Speaker- Heleen Demeyer

Traditional versus alternative pulmonary rehabilitation models were compared using two 2023 guidelines: one from the Thoracic Society and the other from the British Thoracic Society. Although based on the same evidence, the guidelines differed on tele-rehabilitation use. She presented a case of a 47-year-old chronic obstructive pulmonary disease (COPD) patient with two recent exacerbations. The patient had treatable traits, including high dyspnea, low exercise capacity, reduced muscle strength, and a sedentary lifestyle, indicating a need for pulmonary rehabilitation. While traditional rehabilitation occurred in a hospital setting, alternative models such as home-based interventions, web platforms, and video teleconferencing were explored to enhance patient uptake. 

The American Thoracic Society (ATS) guideline recommended offering patients a choice between center-based and tele-rehabilitation, as no intervention was favored over the other. In contrast, the British Thoracic Society guideline advised referring all patients to directly supervised center-based rehabilitation, with alternative models offered only if patients declined or dropped out. Evidence from a Cochrane review indicated minimal differences in effectiveness between center-based and home-based rehabilitation models. However, several considerations were noted: many interventions did not exceed the minimal important difference in exercise capacity, real-world data showed lower effectiveness for home-based programs and significant variability in intervention content and outcomes. The ATS statement balanced desirable and undesirable effects, suggesting no superior model, while the British Thoracic Society emphasized center-based rehabilitation based on these considerations.

Both guidelines agree on face-to-face testing, including a valid exercise test to ensure appropriate exercise intensity and safety. This baseline assessment aligns with the ATS workshop report, which emphasizes endurance and strength training as essential components of modern pulmonary rehabilitation. Comparing daily exercise training with center-based rehabilitation may overlook the benefits of interdisciplinary care, including input from dietitians and psychologists, which is beneficial for patients with low fat-free mass and high anxiety and depression symptoms. Patient preferences also play a role, with a 2022 study indicating that only a minority preferred web-based or video conference rehabilitation. Additionally, the generalizability of data from studies predominantly involving COPD patients from specialized centers is uncertain for other populations and settings. The speaker proposed exploring hybrid care models, which combine elements of both center-based and home-based rehabilitation. An example from Marieke Woerdts in Leuven compared a center-based program with a hybrid model involving center- and home-based care. The hybrid approach, which included weekly center visits and home-based sessions, demonstrated equal effectiveness compared to traditional center-based care. In conclusion, while the two guidelines differ in their interpretations, future research should address patient preferences and consider hybrid models that integrate the strengths of both approaches.

In Belgium, primary care physiotherapists are readily available within five kilometers of most patients' homes, influencing rehabilitation guidelines. The healthcare system's structure is crucial in determining whether patients should be referred to primary care physiotherapists or consider alternative rehabilitation models. In countries like the U.S., Australia, and Canada, where access to physiotherapists is less frequent, alternative models are more necessary. Rehabilitation guidelines are generally focused on stable patients, but for those experiencing exacerbations, rehabilitation should begin as soon as feasible during hospital admission. Muscle strength training, which requires less ventilation and leads to reduced breathlessness, is a suitable modality during hospitalization. Endurance training, however, is often postponed until after discharge. Strength training should be initiated immediately after discharge, with endurance training gradually introduced later. Studies have shown that referring patients to primary care physiotherapists within five days of discharge allows for the timely initiation of exercise training programs. Trial design for rehabilitation interventions faces challenges, as the recruitment process may bias results. Patients often choose home-based rehabilitation because they believe it requires less effort, which may skew the cohort being studied. Offering center-based rehabilitation first, followed by the option for home-based care, may address this issue. Both models of care should be balanced, with guidelines like those from the British Thoracic Society supporting this approach. Additionally, inpatient rehabilitation following acute exacerbations, common in countries like Germany, has shown significant effectiveness, but ensuring long-term benefits remains critical. Combining inpatient rehabilitation with tailored care models can enhance outcomes, particularly in the transition to home-based rehabilitation.

In many countries, access to primary rehabilitation services is a significant challenge in rehabilitation. The idea of implementing inpatient rehabilitation immediately following an acute exacerbation that necessitates hospitalization has gained traction. Inpatient rehabilitation has been extensively tested and shown comparable effectiveness to other models. For example, large centers in Germany have reported success with three-week inpatient rehabilitation programs, conducting sessions five times a week. However, while inpatient rehabilitation is effective, ensuring long-term benefits remains crucial. Tailored rehabilitation programs can effectively bridge the gap between initial inpatient care and ongoing rehabilitation, combining the strengths of both models. In the maintenance phase, patients who understand what is required of them and have already participated in structured rehabilitation will likely experience reduced breathlessness and improved overall well-being. This dual approach optimally supports patient recovery and enhances their quality of life post-hospitalization.

European Respiratory Society Congress 2024, 7–11 September, Vienna, Austria.