COMPARATIVE EFFECTIVENESS OF TELEREHABILITATION APPROACHES IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Chronic obstructive pulmonary disease (COPD) is a respiratory condition characterized by prolonged airflow restriction, progressive dyspnoea, and frequent exacerbations. [1,2].  The treatment of COPD depends on both non-pharmacological and pharmaceutical approaches. Non-pharmacological treatments, particularly pulmonary rehabilitation (PR), leads to improvement exercise endurance, dyspnoea, and functional ability [3,4]. Despite its efficacy, access to PR remains limited.

Barriers such as geographic distance, lack of trained personnel, high costs, transportation constraints, and adherence challenges particularly affect rural and resource-limited populations [5,6]. These obstacles underscore the need for alternative, accessible delivery models.In this context, telehealth innovations, including videoconferencing and video-based interventions, have emerged as promising alternatives to conventional PR. These models facilitate remote delivery of structured rehabilitation sessions, supervision, and patient engagement while minimizing geographic and logistical constraints [7].

Studies have concluded that telerehabilitation (Tele-R) significantly improves exercise capacity (6-minute walk distance [6MWD]), dyspnea (mMRC), and disease control (COPD Assessment Test [CAT]) compared to no rehabilitation; outcomes were comparable to center-based PR [8,9]. In comparison to traditional PR, videoconference-based PR also produced improvements in health-related quality of life and decreases in anxiety and sadness [10]. Videoconference PR produced comparable increases in patient understanding to in-person delivery, according to other observational studies [11]. Notably, existing studies primarily assess functional or patient-reported outcomes — for example, Modified Borg scale,6MWD, CAT, adherence, knowledge — and less frequently target pulmonary function parameters such as FEV₁, FVC, and FEV₁/FVC ratio. Spirometric indices, however, are fundamental markers of lung function, disease progression, and treatment response, and remain underexplored in the context of telehealth interventions [9].

This randomized clinical study aims to evaluate the effect of videoconferencing and video-based rehabilitation approaches on pulmonary function parameters (FEV₁, FVC, FEV₁/FVC ratio) in patients with COPD. By comparing these digital interventions with standard care, the study seeks to determine their capacity to yield meaningful improvements in objective lung function metrics alongside functional and patient-centered outcomes. This evidence may inform scalable, patient-centered, technology-enabled models for COPD management, with potential applicability in low-resource and rural healthcare settings.

Statistical Analysis

SPSS software version 25.0 was used for statistical analysis. Categorical variables were expressed as frequencies and percentages, while continuous variables were presented as mean ± standard deviation (SD)(p< 0.05). Comparison for within and between group differences for various outcome measures namely pulmonary functions (FeV1, FVC, FeV1/FVC ratio, PEFR, TV & IC), modified Borg Scale Score, 6-MWT, CAT and SGRQ at time-intervals: - baseline (PRE) and after six weeks of treatment (POST), for VCF Group and VBT Group was done using paired sample t-test and independent sample t-test (p< 0.05). Evaluation of treatment effect size was done by calculating between group- mean differences (delta mean values) and 95% C.I, for various outcome measures using an independent t-test. Bland- Altman plots were constructed to analyze between group- mean differences for various outcome measures.

There were no significant differences between mean values of age (p= .678), modified Borg scale score (p=.314), FVC( p=.249), FeV1 (p=.122 ),  FeV1/FVC (p=.199), PEFR (p=.072), IC (p=.857), TV (p=.482), 6-MWT (p=.510), CAT score (p=.525), SGRQ (p=.531) and gender-wise distribution (p=0.617) of VCF Group and VBT Group study participants (table-2).

Within group analysis using paired t-test showed that there was highly significant increase (p<0.001) in outcome measures including FeV1, FeV₁/FVC, Modified Borg’s Scale score and CAT score after 6 weeks of training within both groups. But FVC & PEFR in VCF Group was not statically significant (table 3). In VBT, 6-MWT was not statically significant. IC & TV were not significant in both groups. In comparison to baseline measures there was higher percentage increase in mean scores of pulmonary function tests, MBS scores and 6-MWT in participants of VCF group compared to those VBT group.

Between group comparison with independent sample t-test revealed a significant intergroup difference was observed in the mean change of Δ modified Borg’s scale score, Δ FeV1/FVC, Δ CAT score and Δ 6-MWT, whereas no significant differences were detected in Δ FEV₁, Δ FVC, Δ PEFR, Δ IC, ΔTV, and Δ SGRQ between the two approaches. In contrast, the improvement in Δ FEV₁/FVC ratio was significantly greater in VCF Group, indicating that videoconferencing-based rehabilitation may confer a superior effect on this parameter compared to video-based rehabilitation (table 4).

The findings of this randomized controlled trial provide valuable insight into the effectiveness of VCF and VBT telerehabilitation approaches in improving pulmonary function parameters among patients with chronic obstructive pulmonary disease (COPD). Both modalities of pulmonary rehabilitation resulted in significant improvements, though the magnitude of changes varied across groups for specific parameters.

After six weeks of intervention, Group B (VBT) in this study showed a considerable improvement in forced vital capacity (FVC), while Group A (VCF) exhibited no change. This suggests that lung capacity may have been more significantly impacted by the repetitive and structured nature of video-based training. Modified Borg's scale was used to quantify dyspnoea and the results showed that both groups had a significant reduction in dyspnoea after 6 weeks of telerehabilitation. The reduction in dyspnoea was more apparent in Group A. There was a substantial disparity between Groups A and B. Priya et al.18 conducted an analogous study and found that telerehabilitation resulted in a significant decrease in Borg score.The study was further supported by Cox N S et al. [7] systematic review on telerehabilitation for chronic respiratory diseases. This analysis concludes that primary pulmonary rehabilitation or maintenance therapy administered by telerehabilitation for persons with chronic respiratory disease yields comparable outcomes to typical center-based pulmonary rehabilitation, with no safety concerns found. This shows that the videoconferencing method was more effective at minimizing dyspnoea. Tousignant M et al. [20]did a study on home telerehabilitation for older people with chronic obstructive pulmonary disease, and considerable improvement was noted in the Borg dyspnoea score.

Elkhateeb et al. found similar results, observing considerable increases in FVC following pulmonary rehabilitation, which they attributed to better respiratory muscle function and less airway blockage [16]. Programs for pulmonary rehabilitation that include deep breathing and inspiratory muscle exercises are believed to improve FVC by strengthening the respiratory muscles. On the other hand, Won et al. found no discernible increases in FVC after pulmonary rehabilitation, indicating that patient response varies based on modality and adherence [17]. There was no statistically significant difference between the two groups, but both showed notable increases in forced expiratory volume in one second (FEV₁). This aligns with the findings of Priya et al., who found that FEV₁ significantly improved in individuals with COPD following pulmonary rehabilitation [18]. These findings highlight the effectiveness of telerehabilitation in improving expiratory airflow and lowering airway obstruction in patients with COPD, regardless of whether treatment is provided using videoconferencing or video-based techniques. In both groups, the FEV₁/FVC ratio increased considerably; however, Group A (videoconferencing) showed an overall improvement than Group B. This result is consistent with that of Ghadimi et al., who showed that when COPD patients underwent rehabilitation, their FEV₁/FVC ratio significantly improved [19]. It's possible that the real-time monitoring, encouragement, and feedback given during videoconferencing improved exercise performance accuracy and adherence, which would account for Group A's better results. Overall, the findings show that both videoconferencing and video-based telerehabilitation techniques can improve pulmonary function in patients with COPD. However, the two methods offer different advantages: videoconferencing may improve the FEV₁/FVC ratio more effectively than video-based rehabilitation, which seems to be more effective at improving FVC. These results highlight the potential of remote pulmonary rehabilitation as a scalable substitute for traditional center-based programs, especially in environments with limited resources or accessibility.

Peak Expiratory Flow Rate (PEFR), Inspiratory Capacity (IC), and Tidal Volume (TV)—were also assessed to compare telerehabilitation approaches in COPD patients. Post-intervention, Group-B demonstrated significant improvement in PEFR after six weeks of video-based telerehabilitation, while Group-A showed only a non-significant change; however, no significant difference was seen between the groups overall. These findings imply that video-based telerehabilitation could offer greater benefit for PEFR, consistent with Cecily John S. H. and Alotaibi A. A. et al. (2013) [21] where breathing exercises improved pulmonary function in similar populations. Other studies Ma H. et al. (2022) [22] confirm improvements in PEFR after pulmonary rehabilitation, attributed to enhanced lung mechanics and respiratory muscle activation via deep breathing maneuvers. Nonetheless, some published research Kim H. T. et al. [23] indicate that not all interventions yield significant PEFR changes, highlighting variability across rehabilitation modalities.IC, results showed no significant improvements within or between groups, corroborating previous study by Varol Y et al. [24] & Moradians V et al. [25] that found limited effects of certain rehabilitation programs on inspiratory capacity. TV also remained unchanged between and within groups after the intervention, further aligning with published evidence by O. Georgiadou et al. [26]&Moradians V et al.[25]suggesting pulmonary rehabilitation often produces only modest effects on tidal volume in COPD patients. The reductions in the operational chest wall volumes during exercise after rehabilitation were mainly reflected in the abdominal and not in the ribcage compartment. After six weeks of telerehabilitation, Group-A showed significant improvement in the 6-Minute Walk Test (6-MWT), while Group-B did not, and the difference between groups was also significant. This suggests that videoconferencing-based rehabilitation more effectively improves aerobic capacity in COPD patients. The reason might may be low dropout rate and the high compliance with exercise training as supported by previous studies TSAI et al. [27] &P. Bernocchi et al. [28], while non-significant results may reflect differences in patient adherence or training intensity, supported by Hansen H et al. [29]

Both groups showed significant improvement in SGRQ scores after 6 weeks of telerehabilitation, with no significant difference between groups. Vasilopoulou et al. [12] reported that home-based telerehabilitation reduces COPD exacerbations and hospital visits, showing significant SGRQ improvement via videoconferencing. Similarly, Liu et al. [30] found significant SGRQ improvements after intervention. These benefits are attributed to high patient adherence, compliance with home exercises, empowerment, and effective self-management techniques.

Both groups showed a significant reduction in CAT scores after 6 weeks of telerehabilitation, with a significant difference between groups. These findings align with Zanaboni et al. [2]and Ghadimi et al. [31], supporting that both videoconferencing and video-based approaches effectively improve quality of life in COPD patients

STRENGTHS

The study has several strengths. First, it is one of the few randomized controlled trials conducted in the Indian population comparing two different telerehabilitation modalities in COPD patients. Second, randomization and standardized outcome measures such as  Modified Borg scale score, spirometry, 6-MWT, CAT score and SGRQ strengthened the internal validity of the findings. Third, the study utilized accessible technologies such as smartphones, making the interventions scalable and feasible in resource-limited settings.

LIMITATIONS

Certain limitations should be acknowledged. The study duration was limited to six weeks, and long-term effects of the interventions on pulmonary function and quality of life were not assessed. Furthermore, the study did not explore patient satisfaction, cost-effectiveness, or psychosocial outcomes, which are important considerations for long-term implementation of telerehabilitation programs.

Clinical Implications

The outcomes of this study highlight the clinical utility of both videoconferencing and video-based approaches as effective, accessible, and scalable alternatives to traditional center-based pulmonary rehabilitation programs. Videoconferencing provides the added advantage of real-time interaction, monitoring, and feedback, which may improve patient adherence and exercise technique, particularly for those requiring greater supervision.

Table-1: Exercise Training Protocol

Table-2: Baseline characteristics of study participants.

**t- values and p values for within group comparisons

^##   t- values and p values for between group comparisons

(**The mean difference is significant at <0.01 level)

(NS- non-significant)

Table 3:- Comparison of pulmonary function parameters within VCF Group and VBT Group.

(**The mean difference is significant at <0.01 level), (NS- non-significant)

Table 4--Comparison of pulmonary function parameters between VCF Group and VBT Group.