A multitude of published systematic reviews and clinical guidelines support that pulmonary rehabilitation (PR) improves functional capacity and quality of life.1-4 While optimal medical management is helpful, it cannot reverse the pathologic changes secondary to COPD, but pulmonary rehabilitation teaches patients how to manage their symptoms and attain their maximum level of functioning. According to the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR),5 PR consists of collaborative self-management, exercise, and psychosocial assessment and interventions. PR exercise comprises exercise sessions of 30 to 90 minutes three to five times per week, conducted in an inpatient or outpatient setting. The use of the home setting for pulmonary rehabilitation is not the standard of care in the United States.

HOME-BASED PR: WHAT DOES THE EVIDENCE TELL US?

While there is an emerging body of research related to home-based PR, the evidence is not yet overwhelming. Several reviews introduced and evaluated published research on home-based PR. Ashworth and colleagues6 conducted a Cochrane Systematic Review evaluating home physical activity programs compared to outpatient center programs in older adults focusing on cardiovascular disease, COPD, and osteoarthritis. Overall, only six articles were reviewed and reported (four for cardiovascular, two for COPD, none for osteoarthritis), with evidence in COPD found to be conflicting.

Vieira et al7 evaluated the evidence for home-based PR in COPD patients. Included were 12 studies that met the inclusion criteria: eight studies comparing home PR to usual care; three studies comparing home PR to outpatient PR; and one study comparing three groups—home PR, outpatient PR, and usual care. Home PR has been shown to improve exercise capacity and health-related quality of life versus no PR, but no significant differences were noted between outpatient PR and home PR. The authors concluded that home PR may be an alternative to outpatient PR. A third systematic review also supported that home PR was as effective as outpatient PR based on four studies.8 A narrative review describes home-based PR as a safe and effective model; however, cost-effectiveness is not well described in the literature.9 While there has been a spate of recent publications testing home PR,10-13 the evidence is of differing levels of methodological quality. One randomized control trial stands out for diversity of sites and the large sample.14 A multicentered (n=10 sites in Canada) trial comprising 252 patients with moderate to severe COPD was conducted to determine whether self-monitored home PR is as effective as outpatient PR in COPD patients. The PR programs were 8 weeks in length, with patients receiving continued follow-up for 40 weeks to 1 year. This high-quality study assessed the change in the Chronic Respiratory Disease Questionnaire (CRQ) dyspnea subscale at 1 year. The study found that both interventions (home PR and outpatient PR) produced similar improvements in the dyspnea subscale, with small differences determined to be clinically unimportant at 1 year following the intervention. No serious adverse events were accountable to the interventions, supporting the safety of home PR.14

PRACTICAL CONCERNS FOR HOME PR

As the evidence continues to evolve around home PR, practical and operational concerns will need to be addressed. In many studies, collaborative self-management education was conducted in the outpatient center, but is there a role for in-home based education? How/what are the best methods to deliver the educational content? How does individual home education requiring specially trained health professionals (RRTs, RNs) impact quality and cost? Home PR with a required outpatient education component, while cost-effective and shown to be efficacious by the evidence, raises an important question: How does this impact the enrollment of potential PR participants who cannot attend an outpatient setting due to location or health limitations?

Descriptions of exercises used in home PR are needed to provide detailed information for the health care professional teaching the PR patient who will conduct the exercises unsupervised. A few published studies provide details for home PR exercise and specific modalities (free walking, treadmill, or cycle ergometer for lower extremity training; specifics for upper extremity training).12,15,16 A consistent theme throughout the studies is the need for home PR to be conducted at a lower intensity over a longer time period for safety and to promote adherence to the activity. The Canadian multicenter trial also published detailed information on the rationale and methods used in the study in a separate publication,15 including specifics that the PR aerobic training via cycle ergometer was conducted for 30 minutes at an intensity up to 80% of the maximal heart rate in the outpatient setting, while the same cycle ergometer aerobic training used an intensity up to 60% of maximal work rate for 40 minutes in the home setting.

Boxall and colleagues describe a walking program with 10 levels, with level 1 including walking for 1 minute on level ground, rest up to 2 minutes, then walk again for 1 minute, progressing to level 10 where the patient walks for 15 minutes, rests, then walks for an additional 15 minutes.12 A home exercise program example following a formal outpatient program is described in the AACVPR Guidelines.5 This home program example includes instructions on breathing exercises; floor exercises; strength training using Thera-Bands, cuff weights, and dumbbells; as well as instructions for biking or walking programs, including walking program progression.5 Upper extremity movements based on proprioceptive neuromuscular facilitation are detailed in two published studies and include exercise and weight progression algorithms.

Bauldoff and colleagues published a three-exercise program described in detail, as well as a 13-level progression plan for a home-based upper extremity training program.16 Boxall et al also provide descriptions of a three-exercise standard arm exercise program that progresses over 18 levels.12 Both the Bauldoff and Boxall upper extremity training exercises are based on the proprioceptive neuromuscular facilitation exercise program designed and evaluated by Ries and colleagues.17 Exercise progression is an important consideration in PR, but requires additional considerations for home PR. These considerations focus on safe and appropriate progression, patient education about exercise progression, and instruction about expected symptoms (mild muscle soreness? increased dyspnea during the activity?) versus adverse events that are unexpected and not desired. Reimbursement questions are another consideration for PR. At this time, home PR is not covered by the Centers for Medicare and Medicaid Services. Only outpatient PR with physician supervision is the covered delivery method. As of June 2010, the Healthcare Common Procedure Coding System (HCPCS) G0424 is the billing mechanism for PR for patients with moderate, severe, and very severe COPD. A PR reimbursement tool kit is available on the AACVPR Web site at: www.aacvpr.org/Portals/0/policy/PRReimbursementToolkitFINAL.pdf. This tool kit was developed by and in cooperation with the AACVPR, the American Association for Respiratory Care, the American Thoracic Society, the American College of Chest Physicians, and the National Association for Medical Directors of Respiratory Care. Issues concerning in-home patient supervision, physician oversight, and PR efficacy across diverse home environments remain unresolved. With the continued advancements in tele-health and tele-rehabilitation, new supervisory models may be developed, along with intervention modifications to address diverse home environments. While home PR shows promise, there are many questions and issues that need to be addressed before widespread adoption of home PR can be considered.


Gerene S. Bauldoff, PhD, RN, FAACVPR, is professor of clinical nursing at the Ohio State University College of Nursing, Columbus. She serves as a member of the board of directors of the AACVPR and is active in the American Thoracic Society. She holds fellowships in the American College of Chest Physicians and the American Academy of Nursing. For further information, contact [email protected]om.

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