated in other studies and this pilot is not powered to do so.
If proven to be feasible and acceptable by patients, a larger prospective randomized and
controlled multicenter study will follow.
The home-based rehabilitation consists of a heartrate monitor and a smartphone application.
Participants will receive weekly communication through messages on a secured website, these
messages are based on an overview of a participant’s activity and their goals that have been
previously set. The focus of the home-based rehabilitation program is on stimulating exercise,
currently there is no information module but this will be added in the future.

5
Hypothesis and research question
Statistics and previous studies have shown the need for a more patient directed approach to
pulmonary rehabilitation. The aim of this approach is to reach patients who are not able or
willing to go to a center-based rehabilitation program, and give them the option of a home-
based rehabilitation program with comparable effectivity but with better accessibility. The
primary goal of this pilot study is to assess the feasibility and acceptability of a home-based tele
monitoring guided pulmonary rehabilitation program. Therefore, our primary hypothesis is that
tele monitoring guided pulmonary rehabilitation is an acceptable and feasible method of
pulmonary rehabilitation. This is tested by monitoring dropout within the study and collecting
qualitative data to access patient satisfaction with the program, ease of use and perceived
usefulness of further use.
Our secondary objective will be to investigate whether more than 50% of the COPD patients
included in the study will comply with the use of the smartphone provided. Here compliance is
defined as participants at least performing 60% of all prescribed exercise.
Thirdly, we will measure if the addition of tele-monitoring guidance for home-based
rehabilitation will result in a preserved exercise tolerance and quality of life within the
participating COPD patients.

6
Materials and methods
Design
This was a single-center, prospective pilot study, performed to assess the feasibility,
acceptability and effectiveness of a 12-week home-based tele monitoring rehabilitation
program. The pilot study was performed in preparation of a large prospective randomized and
controlled multicenter study.
A total of 16 patients participated in this pilot study. These 16 participants took part in a home-
based rehabilitation program with a smartphone application and mobile guidance. During the
home-based rehabilitation, participants were asked to perform moderate exercise 5 times a week
during at least half an hour. Patients were required to record the kind of activity they performed,
and the smartphone application registered their heartbeat and Borg scores. This data was sent
to a secure server to create an overview of their physical activity. The data collected was used
to give participants mobile guidance and improve their compliance to the program, which will
be discussed in more detail below.
Informed consent was given by all participants and participants could stop at any time without
consequence.
The study was approved by the medical ethical review committee of Isala hospital. The pilot
took place between January 2018 and May 2018.

Patient selection and sample size

A total of 16 patients diagnosed with COPD were retrospectively identified from a database
which contained all patients who had participated in a rehabilitation program within the Isala
hospital in 2016 and 2017. Inclusion criteria were: a minimum age of 50 years old; diagnosis
of COPD of at least moderate severity (GOLD 2 and above); smoking history of more than 10
packyears; living within 30 minutes of the hospital.
Exclusion criteria were: contraindication to pulmonary rehabilitation; mental impairment
leading to inability to cooperate; severely impaired ability to exercise; insufficient knowledge
of the native language.
Patients in the database who fit the in- and exclusion criteria were then called and given a brief
summary of what this pilot study entailed. When a patient was interested in participating they
were given the choice to get an introductory meeting at home or in the hospital. During this
introductory meeting they received additional information on their role and the purpose of the
study and were asked if they wanted to participate.
Sample size calculations for the main follow-up study will be based on the study by Holland et
al. (11). 144 patients are required to be 80% sure that the 95% CI excludes a difference in the
change in 6-minute walking distance of more than the equivalence limit of 25m, assuming a SD
of 51m. Anticipating 15% dropout, 170 patients are needed. According to an article by Connelly
in 2008 extant literature suggests that a pilot study sample should be about 10% of the sample
projected for the larger parent study, so in this case 15 participants without any dropout will
suffice (12). In the first 2 weeks dropout will be compensated with new participants.

7
Measurements
All patients were assessed at the start of the home-based rehabilitation program and after 12
weeks of participating in the program. Patient characteristics like age, gender, weight, smoking
status and GOLD class were recorded at the start of the study. Both the initial and the last
assessment included a 6-minute walking test and an assessment of the quality of life and
perceived burden of disease using the St. George's Respiratory Questionnaire (SGRQ) (13), the
COPD Assessment Test (CAT) (14) and the clinical COPD questionnaire (CCQ) (15).
Both the CAT and the CCQ scores are strongly associated with low BMI, COPD exacerbations,
heart disease, anxiety/depression and COPD stage, which makes these questionnaires great for
assessing quality of life in patients with COPD.(16)
The final assessment also included a questionnaire where we assessed the amount of healthcare
accessed (general practitioner visits, hospital visits and additional diagnostics like a X-Thorax),
the perceived benefit of the tele-revalidation, adherence to the use of the smartphone and use
of the corresponding website. Participants were also asked to rate the use of the tele-
revalidation program with a mark between 0 and 10.
The primary outcomes were feasibility and acceptability. Feasibility was assessed using
dropout from the study (in %) and the percentage of patients contacted who wanted to
participate. Acceptability was assessed using patients ‘satisfaction with pulmonary
rehabilitation indicated by a mark between 0 and 10’ and the adherence to the program which
was predefined as performing 30 minutes of exercise at least three days a week.
Secondary outcomes were exercise tolerance and quality of life. Exercise tolerance was
assessed using the 6-minute walking test, which was performed by the physiotherapy
department of Isala hospital. Quality of life was assessed using the questionnaires described
above.

Tele-monitoring guidance
The home- based rehabilitation platform that was used in this pilot was developed and provided
by HC@Home. The platform provided by HC@Home is registered with the inspection for
healthcare as a class 1 medical tool under number NL-CAOO2-2014-32838. Their home- based
rehabilitation platform has previously been used in a cardiac rehabilitation study (17), and since
then has been in constant development.
The participants of this pilot study received a smartphone (Samsung Galaxy Young 2, Korea)
and a Bluetooth heart rate monitor (Zephyr, Annapolis, USA). Using the heart rate monitor the
device can register training intensity and duration. By asking the patient afterwards how
demanding they perceived their registered activity, it also measures a BORG score.
The participants were all given a minimum and maximum heart rate, when in this range the
activity was deemed of moderate to high intensity. This was established based on their age and
on their previous ergometry test. Participants were encouraged to stay within this range when
performing an activity for optimal conditional training. All collected data was sent to a secured
website through an encrypted wireless connection. Participants were given access to their
individual webpage where they could view their performed activities, collected data like
average heartbeat, length of the activity and an estimated amount of calories burned for the
performed activity.
During the pilot they received 1-2 text messages a week, in these messages patients received
advice and encouragement based on the registered performed activities. When a patient
repeatedly wouldn’t respond to text messages, verbal contact was established by phone.

8
Statistical analysis
All paper questionnaires were checked for missing data before calculating scores and being
entered in a secure database (Research Manager, Deventer, Netherlands). All data was exported
to Statistical Package for the Social Sciences (SPSS, Chicago, Illinois, USA).
For continuous data median and range were provided and for dichotomous and categorical data,
frequency and percentage were calculated.
Normal distribution could not be ascertained because of the small sample size. Therefore, in all
cases a non-parametric test was used. If the tested values were unpaired the Mann-Whitney U
test was used, when paired the Wilcoxon signed rank test was applied. P-values were 2-tailed
and a value of P <0.05 was considered statistically significant.
Analyses of correlation were done on gender, severity of disease and exercise capacity at
baseline.
All analyses were carried out using the Statistical Package for the Social Sciences, version 25.0
for Windows (SPSS, Chicago, IL, USA), with a p-value of 0.05.

9
Results
Descriptive statistics
Twenty-two patients with COPD were contacted of which sixteen were included in the study.
(Figure 1). In terms of acceptability and feasibility these are great numbers. Patients were on
average 64 years old and had 50 packyears. The majority of participants were male, were
relatively experienced with using a smartphone and had severe COPD (GOLD III) (Table 1).

Figure 1. Flowchart of the recruitment process and the following dropout.

Table 1. Descriptive statistics of study participants.

Characteristic Mean ±SD Range (minimum –
or N maximum) or
frequency (%)
Age 64.1 ± 9.3 52 - 79
Male 12 75 %
Female 4 25 %
Weight 90.7 kg ± 52 – 145 kg
30
Pack Years 50 ± 19 25 – 102
Gold Stage
II (moderate) 4 25 %
III (severe) 9 56.3 %
IV (very severe) 3 18.8 %
Charlson comorbidity 4 ± 1.8 2–7
index
Smartphone experience
Experienced 8 61.5%
Novice 3 23.1%
No experience 2 15.4%

10
Feasibility
In general patients were happy to participate with 4 out of 22 patients declining to participate
in the study (Figure 1). The main reason for declining being that they found themselves too fit
to participate. Both patients who were not eligible were recovering after an exacerbation and
were not fit enough to attempt exercise.
Sixteen out of twenty-two patients contacted were willing to participate, resulting in a73%
participation rate. During the study three patients dropped out, accounting for 18.7% of the
participating patients. Two of these patients had to stop due to illness and one stopped because
he did not deem the program to be sufficiently beneficial to him.

Acceptability
Patients’ satisfaction with home-based pulmonary rehabilitation was evaluated with a mark
between 0 and 10, furthermore patients were also asked to give a mark between 0 and 10 for
the ease of use. The average satisfaction was 7.54 and ease of use had a mean of 6.85. (Table
2). All patients said that they would recommend others to participate in the tele revalidation
program, two out of 13 would recommend it but it had to become easier to use. Patients
satisfaction was a significant predictor of the average days of revalidation (P=0.011).
Surprisingly ease of use was not associated with average days of revalidation (P=0.94).

Table 2 Acceptability
Minimum Maximum Mean Std. Deviation
Ease of use 4 10 6,85 1,725
Average days of 1 7 3,23 2,048
revalidation.
Patients satisfaction with 6 9 7,54 1,050
pulmonary
rehabilitation

Another factor that determines acceptability of a revalidation method is the adherence to the
program. With adherence defined as performing 30 minutes of exercise at least three days a
week, 8 out of 13 patients (61.5%) fulfilled this criterion. One of the main reasons given by
patients for not meeting the exercise criteria was an exacerbation of their COPD, with 3 out of
the 5 patients who did not meet the criteria needing treatment. The minimum days rehabilitated
was one day and the maximum seven days (Table 2).
The last factor to keep in mind when looking into the acceptability of a way of rehabilitation is
the number of adverse events that occurred. During the twelve weeks of this study there were
no exercise related injuries nor any other adverse event like nausea, chest pain, shortness of
breath or a need to stop the exercise. Two patients briefly spent time in hospital for an
exacerbation of their COPD, unrelated to the performed rehabilitation, and continued
rehabilitation afterwards.

Exercise capacity and COPD related quality of life

Exercise capacity was measured by the distance travelled in meters during the 6MWT. As
normality could not be proven the Wilcoxon’s signed rank test was used to compare the results
of the 6MWT at baseline and after 12 weeks of use (Table 3). There was no significant
difference between baseline and 12 weeks into the program (P=0.075), not even when we
excluded people who did not meet the adherence criteria (P=0.499). An upward trend (mean
increase of 24m ± 47) was seen in the general exercise capacity, as shown in figure 2.

11
Figure 2. Graphic display of the difference in the 6MWT per patient.

As previously mentioned are CCQ and the CAT two common tests used to assess the health
status and quality of life in patients with COPD. Using the Wilcoxon’s signed rank test, we
compared the results between the scores at baseline and at 12 weeks (Table 3). For both the
CCQ (P=0.575) and the CAT (P=0.293) no significant change occurred during the rehabilitation
program. When excluding the patients who did not exercise three or more days a week and thus
did not meet the adherence criteria these results do change (Table 3). Both the CCQ (P=0.035)
and the CAT (P=0.042) now show a significant decrease in scores, which correlates with an
overall better quality of life.
The last questionnaire used to assess the quality of life is the SGRQ, this is the most
comprehensive test of the three. The SGRQ showed comparable results to the CAT and the
CCQ but were more pronounced. The SGRQ was almost statistically significant when including
all patients (P=0.086). It became significant (P=0.012) when excluding the patients who did not
meet the adherence criteria (Table 3).

Table 3 Exercise capacity and quality of life.

Outcome Baseline 12 weeks ∆ baseline P value P value for
measure mean ± mean ± SD and 12 between patients meeting
SD weeks mean measurements adherence
± SD criteria.
6MWT 413 ± 109 437 ± 133 23.7 ± 47.3 0.075 0.499
CCQ 24.4 ± 11.1 23.2 ± 10.6 -1.2 ± 6.5 0.575 0.035
CAT 20.2 ± 6.4 17.8 ± 8.2 -2.4 ± 7 0.293 0.042
SGRQ 50.8 ± 15.5 45.6 ± 16.6 -5.2 ± 9.1 0.086 0.012

Analyses of correlation of the aforementioned outcome measures and age, gender and COPD
stage did not show a significant correlation. The only clinically significant correlation was
between adherence to the rehabilitation program and an increase in the 6MWT (P=0.03) and a
decrease in the CCQ (P=0.011).

12
Discussion
In this pilot study, the acceptability and feasibility of a home-based pulmonary rehabilitation
program were investigated in Isala hospital. A secondary goal was to assess the effectiveness
of the rehabilitation program on exercise capacity and quality of life.
Regarding our main goal of assessing the acceptability and feasibility we have shown that 73%
of all patients contacted were willing to participate, and that overall patient satisfaction was
good, represented by an average patient rating of 7.5 out of 10. Additionally, patients were
content with the ease of which they could communicate with their healthcare provider. The
main downside reported were the technical difficulties experienced with the heart rate monitor.
The monitor sometimes stopped registering the activity, but because of an easy to reach
customer service, all problems could be solved remotely and without the need for the patient to
travel. While participating in the rehabilitation program, none of the patients recorded any
adverse events.
The high participation and satisfaction shown is in accordance with a similar study by Paneroni
et al. In their study they had a comparable participation rate of 82% and a high patient’s
satisfaction, with 67% of all patients rating the program as very good and 88% willing to
recommend the program to other patients. The group characteristics in both studies are similar,
with a male predominance, COPD gold III being the most frequent classification and a mean
age difference of three years. The main differentiation between our study and the study by
Paneroni et al. is that we performed a within-group analysis of tele-rehabilitation and Paneroni
et al. compared tele-rehabilitation versus normal in-hospital rehabilitation (18).
Adherence to rehabilitation is a substantial barrier to successful pulmonary rehabilitation, as
identified in the systemic review by Keating et al. (9). This is made clear by the fact that just
below 50% of all participants finish their prescribed standard care pulmonary rehabilitation
programs (19). With this study showing a 63% adherence rate, we improve upon this number,
but the adherence rate is still far from optimal and needs further improvement.
In similar pulmonary tele-rehabilitation studies adherence rates were higher, with an adherence
between 70 to 90% (11,18,20,21). The best adherence is seen in studies that use a personalized
exercise program for participants and perform weekly electronic checkups (11,18,20,21). The
reason for the adherence in this study being lower than in these studies could be because of a
lack of a personalized exercise program, or because the study took place during a flu epidemic
in the Netherlands (22), accounting for a considerable number of missed exercise days.
Our secondary goal was to assess the effectiveness of our home-based pulmonary rehabilitation
program on exercise capacity and quality of life. Our results regarding the effectiveness show
a trend of an improving exercise capacity and quality of life in participating patients.
This improvement in exercise capacity is shown by an upward trend in the 6MWT of 24m ±
47.3. According to a 2010 study by Puhan et al. this is just short of being clinically noticeable
by patients, they have shown that an increase of 26m ± 2 is the minimal improvement needed
for a patient to notice a difference in exercise capacity.(23) We could expect a clinical
significant improvement when this study were to be continued for a longer duration of time.
The improvement in quality of life is mainly shown by an improvement of -5.2 ± 9.1 in the
SGRQ, but is also significantly improved in both the CCQ (-1.2 ± 6.5) and CAT (-2.4 ± 7) when
taking adherence into account. The improvement of quality of life shown in these questionnaires
might not seem clinically significant, but they do seem promising when considering that the
duration of the program was only 12 weeks. Both the increase in the 6MWT and the quality of
life questionnaires are in concordance with other studies researching home-based tele-
rehabilitation (11,20,21,24). The aforementioned studies do differ from this study, in that they

13
compare tele-rehabilitation to usual care, but the interventions used and the patient population
are similar.
As mentioned above, these studies have similar ways of providing home-based tele-
rehabilitation, but there is a slight difference in the precise way of tele-monitoring, from using
only phone calls, to the use of webcams and mobile applications to monitor vital signs and
exercise (20). The current trend in telehealth applications seems to be having further built-in
functions to use the application to fill in questionnaires and communicate with the healthcare
provider, this to further decrease the need for patients to travel and decrease program costs.
When looking at the current usual care rehabilitation programs the effects of rehabilitation
diminish quickly, with the improved exercise capacity and quality of life diminishing after one
year and returning back to baseline after two years (25). This diminishing effect on the positive
effects of the rehabilitation program could also be a possible footnote to the increase in exercise
capacity found in most home-based tele-rehabilitation studies. We would expect that the results
achieved by tele-rehabilitation would take longer to fall back to baseline. Participants have been
given a structured way to be active at home, where they don’t rely on a group-setting, this would
make it easier to continue after the program has finished.
In a 1999 study by Foglio et al. they show that the mean SGRQ did not diminish after 12 months,
while the 6MWT and BORG scores did almost regress to pre-rehabilitation levels after 12
months (26). In contrast, a 2015 study by Grosbois et al. showed that the effects of home based
rehabilitation for both exercise capacity and quality of life remained after 6 (medium term) and
12 months (long term) (27). These contradicting results may be because of a different method
of tele-rehabilitation or because of an improvement in technology over the years, but it does
warrant further research into the long-term effects of pulmonary tele-rehabilitation.

Study limitations
While we have shown that home-based tele-rehabilitation is something that is acceptable and
feasible in Isala hospital, some limitation and biases could not be avoided. The main limitation
being the small sample size of our study. As a result of the small sample size individual
variances had a substantial impact on the results. An example being that one of the participants
just had inguinal hernia surgery before their 12-week 6MWT, resulting in an obvious decreased
result in the 6MWT because of inguinal pain during walking. Another limitation is a selection
bias that was created by only contacting patients who had already followed an in-hospital
rehabilitation program. The patients that already followed an in-hospital program are
presumably more inclined to participate in a rehabilitation study. This is because this group of
patients was already part of the 10% of COPD patients needing rehabilitation, that was
motivated enough to participate in a rehabilitation program. The selection bias was created
because inclusion would be quicker and COPD education would not be needed in the tele-
rehabilitation program, since this was already covered in the in-hospital program.
In our study there were no predetermined exercise plans given to patients. On the plus side this
made it easier for patients to adjust the kind of exercise to their level of fitness. The negative
side of this being that patients had less structure in their exercise and that some participants
may have also logged activities that were not as intensive as intended. Furthermore, not having
a predetermined exercise plan made it harder for the observer to coach the participants in their
exercises, since there was no plan to fall back on when addressing a participant’s adherence or
progress. Another plus of having a predetermined exercise plan is that you can more easily
compare results. When walking is a main part of the exercise plan it is useful to assess progress
by a 6MWT. Although when cycling is the main component of exercise, using a 6MWT could
give less progress then what the patient truly experiences. In that case a cycle endurance test
(CET) could be a better suited assessment, the CET has been previously used to assess exercise
capacity in COPD patients (20).

14
Communication and coaching was an important part of the support given to all participants
during the rehabilitation program. During this pilot study coaching was given by a doctor in
training with experience in motivational interviewing and exercise programming, but without
any specific training or experience with a pulmonary rehabilitation program. It could help to
increase adherence and overall patient satisfaction when a specifically trained medical
professional does the communication and coaching, for instance a nurse practitioner with
training in motivational interviewing and pulmonary rehabilitation.
What patients themselves put up as a limitation was the heartrate monitor that was used. As the
heart rate monitor measured heartrate on the chest, some patients found that it took too long to
put on. This was mostly the case for older males who wear a buttoned-up shirt and multiple
layers of clothing. Other complaints about the heartrate monitor were that it took some time to
connect with the phone’s Bluetooth, that it didn’t always connect and that the connection
sometimes got lost while doing exercise. The choice for a chest heartrate monitor was made
because this measures heart rate more accurately then a wrist heartrate monitor. In our opinion
this accuracy can be sacrificed for a more user-friendly way of measuring the heartrate, since
accuracy is not paramount when registering an activity. The main reason for registering the
heartrate being that we can guide a patient to exercise with an intermediately elevated heartrate,
this to ensure that the patient improves condition wise.
For further research we recommend a randomized controlled trial with a larger sample size, a
structured exercise plan given at baseline, heartrate monitoring via the wrist and an experienced
healthcare professional with training in motivational interviewing and pulmonary rehabilitation
performing all communication and coaching.

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Conclusion
We have shown that home-based pulmonary tele-rehabilitation is acceptable and feasible in
Isala hospital while also being an effective way to improve the overall quality of life in patients
who followed the program for 3 or more days a week. Furthermore, a promising upward trend
in an increased 6MWT was shown which bodes well for future tele-rehabilitation programs that
take longer than 12 weeks.
Tele-rehabilitation is an acceptable and feasible way in providing remote rehabilitation to
patients with moderate to severe COPD. With some minor improvements and all the technical
advances being made in telehealth, home-based pulmonary tele-rehabilitation seems like a
promising addendum to modern healthcare. There is however need for further research in the
form of a large randomized controlled trial to assess the effectivity, cost effectiveness and long-
term effects of mobile pulmonary tele-rehabilitation.

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