Effect of telemonitoring and telerehabilitation on physical activity, exercise capacity, health-related quality of life and healthcare use in patients with chronic lung diseases or COVID-19: A scoping review

Abstract

Background

Telemonitoring and telerehabilitation can support home-based pulmonary rehabilitation (PR) and benefit patients with lung diseases or COVID-19. This study aimed to (1) identify which telemonitoring and telerehabilitation interventions (e.g. videoconferencing) are used to provide telehealth care for people with chronic respiratory conditions or COVID-19, and (2) provide an overview of the effects of telemonitoring and telerehabilitation on exercise capacity, physical activity, health-related QoL (HRQoL), and healthcare use in patients with lung diseases or COVID-19.

Methods

A search was performed in the electronic databases of Ovid MEDLINE, EMBASE, and Cinahl through 15 June 2021. Subject heading and keywords were used to reflect the concepts of telemonitoring, telerehabilitation, chronic lung diseases, and COVID-19. Studies that explored the effect of a telerehabilitation and/or telemonitoring intervention, in patients with a chronic lung disease such as asthma, chronic obstructive pulmonary diseases (COPD), or COVID-19, and reported the effect of the intervention in one or more of our outcomes of interest were included. Excluding criteria included evaluation of new technological components, teleconsultation or one-time patient assessment.

Results

This scoping review included 44 publications reporting the effect of telemonitoring (25 studies), telerehabilitation (8 studies) or both (11 studies) on patients with COPD (35 studies), asthma (5 studies), COPD and asthma (1 study), and COVID-19 (2 studies). Patients who received telemonitoring and/or telerehabilitation had improvements in exercise capacity in 9 out of 11 (82%) articles, better HRQoL in 21 out of 25 (84%), and fewer health care use in 3 out of 3 (100%) articles compared to pre-intervention. Compared to controls, no statistically significant differences were found in the intervention groups’ exercise capacity in 5 out 6 (83%) articles, physical activity in 3 out of 3 (100%) articles, HRQoL in 21 out of 25 (84%) articles, and healthcare use in 15 out of 20 (75%) articles. The main limitation of the study was the high variability between the characteristics of the studies, such as the number and age of the patients, the outcome measures, the duration of the intervention, the technological components involved, and the additional elements included in the interventions that may influence the generalization of the results.

Conclusion

Telemonitoring and telerehabilitation interventions had a positive effect on patient outcomes and appeared to be as effective as standard care. Therefore, they are promising alternatives to support remote home-based rehabilitation in patients with chronic lung diseases or COVID-19.

Introduction

Chronic lung diseases and COVID-19 are leading causes of disease, death and disability globally^1–4 which entail a substantial burden on the individual^5–7 and healthcare systems.^8,9 Pulmonary rehabilitation (PR) is defined by the “National Heart, Lung, And Blood Institute” as a “supervised program that includes exercise training, health education, and breathing techniques for people who have certain lung conditions or lung problems due to other conditions” ¹⁰ is widely recognized as an important treatment for patients suffering from chronic respiratory diseases,^11,12 and has been recommended as a potential beneficial intervention for post-COVID-19 patients. ¹³ PR has been shown to provide statistically and clinically significant improvements in physical activity, exercise capacity, self-efficacy, and health-related quality of life (HRQoL), and a decrease in healthcare use in patients with lung diseases.^11,14 Despite the multiple benefits identified, it has been estimated that less than 3% of people with chronic lung diseases accessed PR programs ¹⁵ which are also hampered by low participation, insufficient attendance, and high dropout rates.^16–19 Home-based PR programs seem to offer a promising alternative^20,21 to overcome well-known PR barriers including, but not limited to, symptom severity, acute exacerbations, transportation, financial difficulties, disruption of daily routines and access to care in remote locations.^{17,18,22–25} In addition, the COVID-19 pandemic has highlighted the need for delivering PR programs remotely, safely, and efficiently. ¹⁵

Advances in technology have boosted at-home health service delivery^26,27 and popularized telehealth for those with chronic diseases.^27–30 Telehealth can be described as the use of electronic information and communication technology by professional health care providers to provide and support at-home health care to patients in case of long distances. ³¹ Evidence indicates that telehealth can enhance healthcare use,^32,33 especially among the populations who cannot otherwise access care. ³⁴ There are several terms used to describe telehealth systems based on their applications. Telerehabilitation is defined as the delivery of rehabilitation services (e.g. assessment, prevention, treatment, education, and counseling) via information and communication technologies. ³⁵ It has been associated with lower healthcare costs compared with traditional inpatient or person-to-person rehabilitation.^36,37 Recent advances in sensor technology have also enabled remote patient telemonitoring, which is the transmission of physiological and other noninvasive data (e.g. heart rate, blood pressure, oxygen saturation, weight, symptoms, etc.) directly to care providers via Bluetooth or digital/broadband/wireless.^36,38 Telemonitoring can be used to recognize and treat changes in the patient's health status as a stand-alone approach (e.g. early detection) or as part of a telerehabilitation intervention. This paper focuses on telemonitoring and telerehabilitation as types of telehealth that can support home-based PR and benefit patients with lung diseases or COVID-19. The purpose of this paper is to depict the use of telemonitoring and telerehabilitation interventions in patients with chronic lung diseases, such as asthma, chronic obstructive pulmonary diseases (COPD), or COVID-19 patients and their association with patient health outcomes. The objectives of this paper were to (1) identify which telemonitoring and telerehabilitation interventions (e.g. videoconferencing) are used to provide telehealth care for people with chronic respiratory conditions or COVID-19, and (2) provide an overview of the effects of telemonitoring and telerehabilitation on exercise capacity, physical activity, HRQoL, and healthcare use in patients with lung diseases or COVID-19.

Methods

A health sciences librarian (HL), in consultation with the research team, developed and performed a search in the electronic databases of Ovid MEDLINE, EMBASE, and Cinahl through 15 June 2021. Subject heading and keywords were used to reflect the concepts of telemonitoring, telerehabilitation, chronic lung diseases, and COVID-19 (see supplement 1 for the OVID Medline search). The search was limited to full-text articles published in the English language with full text available. This scoping review of the literature, which has not been registered, was conducted using Preferred Items for Systematic Reviews and Meta-Analysis (PRISMA) (Figure 1). The search retrieved 3013 references. After removing the duplicates, two researchers screened 2941 titles and abstracts and read in full the text of 227 articles. Both researchers reviewed independently the articles and selected 44 publications that met the inclusion criteria of (1) the study explored the effect of a telerehabilitation and/or telemonitoring intervention, (2) in patients with a chronic lung diseases, such as asthma, COPD, or COVID-19 patients, (3) and reported the effect of the intervention in one or more of the following outcomes: exercise capacity, physical activity, HRQoL, or healthcare use. The main reasons for exclusion of the studies included: (1) the study aimed to validate a new technological component instead of evaluating an intervention, (2) the intervention was only teleconsultation or one-time assessment, or the effect of the intervention in one of the (3) populations or (4) outcomes of interest were not reported.

Fig. 1.

PRISMA—Literature selection process.

Data extraction and synthesis

Information from the 44 articles was summarized in Table 1, which presented: (1) author(s)’ name, (2) country of the study, (3) type of study, (4) intervention group and control group, (5) technology used in the study, (6) duration of the intervention, (7) participants’ condition, and (8) description of the study population. The effect of telemonitoring and telerehabilitation on physical activity, exercise capacity, health-related quality of life and healthcare use in patients with chronic lung diseases or COVID-19 was extracted and compiled in Tables 2–4.

Table 1.

Main characteristics of the studies included.

Author Year Country	Type of study	Intervention Group (IG) Control Group (CG)	Technology	>1 Monitoring devices involved (Yes/no)	Duration of the intervention	Disease	Intervention group			Control group
							Number of participants	Age mean years (SD)	Males N (%)	Number of participants	Age Mean years (SD)	Males N (%)
Telemonitoring
Antoniades, Nick 2012 39	RCT	IG: Remote In-home monitoring (TeleMedCare) + standard best practice. CG: Standard best practice	Laptop (software), daily monitoring spirometry, vital functions, oximetry, etc.	Yes	12 Months	COPD	22	70 (10)	10 (83)	22	68 (9)	10 (83)
Australia
Au, David 2015 40	Matched group design (1:1)	IG: Telehealth system combined with care management program (Health Buddy Program) CG: Matched to similar baseline characteristics	Four button Health Buddy device; asks for vital signs, disease symptoms, provides feedback, and categorizes patient's medical risk.	No	3 Years	COPD	619	75 (8)	338 (55)	619	74 (10)	338 (55)
USA
Boer, Lonneke 2019 41	RCT	IG: Smart mobile health tool for self-management (mHealth tool). CG: Paper action plan	Mobile phone (app), collected information on symptom changes and physiological measurements using a pulse oximeter, spirometer, and forehead thermometer.	Yes	12 Months	COPD	43	69 (8)	25 (58)	44	65 (8)	29 (66)
Netherlands
Chan, Debora 2007 42	RCT	IG: Internet-based home monitoring and education. CG: Office-based care	Home computer (website), camera and internet access. Digital video camera to capture patient's performance.	No	52 Weeks	Asthma	60	10 (3)	38 (63)	60	9 (3)	37 (62)
USA
Chau, Janita 2012 43	RCT	IG: Telecare service (ASTRI) + nurse home visit (education) CG: Only nurse home visit (education)	Mobile phone, respiratory rate sensor, pulse oximeter. Internet and wireless systems, databases and software for critical decision analysis, and support.	Yes	2 Months	COPD	22	73 (6)	21 (95)	22	72 (6)	18 (82)
Hong Kong
Cushen, Brenda 2021 44	Pre-post	GI: Community virtual ward model (patient information transferred to hospital portal)	Bluetooth-enabled smartphone and hospital portal. Remote monitoring of daily oxygen saturations, heart rate, and spirometry measurements.	Yes	Mean 10 (4) days admission to discharge	COPD and/or asthma	20	64 (13)	7 (35)	N/A	N/A	N/A
Ireland
de Jongste, Johan 2009 45	RCT	GI: Daily telemonitoring of exhaled nitric oxide  +  monitoring symptoms CG: Symptoms monitoring only	PalmOne, airway inflammation monitor (NIOX MINO; Aerocrine, Solna, Sweden) that measures FENO0.05	No	30 Weeks	Asthma	77	11 (2)	46 (60)	74	11 (4)	54 (73)
Netherlands
Deng, Ning 2020 46	Pre-post	GI: Mobile health technology to deliver a community-based closed-loop management system (app)	MHealth system: smartphone (patient app), workstation (doctor), a cloud server, and a simple peak flow meter.	No	6 Months	COPD	39	61 (6)	36 (92)	N/A	N/A	N/A
China
Ding, Hang 2014 47	Pre-post	GI: A mobile-phone-based home monitoring system (app)	Mobile phone to record COPD symptoms and vital signs on portal. Thermometer, pulse oximeter.	Yes	6 Months	COPD	10	65 (9)	5 (50)	N/A	N/A	N/A
Australia
Farias, Raquel 2019 48	Pre-post	GI: Phone interactive telesystem (computer-linked interactive phone telesystem)	Card (PIN) and the Telesystem contact information with automated phone call questions and a callback notification.	No	12 Months	COPD	256	70 (9)	117 (46)	N/A	N/A	N/A
Canada
Farmer, Andrew 2017 49	RCT	GI: Digital health system (EDGE, Self-management, anD support prorGrammE). CG: Standard care	EDGE platform, tablet, and Bluetooth-enabled oximeter.	No	12 Months	COPD	110	69 (9)	68 (62)	56	69 (10)	34 (61)
UK
Jódar-Sánchez, Francisco 2013 50	RCT	IG: Home telehealth program (Tele-Modem, Aerotel Medical Systems) CG: Usual care.	Spirometer, a pulse oximeter, heart rate, blood pressure monitor (model UA-767 BT, A&D Company). Data sent via a hub (Tele-Modem, Aerotel Medical Systems) connected to the patient's home telephone line.	Yes	4 Months	COPD	24	74 (8)	23 (96)	21	71 (10)	20 (95)
Spain
Koff, Patricia 2021 51	Quasi-randomized clinical trial	IG: Proactive iCare (healthcare delivery model that couples integrated care with remote monitoring) CG: Usual care	Health buddy, finger pulse oximeter, handheld spirometer and pedometer.	Yes	9 Months	COPD	352	68 (8)	205 (58)	159	68 (9)	106 (67)
USA
Lewis, Keir E 2010 52	RCT	IG: Home telemonitoring (telemonitoring via the home telephone line)  +  standard care CG: Standard care	Handheld telemonitor connected via telephone line, thermometer, and pulse oximeter probe connected to the monitor.	Yes	6 Months	COPD	20	70 (range 61–73)	10 (50)	20	73 (range 63–79)	10 (50)
UK
McDowell, Janet 2015 53	RCT	IG: Home-based healthcare with telemonitoring (telecommunications device connected directly to patient's phone line) CG: Usual care	Home telehealth system (HomMed, Honeywell, USA) self-monitoring to record vital signs (finger probe and blood cuff) and answer questions.	Yes	6 Months	COPD	55	69 (7)	32 (58)	55	70 (7)	30 (54)
Ireland
Pare, Guy 2013 54	RCT	IG: Home telemonitoring (touchscreen, modem) CG: Regular home care visits.	Touch screen with an integrated modem (TELUSTM) to send clinical data.	No	21.5 Months	COPD	60	67 (6）	19 (32)	60	68 (6)	19 (32)
Canada
Pedone, Claudio 2013 55	RCT	IG: Multiparametric telemonitoring of vital signs CG: Standard care	Cellular telephone coupled with wristband containing Bluetooth sensors (heart rate, physical activity, body temperature, and a pulse-oximeter).	No	9 Months	COPD	50	74 (6)	36 (72)	49	75 (6)	31 (63)
Italy
Persson, Hans 2020 56	Cohort study	IG: Health Diary Telemonitoring and Hospital-Based Home Care (HBCH).	Digital pen and a Health Diary paper form to report daily health status.	No	12 Months	COPD	36	75 (6)	14 (39)	NA	NA	NA
Sweden
Pinnock, Hilary 2013 57	RCT	IG: Touch screen telemonitoring equipment + clinical care. CG: Clinical care.	Touchscreen Telemonitoring equipment to record and transmit daily questionnaires and monitor oxygen. Algorithms alerts.	No	12 Months	COPD	128	69 (8)	53 (41)	128	68 (8)	63 (49)
UK
Rasmussen, Linda 2005 58	RCT (3 groups)	IG: Internet-based monitoring asthma tool. CG1: Asthma specialist treatment CG2: General practitioner treatment	Internet diary or push-button phone. Peak flowmeter (Vitalograph, Ltd, Maid Moriton, Buckingham, United Kingdom).	No	6 Months	Asthma	85	28 (range 14–44)	27 (32)	CG1: 88 CG2:80	CG1: 30 (range 19–45) CG2:30 (range 20–45)	CG1: 30 (34) CG2: 30 (38)
Denmark
Schou, Lone 2013 59	RCT	GI: telemedicine-based treatment (videoconferencing system-daily ward rounds) CG: conventional hospital admission	Touch screen PC and additional devices (pulse oximeter, spirometer, and thermometer) for monitoring the vital signs.	No	3 Months	COPD	22	68 (12)	10 (45)	22	73 (10)	8 (36)
Denmark
Stamenova, Vess 2020 60	RCT (3 arms)	IG: Technology -Enabled remote monitoring program. CG1: Technology-Enabled Self-Management (web-based) CG2: Standard care	Web-based portal and Bluetooth devices: custom tablet computer pulse wave wrist cuff monitor, oximeter, weighing scale, and thermometer.	Yes	6 Months	COPD	41	71 (9)	23 (56)	CG1: 41 CG: 40	CG1: 71 (7) CG2: 72 (9)	CG1: 23 (56) CG2: 21 (52)
Canada
van Gaalen, Johanna 2013 61	RCT (multicenter nonblinded, pragmatic randomized controlled parallel trial)	IG: Internet-based self-management support. CG: Usual care.	Website platform. Handheld spirometer and reporting symptom score.	No	30 Months	Asthma	47	36 (8)	12 (26)	60	37 (8)	19 (32)
Netherlands
Vianello, Andrea 2016 62	RCT	IG: Home telemonitoring (Gateway device for data transmission over telephone) CG: Usual care	TM system: finger pulse-oximeter and a gateway device for data transmission over a telephone line to a central data management unit located at the Veneto Regional e-Health Centre.	No	12 Months	COPD	230	75 (6)	164 (71)	104	76 (6)	76 (73)
Italy
Zairina, Elida 2015 63	RCT	IG: Telehealth program CG: Usual care	Mobile application Breathe-easy© supported by a Bluetooth-enabled handheld device (COPD-6 R), which was used for self-monitoring of lung function.	No	6 Months	Asthma	36	31 (4)	0	36	31 (4)	0
Australia
Telerehabilitation
Bermejo-Gil, Beatriz 2021 64	Pre-post	IG: Home-based telerehabilitation system (RespiraCon Nosotros)	Web application for respiratory exercises and chat function for interaction compatible with computer, tablet, television, and mobile.	No	1 Month	COVID-19	15	range 28–38	8 (53)	NA	NA	NA
Spain
Burkow, Tatjana 2015 65	Pre-post	IG: PR in home-based online groups (videoconference)	Internet-based comprehensive, multidisciplinary pulmonary rehabilitation program  +  step counter.	No	9 Weeks	COPD	10	61 (range 46–72)	5 (50)	N/A	N/A	N/A
Norway
Hansen, Henrik 2020 66	RCT	IG: Pulmonary Telerehabilitation program (videoconference). CG: Conventional PR program	Videoconference software system installed on a single touch screen.	No	10 Weeks	COPD	67	68 (8)	32 (48)	67	68 (9)	28 (42)
Denmark
Yuyu 2020 67	RCT	IG: Pulmonary internet explorer Rehabilitation (PeR) program based on social media (WeChat) CG: Face-to-face PR rehabilitation	PeR includes two ports: the computer end and the WeChat end.	No	3 Months	COPD	53	70 (6)	44 (83)	53	71 (7)	43 (81)
China
Jiménez-Reguera, Begoña 2020 68	RCT	IG: mHealth Web-Based platform (HappyAir) CG: Hospital scheduled evaluations.	HappyAir app: educational program and data collection related to physical activity and disease, recording medication intake, daily exercise time (minutes), level of tiredness and daily mood.	No	12 Months	COPD	20	68 (6)	9 (41)	24	68 (7)	13 (59)
Spain
Lewis, Adam 2021 69	pre-post	IG: Online platform delivery of PR	E-learn Moodle platform (videoconference, messaging)	No	6 Weeks	COPD	17	69 (10)	8 (47)	NA	NA	NA
UK
Stickland, Michael 2011 70	RCT	IG: PR delivered via Telehealth CG: PR delivered in person (standard outpatient hospital-based program)	Videoconference	No	8 Weeks	COPD	147	69 (8)	78 (53)	262	69 (9)	125 (44)
Canada
Telemonitoring and telerehabilitation
Benzo, Roberto 2021 71	RCT	IG: Home-based program with video-guided exercises (website) + phone call health coaching* CG: Waiting list 8 weeks and the intervention was offered afterwards	Computer tablet: video-guided exercises using an oximeter, an activity monitor and daily self-report of symptoms.	Yes	8 Weeks	COPD	72	69 (8)	34 (47)	74	68 (9)	37 (50)
USA
Bhatt, Surya 2019 72	Matched group design (1:2)	IG: Telehealth PR (video conference) * CG: Contemporaneous subjects who had been hospitalized for a COPD exacerbation but did not receive the intervention	Smartphone with video capabilities to facilitate two-way live videoconferencing. Automatic sphygmomanometers (blood pressure), and a pulse oximeter (heart rate and oxygen saturation).	Yes	12 Weeks	COPD	80	64 (10)	49 (61)	160	63 (11)	92 (57)
USA
Broadbent, Elizabeth 2018 73	RCT	IG: iRobi robot (monitor health and prompt medical contact) CG: Standard care	Robot with Wi-Fi linked smart inhalers: (1) Measure pulse oximetry, forced expiration volume, heart rate, and symptoms, mental state, and functional status using the Clinical COPD Questionnaire (2) reminding medication and inhalers and record their adherence several times a day; (3) remind rehabilitation exercises (4) provide education about COPD; (5) I am feeling unwell function (6) trends over time health status and adherence.	No	4 Months	COPD	30	70 (10)	11 (37)	30	69 (9)	12 (40)
New Zealand
Galdiz, Juan 2021 74	RCT	IG: Pulmonary Telerehabilitation program (web-based platform) CG: Standard care	Web-based platform, and a telerehabilitation kit (mobile phone, pulse oximeter, dumbbells and exercise bicycle).	No	12 Months	COPD	46	62 (8)	30 (65)	48	63 (6)	33 (68)
Spain
Gilmutdinova, Ilmira R 2021 75	pre-post	IG: Telemedicine platform (COVIDREHAB)	A mobile phone, tablet or computer, an Internet connection and an e-mail address on this device. Platform: information and analytical system for remote monitoring of medical rehabilitation.	No	2 Weeks	COVID-19	178	50 (range 32–82)	70 (39)	NA	NA	NA
Russia
Holland, Anne 2013 76	Pre-post	IG: Telerehabilitation (video collaborative software)	A tablet computer was used for videoconferencing. A pulse oximeter (oxyhemoglobin saturation and heart rate).	No	8 Weeks	COPD	8	66 (range 56–83)	3 (38%)	NA	NA	NA
Australia
Marquis, Nicole 2015 77	Pre-post	IG: In-home PR (video conferencing system)	Videoconferencing system, internet connection with encrypted transmission. Wireless oximeter (oxygen saturation and heart rate).	Yes	6 Months	COPD	23	65 (7.1)	8 (35)	NA	NA	NA
Canada
Paneroni, Mara 2015 78	controlled, non-randomized pilot study	IG: Telerehabilitation (satellite platform) CG: Standard outpatient rehabilitation program	Home telemonitoring platform, medical devices (oximeter, steps counter)	Yes	40 Days	COPD	18	6 5(10)	16 (89)	18	66 (6)	15 (83)
Italy
Rassouli, Frank 2018 79	Observational (pre-post)	IG: Digital multidisciplinary PR (App)	Multiplatform smartphone application with exercise videos. Pedometer.	No	20 Days	COPD	34	59 (8)	8 (24)	NA	NA	NA
Switzerland, Austria, and Germany
Ringbaek, Thomas 2015 80	RCT	IG: Telehealth care (telemonitoring equipment) with the option of video consultation CG: Usual care	Tablet computer with a web camera, a microphone, and measurement equipment (spirometer, pulse oximeter, and bathroom scale).	Yes	6 Months	COPD	141	69 (9)	55 (39)	140	69 (10)	76 (54)
Denmark
Tsai, Ling 2017 81	RCT	IG: Home-based telerehabilitation (videoconferencing) CG: Usual care without exercise training	Computer with an in-built camera, and a finger-tip pulse oximeter.	Yes	8 Weeks	COPD	19	73 (8)	12 (63)	17	75 (9)	6 (86)
Australia
Vitacca, Michele 2009 82	RCT	IG: Tele-assistance program (modem system through telephone line) CG: Standard care	Pulse oximetry device with solid memory card  +  modem telephone.	No	12 Months	COPD	57	61 (7)	NR	44	61 (17)	NR
Italy

SD: standard deviation; PR: pulmonary rehabilitation; SBP: standard best practice; N/A: not applicable; NR: not reported.

Table 2.

Effect of telemonitoring and/or telerehabilitation on physical activity and exercise capacity in patients with lung diseases or COVID-19.

	Disease	Study	Exercise capacity			Physical activity
			IG change from pre-intervention	IG effect in comparison with CG	Instrument/tool used to assess the outcome	IG change from baseline	IG effect in comparison with CG	Instrument/tool used to assess the outcome
Telemonitoring	COPD	Koff, P. 2021 51	↑	↑	6MWT
Telerehabilitation	COVID-19	Bermejo-Gil, B. 2021 64	↑	NA	Borg scale
	COPD	Hansen, Henrik 2020 66	↑	=	6MWT, 30 s sit-to stand test	no	=	Triaxial accelerometer
		Stickland, M. 2011 70	↑	=	12 min walk test
		Lewis, A. 2021 69	↑	NA	1 min sit-to stand test
		Jiménez-Reguera, B. 2020 68	no	=	6MWT
Telerehabilitation and telemonitoring	COPD	Benzo, R. 2021 71				NR	=	ActiGraph
		Tsai, L. 2017 81	↑	↑	Endurance shuttle walk test	no	=	Triaxial accelerometer
			↑	=	6MWT
		Paneroni, M. 2015 78	↑	=	6MWT
		Holland, A. 2013 76	↑	NA	6MWT
		Marquis, N. 2015 77	↑	NA	6MWT
		Galdiz, J. 2020 74	no	=	6MWT

IG: Intervention group; CG: control group; 6MWT: 6-min walking test NA: not applicable. ↑: significantly better outcome; =: no significant difference in outcome change between groups. not reported. NR: data and/or significance level not reported.

Table 3.

Effect of telemonitoring and/or telerehabilitation on health-related quality of life and/or health status in patients with lung diseases or COVID-19.

	Disease	Study	Health-related quality of life (HRQoL) and/or health status
			IG change from pre-intervention	IG effect in comparison with CG	Instrument/tool used to assess the outcome
Telemonitoring	Asthma	Rasmussen, L. 2005 58	↑	↑ (than the 2 CGs)	Asthma-related quality of life (AQLQ)
		van Gaalen, J. 2013 61	↑	↑	AQLQ
		Zairina, E. 2015 63	↑	↑	mAQLQ (mini asthma quality of life questionnaire)
		de Jongste, J. 2009 45	↑	=	Pediatric asthma caregiver quality of life questionnaire (PACQLQ)
		Chan, D. 2007 42	↑	NR	Pediatric asthma quality of life questionnaires (PAQLQ) applied to caregiver
	COPD and/or asthma	Cushen, B. 2021 44	no	NA	EQ-VAS questionnaire
	COPD	Koff, P. 2021 51	↑	↑	SGRQ
		Farmer, A. 2017 49	↑	↑	EQ-5D-5L questionnaire
			↑	=	SGRQ
		Stamenova, V. 2020 60	↑	= (in the 3 groups)	SGRQ
		Deng, N. 2020 46	↑	NA	COPD assessment test (CAT)
		Antoniades, N. 2012 39	no	=	Chronic respiratory disease questionnaire (CRDQ), 36-Item short from survey (SF-36)
		Persson, H. 2020 56	no	NA	SGRQ
		McDowell, J. 2015 53	NR	↑	SGRQ
				=	EQ-5D questionnaire
		Boer, L. 2019 41	NR	=	EQ-5D questionnaire, Nijmegen clinical screening instrument (NSCI), Clinical COPD Questionnaire (CCQ)
		Chau, J. 2012 43	NR	=	Chronic respiratory questionnaire (CRQ)
		Jódar-Sánchez, F. 2013 50	NR	=	SGRQ, EuroQoL-5D questionnaire
		Lewis, K. 2010 69	NR	=	SGRQ, and EuroQoL EQ-5D questionnaire
		Pinnock, H. 2013 57	NR	=	SGRQ
		Schou, L. 2013 59	NR	=	SGRQ
		Vianello, A. 2016 62	NR	=	SF-36
Telerehabilitation	COPD	Stickland, M. 2011 70	↑	=	SGRQ
		Burkow, T. 2015 65	↑	NA	SGRQ
		Lewis, A. 2021 69	↑	NA	CRQ
		Rassouli, F. 2018 79	↑	NA	CAT, CRQ
		Jiang, Y. 2020 67	↑	=	CAT, SGRQ
		Jiménez-Reguera, B. 2020 68	↑	=	SGRQ
			no	=	CAT, EuroQOL-5D questionnaire
		Hansen, H. 2020 66	↑	=	Clinical COPD Questionnaire (CCQ)
			no	=	EQ-5D-VAS
Telerehabilitation and telemonitoring	COVID-19	Gilmutdinova, I. 2021 75	↑	NA	Survey (Overall well-being improved in 83% of the participants)
	COPD	Holland, A. 2013 76	↑	NA	CRQ
		Marquis, N. 2015 77	↑	NA	CRQ
		Paneroni, M. 2015 78	↑	=	SGRQ
		Tsai, L. 2017 81	↑	=	CAT
			no	=	CRDQ (Chronic respiratory disease Questionnaire)
		Benzo, R. 2021 71	NR	=	CRQ
		Broadbent, E. 2018 73	NR	=	CCQ
		Galdiz, J. 2020 74	no	=	SF-36, Chronic respiratory disease Questionnaire (CRQ)

IG: Intervention group; CG: control group. NA: not applicable. EQ-VAS: EuroQol-visual analogue scales; CAT: COPD assessment test; SGRQ: St George's Respiratory Questionnaire; CRQ: chronic respiratory disease questionnaire; ↑: significantly better outcome;  =: no significant difference in outcome change between groups. NR: data and/or significance level not reported.

Table 4.

Effect of telemonitoring and/or telerehabilitation on healthcare use in patients with lung diseases.

	Disease	Study	Healthcare use
			IG change from pre-intervention	IG effect in comparison with CG	Instrument/tool used to assess the outcome
Telemonitoring	Asthma	Chan, D. 2007 42	NR	=	Number of ED visits, hospitalizations, unscheduled asthma-related visits.
		Zairina, E. 2015 63	NR	=	Number of unscheduled health-care visits.
	COPD	Koff, P. 2021 51	↓	↓	COPD-related urgent office GP visits (decreased only on IG).
			↓	=	COPD-related hospitalizations, hospital LOS, ED visits, ICU hospitalization.
			no	=	Non-COPD urgent office GP visits, hospitalizations, hospital LOS, ED visits, ICU hospitalizations.
		Ding, H. 2014 47	↓	NA	Hospital admissions, ED presentations, and GP visits.
		Farias, R. 2019 48	↓	NA	Respiratory-related ER visits, and COPD-related hospitalizations.
		Au, D. 2015 40	NR	↓	Quarterly all-cause hospital admissions, respiratory-related hospital admissions.
		Pare, G. 2013 54	NR	↓	Number of hospitalization days and visits to ER.
		Pedone, C. 2013 55	NR	↓	COPD-related hospitalizations.
		Farmer, A. 2017 49	NR	↓	Visits to the GP practice nurses.
			NR	=	Relative risk of hospital admission.
		Vianello, A. 2016 62	NR	↓	Readmission rate AECOPD and/or for any cause, appointment with a pulmonary specialist.
			NR	=	Hospitalization rate for AECOPD (acute exacerbations of COPD) and/or for any cause.
		Antoniades, N. 2012 39	NR	=	Number of COPD-admission/year, COPD-related length of stay (LOS) days/year, total admission/year, total LOS days/year.
		Boer, L. 2019 41	NR	=	Exacerbation-related hospital admissions, unscheduled respiratory-related healthcare consultations.
		Chau, J. 2012 43	NR	=	Number of emergency department visits and hospital re-admissions.
		Jódar- Sánchez, F. 2013 50	NR	=	ED visits, specialized consultations, hospitalizations.
		McDowell, J. 2015 53	NR	=	Number of ED visits, hospitalizations, or contacts with GP.
		Pinnock, H. 2013 57	NR	=	Hospital admissions due to COPD or all cause, duration of hospital admission.
		Stamenova, V. 2020 60	NR	=	Hospitalizations, ED visits, or clinic visits.
Telerehabilitation	COPD	Hansen, H. 2020 66	NR	=	Hospital admission related to COPD exacerbations; all causes of hospitalization.
Telerehabilitation and Telemonitoring	COPD	Bhatt, S. 2019 72	NR	↓	30-day all-cause readmission and AECOPD (acute exacerbation of COPD) readmission.
		Vitacca, M. 2009 82	NR	↓	Hospitalizations, ER admissions and urgent GP calls.
		Ringbaek, T. 2015 80	NR NR	↓	Visits to the respiratory outpatient clinic.
				=	Number of hospital admissions (for COPD or all causes), time to first admission, length of stay, visit to ER.
		Broadbent, E. 2018 73	NR	=	Hospitalizations for respiratory problems, total number of days in hospital for respiratory problems.

IG: Intervention group; CG: control group. ED: emergency department; ER: emergency room; GP: general practitioner; ↓ significantly lower;  =  no significant difference between groups. NA: not applicable. NR: data and/or significance level not reported.

Results

All 44 manuscripts were original research published between 2005 and 2021. The studies were conducted in Australia (5), Canada (5), USA (5), Denmark (4), Italy (4), Spain (4), UK (4), China (3), the Netherlands (3), Ireland (2), New Zeeland (1), Norway (1), Russia (1), Sweden (1), and 1 study in Austria, Germany, and Switzerland. The main characteristics of the included studies are presented in Table 1. Twenty-eight manuscripts reported on randomized controlled studies, 11 pre-post intervention studies, 2 matched population studies, 1 controlled non-randomized study, 1 quasi-randomized clinical trial, and 1 cohort study. Follow-up periods reported range between 10 days and 36 months. The number of participants involved in intervention groups of the studies ranged between 8 and 619 (median: 45). Thirty-five of the studies were conducted in patients with COPD, 5 in patients with asthma, 1 included patients with COPD and/or asthma, and 2 in patients with COVID-19. Two studies were conducted on children and the rest on adult patients (Table 1).

Interventions and technology

Table 1 describes the details of the interventions and the technology used. The effect of telemonitoring (25 studies), telerehabilitation (8 studies) or both interventions combined (11 studies) were reported on the physical activity, exercise capacity, HRQoL and healthcare use of patients with respiratory diseases or COVID-19. These technology-enabled remote interventions were implemented as a stand-alone approach or in combination with other elements (e.g. standard care). Twenty-seven of the studies involved mobile apps, web pages, or virtual platforms accessed using a laptop, tablet or smartphone.^{39,41–44,46,47,49,55,59–61,63–69,71,72,74–76,79–81} In two studies the intervention was delivered using a teleconference platform,^66,76 and one social platform. ⁶⁷ Other transmitting devices/systems used in the studies included the health buddy device,^40,51 the iRobi robot, ⁷³ a PalmOne, ⁴⁵ touch screen telemonitoring equipment, ⁵⁷ a home health system connected to a phone line, ⁵³ a computer-linked interactive phone tele-system, ⁴⁸ a tele-modem,^50,54,62,82 a satellite platform, ⁸³ computer or push-bottom telephone, ⁵⁸ handheld monitor connected to a phone line, ⁵² a digital pen and health dairy paper together with SMS. ⁵⁶ Portable devices used to monitor patients’ remotely included pulse oximeters (oxygen saturation and heart rate), spirometers (lung function), and accelerometers (physical activity) among others. Sixteen studies used more than one device to collect patient data. Information from the monitoring devices was collected using Bluetooth technology, manually entered, or verbally reported by participants to the research team or healthcare providers.

Exercise capacity and physical activity

A significant improvement in exercise capacity was reported in COVID-19 patients who received home-based telerehabilitation ⁶⁴ (Table 2). Increased baseline exercise capacity was also found in COPD patients who received telemonitoring, ⁵¹ telerehabilitation (3 of 4 studies),^66,69,70 or a combination of both.^76–78,81 However, only one study that explored the effect of telemonitoring ⁵¹ and another that combined telemonitoring and telerehabilitation ⁸¹ found greater improvement in exercise capacity in intervention groups compared to controls. Telerehabilitation^76–78,81 alone or in combination with telemonitoring was not associated with changes in physical activity compared to control groups among COPD patients.^66,71,81

HRQoL and/or health status

Overall well-being improved in 83% of COVID-19 patients who participated in an intervention involving telerehabilitation and telemonitoring ⁷⁵ (Table 3). Telemonitoring interventions were associated with an improvement in HRQoL in patients with asthma^{42,45,58,61,63} and COPD (4 of 6 studies),^46,49,51,60 and no changes in HRQoL were identified in one study that included both asthma and COPD patients combined. ⁴⁴ Nevertheless, when compared to control groups, telemonitoring was associated with a greater improvement in HRQoL only in 75% (3 of 4) of studies in asthma patients^{46,49,51,58,60,61,63} and in 23% (3 of 13) of studies in COPD patients.^49,51,53 Telerehabilitation^65–70,79 alone and the combination of telerehabilitation with telemonitoring^76–78,81 were associated with improvement in HRQoL in COPD patients. However, no significant difference in HRQoL change was found between the intervention groups and controls.^{66–68,70,71,73,74,78,81}

Healthcare use

A decrease in pre-intervention hospital admissions, length of hospitalization, and visits to the emergency department and GP's office were reported in COPD patients who participated in telemonitoring interventions.^47,48,51 Furthermore, 6 out of 13 studies reported fewer urgent visits to GP's office, ⁵¹ fewer visits to the pulmonary specialist ⁶² and nurse practitioner, ⁴⁹ fewer hospital admissions,^40,55 and readmissions, ⁶² fewer days of hospitalization, and fewer ER visits ⁵⁴ in patients with COPD who received telemonitoring compared to control groups. However, 7 of 13 studies found no significant difference in health care use between controls and patients with COPD,^{39,41,43,50,53,57,60} who participate in telemonitoring interventions, and the same was reported in two studies among patients with asthma.^42,63 No significant differences were found in COPD exacerbation-related hospital admission or in all causes of hospitalization between COPD participants of a telerehabilitation program compared with a conventional pulmonary rehabilitation (PR) program. ⁶⁶ Three of 4 studies reported lower use of healthcare in COPD patients who participated in interventions combining telerehabilitation and telemonitoring compared with control groups.^72,80,82

Discussion

This paper aimed at portraying the use of telemonitoring and telerehabilitation in patients with chronic lung diseases such as asthma, COPD or COVID-19 patients and the effects of these modalities of intervention on physical activity, exercise capacity, health-related quality of life and healthcare use. A scoping review methodology was followed to explore the literature in the field. 27.3% of the studies retrieved were published after 2020 demonstrating the expanding need for technology in PR, especially after the rise of COVID-19. The first objective was to identify the telemonitoring and telerehabilitation interventions that are used to provide telehealth care for people with chronic respiratory conditions or COVID-19. The literature review identified various technologies and technology-based approaches used to provide telemonitoring and/or telerehabilitation interventions for patients with asthma, COPD, or COVID-19. The technologies used were classified into two types. The first type included portable and mobile technologies to capture physiological and other-non-invasive variables measured by patients themselves at home (e.g. heart rate, oxygen saturation) and the second type included information and communication technologies that allow seamless transfer of health data from the remote location to the healthcare provider. Overall, technologies were diverse, involved various levels of complexity, and were deployed in specific ways depending on the cases used. As such, we have classified the interventions into telemonitoring where only the surveillance of physiological and other non-invasive variables was needed, telerehabilitation where a PR or exercise intervention was administered remotely, or a combination of both.

The second objective of this paper was to provide an overview of the effects of telemonitoring and telerehabilitation on exercise capacity, physical activity, HRQoL, and healthcare use in patients with lung diseases or COVID-19. Results indicated that telemonitoring and telerehabilitation were associated with an improvement in exercise capacity, higher HRQoL, and lower healthcare use in these patients. Furthermore, these interventions produced outcomes comparable to standard care, which aligns with previous evidence that reported similar benefits of telerehabilitation to traditional in-person outpatient PR programs.^84,85 Previous evidence has also suggested that telemonitoring interventions can contribute to better disease management, higher patient empowerment, higher patient engagement and satisfaction, facilitate communication between the patient and healthcare team, and facilitate data collection and data access in patients with COPD. ⁸⁶ Some potential barriers associated with these interventions included heterogeneity of care, lack of patient comfort with technology, patient resistance, time-consuming, increased workload for healthcare providers and staff shortages. ⁸⁶ From the cost-effective perspective, evidence suggested that although technology-based interventions require an initial financial investment, they will substantially reduce costs in the long-term, potentially due to a reduction in healthcare use and travel costs. ⁸⁷

Overall, evidence suggested that telemonitoring and telerehabilitation are potentially valuable mechanisms to improve patient care and access, especially in rural areas, ⁸⁸ and do not increase mortality rates. ⁸⁹ Therefore, policy and decision-makers should consider supporting the implementation of telemonitoring and telerehabilitation interventions by providing an initial investment associated with the cost of the equipment, regulating the practice of telerehabilitation including protected time for healthcare providers, and involving in-institution information and technology services to support data transmission and enable secure remote sessions.^90,91 Future studies should explore mechanisms to reduce potential barriers associated with the use of technology-based interventions, such as lack of standardization and cost-effectiveness analyses.

Strengths and limitations

The results of this study contribute to filling a significant knowledge gap about the value of telemonitoring and telerehabilitation in the management of patients with chronic lung diseases or COVID-19. This knowledge is needed among the first priorities identified by the patients and clinicians after COVID-19 widely affected the delivery of rehabilitation services.^92,93 63.6% of the retrieved manuscript reported on randomized controlled trials demonstrating the current need for evidence about the effectiveness of telemonitoring and telerehabilitation in patients with chronic lung diseases or COVID-19. This paper presented the evidence available as of June 2021. The generalizability of the results of this study may be influenced by the higher variability between the characteristics of the studies included such as the number and age of the patients, outcome measurements, length of the intervention, technological components involved, and additional elements included (e.g. education components, type and numbers of healthcare providers involved, etc.). Due to this heterogeneity, authors suggested a cautious interpretation of the results and compiled the studies characteristics in Table 1 to facilitate the readers’ interpretation.

Conclusion

Telemonitoring and telerehabilitation interventions had a positive effect on patient exercise capacity and HRQoL and are associated with fewer healthcare use in patients with chronic lung diseases such as asthma, COPD, or post COVID-19. Furthermore, the results indicated that the outcomes of these interventions are comparable to standard care. Therefore, they are promising alternatives to support remote home-based rehabilitation in this group of patients that should be supported by policy and decision-making.