Group-based pulmonary telerehabilitation is feasible, safe, beneficial and well-received in patients who have been hospitalised with COVID-19

Discussion

To the best of our knowledge, this is the first study to explore the feasibility and efficacy of a remotely delivered, group-based, supervised, pulmonary rehabilitation programme for patients hospitalised with COVID-19. We have shown that group-based telerehabilitation is feasible, safe, beneficial and well-received in this population. Indeed, data show improvements from baseline to post-rehabilitation in exercise capacity, respiratory symptoms, quality of life, fatigue and mental health. Improvements in wellbeing appear to be accelerated by telerehabilitation, with positive effects observed following telerehabilitation in the fast-track group exceeding the natural recovery observed during the wait-list period by more than the MCID. These results will help to inform larger RCTs of telerehabilitation post-COVID and, in the meantime, provide an additional degree of evidence underpinning clinical guidelines and policy.

The feasibility of group-based telerehabilitation for COVID-19 was assessed using recruitment rate, dropout numbers, intervention fidelity and monitoring of adverse events. Due to the method of recruitment, our study team were only able to collect reliable rates of recruitment from patients who required a high-level respiratory support. These data show that roughly one in five hospitalised COVID-19 patients were eligible and showed initial interest in the study and approximately half of these individuals consented to participate. The reason for nonparticipation, following initial interest, commonly included suitability of class timings; for logistical reasons, we were only able to offer one session timing option for the participants in this study. These logistical issues could be minimised by economies of scale; a benefit of telerehabilitation is that geographical constraints no longer exist [19], and therefore national, rather than regional, telerehabilitation programmes could be envisaged.

The final cohort consisted of slightly more males than females, reflecting that men are more at risk of severe COVID-19 [20]. However, post-COVID-19 syndrome appears to be more female-dominant [20, 21]. The consent-to-completion rate was 68%, with all but one of the participants who completed telerehabilitation attending ≥50% of the exercise sessions. This intervention fidelity is higher than that commonly reported for in-person pulmonary rehabilitation for COPD [9]. The observed recruitment and completion rates would fulfil recruitment requirements for an RCT and would translate into a high service demand.

Only two adverse events occurred during the course of our study and both were considered unrelated to the study protocol. Data from our feasibility trial suggest that telerehabilitation is a safe intervention in patients who have been hospitalised with COVID-19. The safety profile in our trial complements that from trials of in-person pulmonary rehabilitation [22–26] and unsupervised telerehabilitation [27, 28], which have not identified a concern with rehabilitation in this population.

Rehabilitation may benefit anyone with a longer-term disabling illness, at any stage, and may be delivered in a variety of settings [7]. The improvements in exercise capacity and dyspnoea observed in our trial are in line with improvements noted following inpatient [22–24] and outpatient [25, 26] in-person pulmonary rehabilitation for COVID-19 survivors. In studies where rehabilitation is delivered remotely, the interventions have focused primarily on the exercise component of rehabilitation, and tend to neglect the education and psychosocial elements. Several studies have now demonstrated that unsupervised telerehabilitation improved exercise capacity and dyspnoea [27, 28]. The novelty of the present study is that the pulmonary rehabilitation programme was delivered entirely remotely, but maintained the supervised group dynamics. We hypothesise that these aspects contributed to the additional favourable outcomes noted in the psychosocial outcome measures. The importance of group dynamics during rehabilitation in psychosocial health outcomes have been identified previously [29, 30] and mentioned by participants in the service evaluation questionnaire.

Participant feedback was overwhelmingly positive with regard to the programme content, satisfaction with staff and, albeit to a lesser extent, technology. Indeed, all participants indicated that that they believed telerehabilitation helped their recovery from COVID-19. The finding that participants would recommend this programme to others is a testament to the acceptability of the telerehabilitation programme and strongly supports a wider role for telerehabilitation following COVID-19.

We acknowledge that individuals who were unwilling to participate in telerehabilitation or without access to appropriate digital technology would be ineligible for our study, therefore introducing selection bias. Indeed, digital health inequality is a major challenge when considering adoption of digital interventions in healthcare [31]. A pragmatic suggestion may be that telerehabilitation could be conceived as an optional alternative to face-to-face rehabilitation, or vice versa, where appropriate. Indeed, a recent report from Healthwatch [32] suggests that post-COVID digital healthcare should maintain traditional models of care alongside remote methods.

This study has other limitations worthy of discussion. Firstly, the initial protocol [11] suggested that data analysis would be purely descriptive in nature. However, due to the developments in the field and lack of available RCT data, the trial management group agreed to conduct inferential statistical analysis on all outcome measures. Given that the sample size is two-fold larger than that of an 8-week unsupervised pulmonary telerehabilitation programme that showed positive improvements in exercise capacity and exercise-induced dyspnoea in patients recovering from COVID-19 [27], we would consider the study adequately powered. Nonetheless, without a predefined primary clinical outcome measure, the probability of Type 1 errors should be considered. Longer-term follow-up would also allow for assessment of any long-term health and/or behaviour changes resulting from telerehabilitation. Indeed, although positive improvements were seen in many health outcomes following telerehabilitation, these often remained below population-based reference values, e.g. exercise capacity [33].

In conclusion, we have shown that group-based pulmonary telerehabilitation is feasible, safe and well-received in patients who have been hospitalised with COVID-19. Furthermore, we have identified physical and psychosocial benefits of telerehabilitation in this population, which could inform a larger multicentre RCT and, in the meantime, supports development of clinical guidance and policies relating to rehabilitation following COVID-19. The utility of telerehabilitation for delivery of a pulmonary rehabilitation service, which can radically increase service capacity while maintaining social distancing, may be essential in the national recovery from this widespread disease.