Telerreabilitação em tempo real em doenças respiratórias crônicas e pós-COVID-19: revisão sistemática e metanálise

Abstract

INTRODUCTION: Pulmonary rehabilitation (PR) is an intervention that improves both physical and psychological aspects of individuals with chronic respiratory diseases (CRD). However, adherence to in-person PR programs is low due to barriers to access and participation. Telerehabilitation (TR) is an alternative model that may facilitate access and adherence for these individuals. Due to the significant heterogeneity of existing TR studies, it is still necessary to identify the most effective, safe, and cost-effective remote strategy for clinical implementation. Additionally, it is essential to clarify the level of supervision required during physical exercise, which can impact patient safety, adherence to PR, and the quality of exercise execution and intensity progression. OBJECTIVES: To determine the effects of real-time supervised TR on exercise capacity, health-related quality of life, dyspnea, healthcare utilization, and mortality when compared to usual care, in-person rehabilitation, or asynchronous TR. METHODS: A search for randomized controlled trials (RCTs) and controlled clinical trials was conducted in the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform up to 30 April 2023, with no restriction on language or type of publication. Clinical trials of TR that included at least 50% of real-time supervised sessions in adult individuals with a diagnosis of any CRD or post-COVID-19 were included. Two review authors independently performed study selection, data extraction and risk of bias assessment. Only RCTs were included in the meta-analyses, and other studies were presented descriptively. The certainty of evidence for each comparison was assessed using GRADE. RESULTS: Twelve studies with 1540 participants (75% with COPD, 21% post-COVID-19, and 4% with other CRDs) were included. The mean age of participants ranged from 64 to 75 years. In all studies, participants in the intervention group underwent a minimum of 4 weeks of real-time supervised TR via video conferencing. Very-low to moderate certainty evidence showed no difference between TR and in-person PR regarding exercise capacity, quality of life, healthcare utilization, depression, adherence and mortality. The analysis of dyspnea at the end of the follow-up period (> 5 months) showed a mean difference of -0.39 in the mMRC score in favor of TR, but this difference did not reach the minimum clinically important difference. There was no difference between the interventions regarding the number of adverse events. The studies included in this review reported high adherence rates to TR (between 79% and 92% of scheduled sessions). The completion rate ranged from 62% to 93% in the TR group, with no difference compared to in- person PR. When compared to usual care, the results of this review provide low-quality evidence that TR may have a potential effect on exercise capacity at the end of the intervention. Regarding the other evaluated outcomes, no better results were observed in this population with TR compared to usual care. No studies comparing real-time TR with asynchronous TR were found. CONCLUSION: This review suggests that TR is safe and promotes similar effects to inperson PR in exercise capacity, quality of life, dyspnea and healthcare utilization in individuals with CRD and post-COVID-19. However, the certainty of this evidence was limited, and it is not possible to guarantee that the interventions are equivalent. Therefore, TR may be offered as an alternative to traditional PR models for patients with geographical, socioeconomic and symptomatic barriers, as well as in cases where traditional PR programs are not available. This review provides a clear definition of real-time TR, including physical exercise, with the same level of supervision and assistance in all TR groups and using the same standard of technology in all included studies, which facilitates result interpretation and clinical applicability.