Physiological and psychological therapeutic effects of telerehabilitation treatment on patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis

Abstract

[Purpose] Chronic obstructive pulmonary disease is a progressive and fatal respiratory disease that affects older adults. Pulmonary rehabilitation improves symptoms and quality of life but faces barriers such as limited access. Telerehabilitation, enabled by technology, offers remote, personalized care and may overcome these barriers. Although its effectiveness is well-documented, it remains unclear whether telerehabilitation is superior or inferior to face-to-face rehabilitation in chronic obstructive pulmonary disease treatment outcomes. This study aimed to systematically compare telerehabilitation and face-to-face rehabilitation in patients with chronic obstructive pulmonary disease. [Methods] We searched five databases for randomized controlled trials on telerehabilitation for chronic obstructive pulmonary disease from 2003 to 2024. Studies were screened by pre-defined criteria, and quality was assessed using the Physiotherapy Evidence Database scale. Data were analyzed using RevMan 5.4 software. [Results] Eighteen randomized controlled trials (3,108 patients) were included. Telerehabilitation was less effective in improving lung function (six minute walk test) but slightly better in reducing dyspnea and symptoms (modified Medical Research Council score and chronic obstructive pulmonary disease assessment test). It was less effective for quality of life but significantly better at alleviating depression and anxiety. [Conclusion] Both methods effectively alleviated chronic obstructive pulmonary disease. Telerehabilitation may better reduce breathing difficulties and negative emotions, offering an alternative to face-to-face rehabilitation.

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a significant cause of chronic illness and mortality¹⁾. In global terms, according to the 2014 World Health Organization (WHO) report, COPD has become the third leading cause of death²⁾, and estimated to affect over 380 million people³⁾, with prevalence ranging from 7.38% to 12.64% among individuals over 40 years old⁴⁾. Affected patients commonly experience symptoms such as reduced physical capacity, impaired lung function, and difficulty in breathing⁵⁾, and have lower levels of physical activity than healthy individuals⁶⁾. A previous study has shown that reduced levels of physical activity levels increase the risk of all-cause mortality in COPD patients⁷⁾. In addition, because many of the symptoms of COPD are chronic and cannot be completely cured, patients often experience psychological disorders such as depression and anxiety due to factors like long-term breathing difficulties and sleep disturbances⁸⁾. It has been demonstrated that the prevalence of severe depression and anxiety caused by chronic diseases is two to three times higher in these patients than in those with other conditions⁹⁾. Therefore, finding methods to improve their physical activity levels and quality of life is crucial.

It has been demonstrated that in addition to significantly improving their physical capacity, rehabilitation also enhances the quality of life and health status of patients with COPD. The exercise training included in pulmonary rehabilitation plays a key role in alleviating breathlessness and improving physical fitness^10,11,12). When the symptoms of COPD patients are alleviated, psychological disorders such as depression and anxiety are also relieved to some extent, further improving QOL and creating a positive feedback mechanism¹³⁾. With the development of information technology, mobile phones, computers, tablets, and other technological devices have gradually become a part of people’s daily lives, and enabled remote rehabilitation healthcare to be provided for patients at home^{14, 15)}. At the same time, factors such as the aging population and the inconvenience of traveling to the hospitals have led more and more patients with COPD to choose remote rehabilitation healthcare as an alternative to traditional rehabilitation treatments, which are usually provided only in hospitals or rehabilitation centers¹⁶⁾. This approach has been shown to significantly alleviate pressure on medical resources, while also increasing patients’ satisfaction and compliance with rehabilitation treatments^{17, 18)}.

There are two main objectives of this systematic review. First, to investigate whether telerehabilitation has the same effect as face-to-face rehabilitation in improving physical activity and alleviating symptoms such as breathlessness in COPD patients, to verify the accuracy of the previous research findings that “both remote and traditional rehabilitation therapies are effective in improving lung function in COPD patients, with similar efficacy”^{19, 20)}. Second, to explore whether telerehabilitation effectively alleviates psychological disorders such as depression and anxiety in these patients.

METHODS

We conducted a comprehensive search (Keywords used in the literature search are given in Supplementary Table 1) across the following five databases: PubMed, Medline, Cochrane Library, Scopus, and Cumulated Index in Nursing and Allied Health Literature (CINAHL). The search was limited to articles published in the English language between January 2003 and December 2024.

Our systematic review included randomized controlled trials (RCTs) involving patients diagnosed with COPD through the Global Initiative for Chronic Obstructive Lung Disease (GOLD), who received either telerehabilitation interventions (e.g., telemedicine, telecare, teleconsultation, telehealth) as the experimental group, or face-to-face rehabilitation as the control group. In comparison of the effect on the symptoms of COPD patients between telerehabilitation and face-to-face rehabilitation treatments, both physiological and psychological factors were considered. The physiological, assessment was based on the 6 Minute Walking Test (6MWT), modified Medical Research Council Dyspnea Scale (mMRC), and COPD Assessment Test (CAT). The psychological assessment was conducted using depression status, anxiety status, and quality of life (QOL) indicators. All RCTs included in this review contained at least one evaluation measure.

Excluded from the review were duplicate studies and those that were not RCTs. Among the remaining published RCTs, the following exclusion criteria were applied: non-original articles; the participants were not COPD patients or included patients other than COPD patients; telerehabilitation was not used as an experimental intervention; lack of alignment with the research topic; lacking the full text; and provision of an experimental protocol without experimental results, among other criteria.

The outcomes of interest were cardiopulmonary function (measured by 6MWT), degree of breathlessness (measured by mMRC), health status (measured by CAT), depression status (measured by the Hospital Anxiety and Depression Scale [HADS]), anxiety status (measured as General Anxiety Disorder Score [GADS]), and the patient’s daily life and general life satisfaction (measured as QOL).

The quality of the initially selected studies was assessed using the PEDro scale, which consists of 11 criteria. One point is awarded for each criterion met, to give a maximum score of 11. Two reviewers conducted a quality assessment of the initially screened papers. Studies that received a PEDro score of ≤6 from both reviewers were not included in the review.

Review Manager (Rev. Man.) [Computer program] Version 5.4 was used to conduct the meta-analysis. Mean difference (MD) or standard mean difference (SMD) with 95% confidence interval (CI) and the corresponding p-value were used to determine treatment effect between the groups. Unless otherwise specified, a p-value of <0.05 was considered statistically significant²¹⁾. Heterogeneity was evaluated using the I² statistic. A higher degree of heterogeneity indicated decreased reliability of the experimental results.

RESULTS

The search of the five databases identified 598 articles. After the screening by the exclusion criteria, a total of 18 articles were finally included^{22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39)} (Fig. 1).

Fig. 1.

Flowchart of all studies.

CINAHL: cumulated index in nursing and allied health literature; COPD: chronic obstructive pulmonary disease; RCT: randomized controlled trial.

The 18 analyzed studies included 3,108 participants, aged predominantly between 65 and 80 years. The experimental group (n=1,545) received telerehabilitation interventions, while the control group (n=1,334) was provided with face-to-face rehabilitation. Physiological symptoms were monitored through three indicators: 6MWT, mMRC, and CAT; and psychological symptoms were monitored mainly through depression status, anxiety status, and QOL. Characteristics of the included studies are given in Supplementary Table 2.

The mean PEDro score for 18 studies was 8.83. None of the 18 articles failed to meet the screening criteria, and each RCT paper achieved a PEDro score of at least 6. Hence 18 articles were included in the final experimental analysis. The PEDro scores for 18 selected studies are given in Supplementary Table 3.

Ten out of the 18 studies (total participants, 1,039) investigated the impact of telerehabilitation on the 6MWT scores of patients with COPD (Fig. 2). Participants were distributed between the experimental and control groups. Data analysis showed no heterogeneity (I²=0%, p=0.66), indicating that compared to telerehabilitation, face-to-face rehabilitation is more effective in improving physiological functions such as cardiopulmonary function in COPD patients. [MD=−13.85, 95% CI (−24.66, −3.04), p=0.01].

Fig. 2.

Forest plot of impact of treatment type on 6MWT score.

6MWT: 6 minute walking test.

Seven studies (total participants, 1,277) investigated the impact of telerehabilitation on the mMRC dyspnea scale of patients with COPD (Supplementary Fig. 1). Participants were distributed between the experimental and control groups. Data analysis revealed heterogeneity (I²=53%, p=0.05). Although statistical marginally significant, the results indicate that telerehabilitation is more effective than face-to-face rehabilitation in alleviating breathing difficulties in COPD patients [MD=0.18, 95% CI (−0.00, 0.37), p=0.05].

Eight studies (total participants, 843) investigated the impact of telerehabilitation on the CAT scores of patients with COPD (Supplementary Fig. 2). Participants were distributed between the experimental and control groups. Data analysis revealed heterogeneity (I²=19%, p=0.28), indicating that compared to face-to-face rehabilitation, telerehabilitation can better reduce the severity of COPD [MD=1.24, 95% CI (0.11, 2.37), p=0.03].

Seventeen studies (total participants, 2,829) investigated the impact of telerehabilitation on QOL associated with COPD (Supplementary Fig 3). Participants were divided into experimental and control groups. As the studies used disparate measurement instruments, we employed SMD to standardize the experimental criteria, p=0.81 is not significant. Although data analysis failed to detect significant heterogeneity (I²=59%, p=0.001), indicating that there is little difference in impact on the QOL of COPD patients between telerehabilitation and face-to-face rehabilitation, but there is a tendency for telerehabilitation to have a better effect on improving QOL [SMD=−0.02, 95% CI (−0.15, 0.11), p=0.81].

Eight studies (total participants, 1,513) assessed the impact of telerehabilitation on the alleviation of depression in patients with COPD (Supplementary Fig. 4). Participants were distributed between the experimental and control groups. As the studies used disparate measurement instruments, we employed SMD to standardize the experimental criteria. Data analysis failed to detect significant heterogeneity (I²=25%, p=0.23), indicating that the variation across studies was relatively low. The results suggest that telerehabilitation is significant and more effective than face-to-face rehabilitation in alleviating depressive symptoms in COPD patients [SMD=0.16, 95% CI (0.03, 0.29), p=0.02].

Nine studies (total participants, 1,630) investigated the efficacy of telerehabilitation in alleviating anxiety associated with prolonged physical discomfort in patients with COPD (Fig. 3). Participants were divided into experimental and control groups. As the studies used disparate measurement instruments, we employed SMD to standardize the experimental criteria. Data analysis revealed no significant heterogeneity (I²=0%, p=0.87), indicating consistent results across studies. The findings suggest that telerehabilitation is significantly more effective than face-to-face rehabilitation in reducing anxiety in patients with COPD [SMD=0.22, 95% CI (0.12, 0.32), p<0.001].

Fig. 3.

Forest plot of impact of treatment type on anxiety.

DISCUSSION

This review explored differences in treatment effects between face-to-face rehabilitation and telerehabilitation of COPD patients in terms of their physiological and psychological symptoms.

The 6MWT is widely utilized to assess cardiopulmonary function and the capacity to perform moderate- to high-intensity activities in daily life, as well as to evaluate disease severity and treatment efficacy in conditions such as COPD and heart failure. In this meta-analysis of 10 RCTs, face-to-face rehabilitation was found to be more effective than telerehabilitation in improving cardiopulmonary function among COPD patients⁴⁰⁾. However, some individual studies, including that by Stickland et al., reported no significant differences between these two rehabilitation modalities⁴¹⁾. One plausible explanation for the reduced efficacy of telerehabilitation is the need to lower exercise intensity to ensure patient safety during remote sessions, which may limit physiological gains^{42, 43)}. Furthermore, incomplete adherence to testing protocols by participants during telerehabilitation and the presence of patients who show lung function improvement without significant endurance enhancement may also contribute to this finding⁴⁴⁾.

The mMRC Dyspnea Scale is frequently used to evaluate the severity of breathlessness in COPD patients, aiding clinicians in optimizing treatment strategies⁴⁵⁾. Analysis of seven RCTs in this study revealed no statistically significant difference in dyspnea improvement between telerehabilitation and face-to-face rehabilitation, though telerehabilitation showed a slight advantage. Previous research by Bonnevie et al. indicated that telerehabilitation may improve dyspnea more effectively than conventional care⁴⁵⁾, potentially due to its ability to offer personalized guidance tailored to individual patient needs⁴⁶⁾. Additionally, telerehabilitation’s integration into patients’ daily routines facilitates better adherence compared to face-to-face programs, which require travel and fixed schedules¹⁶⁾.

The CAT serves as a comprehensive tool to evaluate symptom severity, physical activity levels, sleep quality, and overall health status in COPD patients⁴⁷⁾. Our meta-analysis of eight RCTs demonstrated that telerehabilitation was more effective than traditional face-to-face rehabilitation in improving patients’ overall health status as measured by CAT scores. These results are consistent with findings by Michaelchuk et al., who reported significant CAT score improvements following remote pulmonary rehabilitation⁴⁸⁾. The enhanced effectiveness of telerehabilitation may be attributed to individualized rehabilitation plans and the continuous monitoring and support enabled by remote technologies, which promote better patient engagement and adherence⁴⁶⁾.

The QOL assessments provide insights into the broader impact of disease and treatment on patients’ satisfaction with daily living⁴⁹⁾. This study found no significant difference in QOL outcomes between telerehabilitation and face-to-face rehabilitation, although face-to-face methods exhibited a slight tendency towards greater improvement. Prior studies by Galdiz et al. support these findings, showing comparable QOL improvements with both approaches^{29, 36)}. Despite this, telerehabilitation’s effectiveness in enhancing physical activity and reducing breathlessness contributes positively to QOL⁴⁶⁾. However, the complexity of equipment and procedures required for telerehabilitation can pose barriers for some patients, leading to frustration and preference for conventional face-to-face rehabilitation⁵⁰⁾. Simplifying technological interfaces and offering personalized support are essential for increasing telerehabilitation’s accessibility and effectiveness in future implementations.

COPD patients often experience physiological changes such as airway narrowing, leading to breathing difficulties that can disrupt sleep and cause psychological issues including anxiety and depression⁵¹⁾. These mental health conditions are known to increase acute exacerbations and hospitalizations, further diminishing patients’ quality of life⁵²⁾. Both telerehabilitation and face-to-face rehabilitation have demonstrated efficacy in alleviating respiratory symptoms^{24, 25, 38)}. However, earlier limitations in telecommunication technologies and subjective psychological assessments have made it difficult to definitively compare their effectiveness in reducing anxiety and depression. Our results indicate that both modalities effectively reduce negative emotions, with telerehabilitation showing markedly superior outcomes compared to conventional care. This advantage may be explained by the reduced stress of home-based rehabilitation, absence of hospital visits, and family support during treatment, which collectively mitigate anxiety and depressive symptoms^53,54,55). Given that most study participants were elderly with an average age of approximately 65 years, factors such as reduced mobility and immunosenescence increase the risks and anxiety associated with hospital visits, further supporting the benefits of telerehabilitation in this population^{56, 57)}.

Overall, while telerehabilitation was less effective than face-to-face rehabilitation based on the 6MWT, it demonstrated superior physiological and psychological benefits, particularly in alleviating depression and anxiety. These findings suggest that telerehabilitation represents a valuable alternative or complement to traditional rehabilitation, especially for elderly COPD patients with limited mobility. Ultimately, effective symptom management through personalized rehabilitation remains paramount, emphasizing the importance of tailoring treatment modalities to individual patient needs and preferences.

Variability in telerehabilitation delivery methods, including video conferencing and real-time communication, as well as the diversity of assessment tools for psychological outcomes and QOL, may have introduced heterogeneity and affected the robustness of our findings. Additionally, this meta-analysis did not stratify patients by COPD severity, limiting the ability to generalize results across all disease stages. Future research should focus on standardizing telerehabilitation protocols and evaluating its efficacy in patients with varying COPD severity to further validate and refine its clinical application.

Ethics

The present study does not require any ethics approval.

Funding

It is supported by a Grant-in-Aid for Scientific Research (C)No.23K08609, 2023-2025 From the Japan Society for the Promotion of Science.

Conflict of interest

None.