Providing heart failure rehabilitation in the home via telerehabilitation

Abstract

Exercise is effective for patients with chronic heart failure (CHF). Despite this, many patients are unable to access traditional exercise-based rehabilitation programs for various reasons, such as transport difficulties and program availability. Telerehabilitation, in which telecommunication technologies are used to provide rehabilitation at a distance, is an alternative approach which may overcome some of these barriers. The current literature suggests that telerehabilitation is effective in patients with cardiopulmonary diseases. However the majority of studies focus on phone-based interventions, so there is a need for more studies on the use of video-based telerehabilitation programs. Video-based telerehabilitation is a new approach which enables patients to exercise in the comfort of their homes, whilst maintaining synchronous audiovisual communication. This approach enables the clinician to watch patients performing the exercises and to provide real-time feedback and modification as required, as well as facilitate the development of rapport between the clinician and patients, and peer support amongst patients. Video-based telerehabilitation also presents a potential way to conduct remote assessment of functional exercise capacity. This thesis aimed to explore a new service delivery model for providing heart failure exercise-based rehabilitation programs. The thesis commences with a systematic review of telerehabilitation in patients with cardiopulmonary diseases (Study 1, Paper 1). The next study aimed to determine the suitability of the timed up and go test (TUGT) as an outcome measurement in heart failure rehabilitation programs (Study 2, Paper 2). In addition, the validity and reliability of telerehabilitation assessments of functional tests including the TUGT were examined in patients with CHF (Study 3, Paper 3). A randomised controlled trial determined the feasibility and effectiveness of a home-based heart failure telerehabilitation program compared with a traditional centre-based program (Study 4, Paper 4). A mixed methods study was also conducted to determine patient experiences and perspectives related to a heart failure telerehabilitation program (Study 5, Paper 5). Based on the systematic review of 11 studies, telerehabilitation appears to be a promising alternative to traditional centre-based programs in patients with cardiopulmonary diseases. In particular, telerehabilitation has been shown to improve exercise capacity and quality of life in these patient groups and has higher adherence rates compared with traditional centre-based programs. However, suitable outcome measures that can be administered via telerehabilitation are required. A possible outcome measure is the TUGT, which is a quick and easy-to-administer functional test. However prior to using the TUGT as an outcome measure in telerehabilitation studies, it was first important to validate its use in both face-to-face and telerehabilitation environments. The TUGT demonstrated excellent test-retest reliability in patients with CHF when the test was assessed face-to-face and was strongly associated with other functional exercise tests. The TUGT appears to be a reliable tool, and may be appropriate for telerehabilitation assessment. This thesis contains the first study to investigate the use of telerehabilitation to determine functional exercise capacity in patients with CHF. More specifically, our study confirmed the validity and reliability of using telerehabilitation to administer the 6 minute walk test, the TUGT and grip strength in this group of patients. Similarly, a telerehabilitation intervention program appears to be a feasible and effective option for people with CHF. The telerehabilitation program designed for the randomised controlled trial in this thesis consisted of a 12-week group-based exercise and education intervention. The program was delivered into the patient’s home twice-weekly, using an online videoconferencing platform. The telerehabilitation program was found to not be inferior to a traditional centre-based program in patients with CHF, on the primary outcome measure of the change in 6 minute walk distance from baseline to post-program. There were also no differences between the two intervention groups in other functional capacity measures, muscle strength, quality of life, urinary incontinence, patient satisfaction or adverse events. The telerehabilitation group had higher attendance rates compared with the control group, with a mean difference (95% confidence intervals) of 6 (2 to 9) sessions. Participants in the heart failure telerehabilitation program reported high visual clarity and ease of monitoring equipment use, but provided suggestions for further improvements. Participants liked their improved health outcomes, easy access to care with reduced transportation requirements and increased social support. Information on patient experiences and perspectives related to telerehabilitation can help to facilitate future uptake and success of this delivery approach. In summary, this thesis provides new information on an alternative model for delivering heart failure rehabilitation programs. Telerehabilitation may complement or replace some traditional face-to-face approaches for patients with CHF such as outpatient clinics, especially when access to specialised health services is limited or difficult. This innovative and novel approach has the potential to widen access, alleviate transport barriers, promote adherence and offer patients an opportunity to exercise in their home environment. Outcomes from this research may drive service delivery change, with the broad effect of optimising outcomes for patients with CHF.