Telerehabilitation Compared to Center-based Pulmonary Rehabilitation for People with Chronic Respiratory Disease: Economic Analysis of a Randomized, Controlled Clinical Trial.

RATIONALE: New pulmonary rehabilitation models can improve access to this effective but underutilised treatment for people with chronic respiratory disease, however cost effectiveness has not been determined. OBJECTIVE: To compare the cost effectiveness of telerehabilitation, including videoconferencing and synchronous supervision, to standard center-based pulmonary rehabilitation. METHODS: Prospective economic analyses were undertaken from a societal perspective alongside a randomised controlled equivalence trial in which adults with stable chronic respiratory disease undertook an 8-week outpatient center-based program or telerehabilitation. Clinical assessment for effectiveness (Chronic Respiratory Disease Questionnaire dyspnoea domain [CRQ-D] score) was undertaken at baseline, following pulmonary rehabilitation and 12-month follow-up. Individual-level administrative and self-report healthcare cost data were collected over 12 months following the program (Australian dollars, 2020) Results: There were no between-group differences for effectiveness (CRQ-D MD -0.2 [SE 1.0], p=0.61) or total costs ($565 [5452], p=0.92) over 12 months. On the cost effectiveness plane, 97.4% of estimates fell between the equivalence margins for effectiveness. Application of a range of values for cost margin demonstrated a 95% probability that telerehabilitation was equivalent to center-based pulmonary rehabilitation when the threshold was $11,000. Results were robust to approach, sensitivity and subgroup analyses. The internal rate of return was 134% over 5 years. Program completion (regardless of model) was associated with a significant reduction in total costs in the following 12 months (ß $-17,960, 95%CI -29,967 to -5952). Conclusions This study supports delivery of telerehabilitation as a cost-effective alternative model of pulmonary rehabilitation for people with chronic respiratory disease.

Association of Calcaneal Bone Marrow Lesions and Plantar Fascia Imaging Biomarkers With Chronic Plantar Heel Pain: A Case-Control Study.

OBJECTIVE: To determine associations between chronic plantar heel pain (CPHP) and imaging biomarkers derived from magnetic resonance imaging (MRI) and ultrasonography. METHODS: We compared 218 participants with CPHP with 100 age- and sex-matched population controls. We assessed imaging biomarkers on MRI (calcaneal bone marrow lesions [BMLs], plantar fascia [PF] signal and thickness, spurs, and fat pad signal) and B-mode/power Doppler ultrasound (PF thickness, echogenicity, and vascularity). Covariate data collected included demographic characteristics, disease history, clinical measures, and physical activity by accelerometry. Data were analyzed using multivariable conditional logistic regression. RESULTS: Plantar calcaneal BML size (mm2 , odds ratio [OR] 1.03 [95% confidence interval (95% CI) 1.02-1.05]), larger plantar spurs (OR for spurs >5 mm 2.15 [95% CI 1.13-4.10]), PF signal (OR for signal penetrating >50% of the dorsoplantar width 12.12 [95% CI 5.36-27.42]), PF thickness (mm, OR for MRI 3.23 [95% CI 2.36-4.43] and ultrasound OR 3.78 [95% CI 2.69-5.32]), and echogenicity (diffusely hypoechoic OR 7.89 [95% CI 4.02-15.48] and focally hypoechoic OR 24.92 [95% CI 9.60-64.69]) were independently associated with CPHP. PF vascularity was uncommon, occurring exclusively in cases (cases with signal n = 47 [22%]). Combining imaging biomarkers into 1 model, plantar BMLs and PF imaging biomarkers, but not fat pad signal or heel spurs, were independently associated with CPHP. CONCLUSION: Calcaneal BMLs and PF imaging biomarkers are associated with CPHP. Further research is required to understand whether these different markers represent distinct phenotypes of heel pain, and if so, whether there are specific treatment implications.

Perceived Autonomy Support in Telerehabilitation by People With Chronic Respiratory Disease: A Mixed Methods Study.

BACKGROUND: Autonomy-supportive health environments can assist patients in achieving behavior change and can influence adherence positively. Telerehabilitation may increase access to rehabilitation services, but creating an autonomy-supportive environment may be challenging. RESEARCH QUESTION: To what degree does telerehabilitation provide an autonomy-supportive environment? What is the patient experience of an 8-week telerehabilitation program? STUDY DESIGN AND METHODS: Individuals undertaking telerehabilitation or center-based pulmonary rehabilitation within a larger randomized controlled equivalence trial completed the Health Care Climate Questionnaire (HCCQ; short form) to assess perceived autonomy support. Telerehabilitation participants were invited 1:1 to undertake semistructured interviews. Interviews were transcribed verbatim and coded thematically to identify major themes and subthemes. RESULTS: One hundred thirty-six participants (n = 69 telerehabilitation) completed the HCCQ and 30 telerehabilitation participants (42%) undertook interviews. HCCQ summary scores indicated that participants strongly agreed that the telerehabilitation environment was autonomy supportive, which was similar to center-based participants (HCCQ summary score, P = .6; individual HCCQ items, P ≥ .3). Telerehabilitation interview data supported quantitative findings identifying five major themes, with subthemes, as follows: (1) making it easier to participate in pulmonary rehabilitation, because telerehabilitation was convenient, saved time and money, and offered flexibility; (2) receiving support in a variety of ways, including opportunities for peer support and receiving an individualized program guided by expert staff; (3) internal and external motivation to exercise as a consequence of being in a supervised group, seeing results for effort, and being inspired by others; (4) achieving success through provision of equipment and processes to prepare and support operation of equipment and technology; and (5) after the rehabilitation program, continuing to exercise, but dealing with feelings of loss. INTERPRETATION: Telerehabilitation was perceived as an autonomy-supportive environment, in part by making it easier to undertake pulmonary rehabilitation. Support for behavior change, understanding, and motivation were derived from clinicians and patient-peers. The extent to which autonomy support translates into ongoing self-management and behavior change is not clear. TRIAL REGISTRY: Australian and New Zealand Clinical Trials Registry; No.: ACTRN12616000360415; URL: https://anzctr.org.au/.

Telerehabilitation for chronic respiratory disease: a randomised controlled equivalence trial.

RATIONALE: Pulmonary rehabilitation is an effective treatment for people with chronic respiratory disease but is delivered to <5% of eligible individuals. This study investigated whether home-based telerehabilitation was equivalent to centre-based pulmonary rehabilitation in people with chronic respiratory disease. METHODS: A multicentre randomised controlled trial with assessor blinding, powered for equivalence was undertaken. Individuals with a chronic respiratory disease referred to pulmonary rehabilitation at four participating sites (one rural) were eligible and randomised using concealed allocation to pulmonary rehabilitation or telerehabilitation. Both programmes were two times per week for 8 weeks. The primary outcome was change in Chronic Respiratory Disease Questionnaire Dyspnoea (CRQ-D) domain at end-rehabilitation, with a prespecified equivalence margin of 2.5 points. Follow-up was at 12 months. Secondary outcomes included exercise capacity, health-related quality of life, symptoms, self-efficacy and psychological well-being. RESULTS: 142 participants were randomised to pulmonary rehabilitation or telerehabilitation with 96% and 97% included in the intention-to-treat analysis, respectively. There were no significant differences between groups for any outcome at either time point. Both groups achieved meaningful improvement in dyspnoea and exercise capacity at end-rehabilitation. However, we were unable to confirm equivalence of telerehabilitation for the primary outcome ΔCRQ-D at end-rehabilitation (mean difference (MD) (95% CI) -1 point (-3 to 1)), and inferiority of telerehabilitation could not be excluded at either time point (12-month follow-up: MD -1 point (95% CI -4 to 1)). At end-rehabilitation, telerehabilitation demonstrated equivalence for 6-minute walk distance (MD -6 m, 95% CI -26 to 15) with possibly superiority of telerehabilitation at 12 months (MD 14 m, 95% CI -10 to 38). CONCLUSION: telerehabilitation may not be equivalent to centre-based pulmonary rehabilitation for all outcomes, but is safe and achieves clinically meaningful benefits. When centre-based pulmonary rehabilitation is not available, telerehabilitation may provide an alternative programme model. TRIAL REGISTRATION NUMBER: ACtelerehabilitationN12616000360415.

Chronic plantar heel pain modifies associations of ankle plantarflexor strength and body mass index with calcaneal bone density and microarchitecture.

Chronic plantar heel pain (CPHP) is associated with calcaneal bone spurs, but its associations with other calcaneal bone features are unknown. This study therefore aimed to determine associations between having CPHP and bone density and microarchitecture of the calcaneus. We assessed 220 participants with CPHP and 100 age- and sex-matched population-based controls. Trabecular bone density, thickness, separation and number, BV/TV, and cortical density, thickness and area were measured using a Scanco Xtreme1 HR-pQCT scanner at a plantar and mid-calcaneal site. Clinical, physical activity and disease history data were also collected. Associations with bone outcomes were assessed using multivariable linear regression adjusting for age, sex, physical activity, BMI and ankle plantarflexor strength. We assessed for potential effect modification of CPHP on these covariates using interaction terms. There were univariable associations at the plantar calcaneus where higher trabecular bone density, BV/TV and thickness and lower trabecular separation were associated with CPHP. In multivariable models, having CPHP was not independently associated with any bone outcome, but modified associations of BMI and ankle plantarflexor strength with mid-calcaneal and plantar bone outcomes respectively. Beneficial associations of BMI with mid-calcaneal trabecular density (BMI-case interaction standardised X/unstandardised Y beta -10.8(mgHA/cm3) (se 4.6), thickness -0.002(mm) (se 0.001) and BV/TV -0.009(%) (se 0.004) were reduced in people with CPHP. Beneficial associations of ankle plantarflexor strength with plantar trabecular density (ankle plantarflexor strength -case interaction -11.9(mgHA/cm3) (se 4.4)), thickness -0.003(mm) (se 0.001), separation -0.003(mm) (se 0.001) and BV/TV -0.010(%) (se 0.004) were also reduced. CPHP may have consequences for calcaneal bone density and microarchitecture by modifying associations of BMI and ankle plantarflexor strength with calcaneal bone outcomes. The reasons for these case-control differences are uncertain but could include a bone response to entheseal stress, altered loading habits and/or pain mechanisms. Confirmation with longitudinal study is required.

The Need for Expanding Pulmonary Rehabilitation Services.

Pulmonary rehabilitation is a strongly recommended and effective treatment for people with chronic lung disease. However, access to pulmonary rehabilitation is poor. Globally, pulmonary rehabilitation is accessed by less than 3% of people with chronic lung disease. Barriers to referral, uptake and completion of pulmonary rehabilitation are well documented and linked with organizational, practitioner and patient-related factors. Enhancing the knowledge of health care professionals, family carers, and people with chronic lung disease about the program and its benefits produces modest increases in referral and uptake rates, but evidence of the sustainability of such approaches is limited. Additionally, initiatives focusing on addressing organizational barriers to access, such as expanding services and implementing alternative models to the conventional center-based setting, are not yet widely used in clinical practice. The COVID-19 pandemic has highlighted the urgent need for health care systems to deliver pulmonary rehabilitation programs remotely, safely, and efficiently. This paper will discuss the pressing need to address the issue of the low accessibility of pulmonary rehabilitation. It will also highlight the distinctive challenges to pulmonary rehabilitation delivery in rural and remote regions, as well as low-income countries.

Home-based pulmonary rehabilitation early after hospitalisation in COPD (early HomeBase): protocol for a randomised controlled trial.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is characterised by exacerbations of respiratory disease, frequently requiring hospital admission. Pulmonary rehabilitation can reduce the likelihood of future hospitalisation, but programme uptake is poor. This study aims to compare hospital readmission rates, clinical outcomes and costs between people with COPD who undertake a home-based programme of pulmonary rehabilitation commenced early (within 2 weeks) of hospital discharge with usual care. METHODS: A multisite randomised controlled trial, powered for superiority, will be conducted in Australia. Eligible patients admitted to one of the participating sites for an exacerbation of COPD will be invited to participate. Participants will be randomised 1:1. Intervention group participants will undertake an 8-week programme of home-based pulmonary rehabilitation commencing within 2 weeks of hospital discharge. Control group participants will receive usual care and a weekly phone call for attention control. Outcomes will be measured by a blinded assessor at baseline, after the intervention (week 9-10 posthospital discharge), and at 12 months follow-up. The primary outcome is hospital readmission at 12 months follow-up. ETHICS AND DISSEMINATION: Human Research Ethics approval for all sites provided by Alfred Health (Project 51216). Findings will be published in peer-reviewed journals, conferences and lay publications. TRIAL REGISTRATION NUMBER: ACTRN12619001122145.

Community Participation by People with Chronic Obstructive Pulmonary Disease.

Little is known regarding community participation in individuals with chronic obstructive pulmonary disease (COPD). The aim of this study was to explore community participation in individuals with COPD and to determine whether there is an association between community participation and activity-related outcome variables commonly collected during pulmonary rehabilitation assessment. We also sought to investigate which of these variables might influence community participation in people with COPD. Ninety-nine individuals with COPD were enrolled (67 ± 9 years, FEV1: 55 ± 22% predicted). We assessed community participation (Community Participation Indicator (CPI) and European Social Survey (ESS) for formal and informal community participation), daily physical activity levels (activity monitor), exercise capacity (6-minute walk test), breathlessness (Modified Medical Research Council, MMRC scale), self-efficacy (Pulmonary Rehabilitation Adapted Index of Self-Efficacy) and anxiety and depression (Hospital Anxiety and Depression Scale). Higher levels of community participation on the CPI were associated with older age and greater levels of physical activity (total, light and moderate-to-vigorous) (all rs = 0.30, p < 0.05). Older age and more moderate-to-vigorous physical activity independently predicted greater community participation measured by CPI. Higher levels of depression symptoms were associated with less formal and informal community participation on ESS (rs = -0.25). More formal community participation on ESS was weakly (rs = 0.2-0.3) associated with older age, better lung function, exercise capacity and self-efficacy, and less breathlessness. Self-efficacy, exercise capacity, and age independently predicted formal community participation in individuals with COPD. Strategies to optimize self-efficacy and improve exercise capacity may be useful to enhance community participation in people with COPD.

Chronic Plantar Heel Pain Is Principally Associated With Waist Girth (Systemic) and Pain (Central) Factors, Not Foot Factors: A Case-Control Study.

OBJECTIVE: To determine the independent associations of potential clinical, symptom, physical activity, and psychological factors with chronic plantar heel pain. DESIGN: Case-control. METHODS: We investigated associations by comparing 220 participants with chronic (more than 3 months in duration) plantar heel pain to 100 age- and sex-matched controls, who were recruited randomly from the electoral roll. Exposures measured were waist girth, body mass index, body composition, clinical measures of foot and leg function, physical activity via accelerometry, depression and pain catastrophizing, symptoms of prolonged morning stiffness anywhere in the body, and multisite pain. Data were analyzed using multivariable conditional logistic regression. RESULTS: Waist girth (centimeters) (odds ratio [OR] = 1.06; 95% confidence interval [CI]: 1.03, 1.09), ankle plantar flexor strength (kilograms) (OR = 0.98; 95% CI: 0.97, 0.99), pain at multiple sites (pain at 1 other site: OR = 2.76; 95% CI: 1.29, 5.91; pain at 4 or more other sites: OR = 10.45; 95% CI: 3.66, 29.81), and pain catastrophizing status (none, some, or catastrophizer) (some: OR = 2.91; 95% CI: 1.33, 6.37; catastrophizer: OR = 6.79; 95% CI: 1.91, 24.11) were independently associated with chronic plantar heel pain. There were univariable but not independent associations with morning stiffness, first metatarsophalangeal joint extension range of motion, depression, and body mass index. There were no significant associations with physical activity or body composition (bioelectrical impedance analysis). CONCLUSION: Waist girth, ankle plantar flexor strength, multisite pain, and pain catastrophizing, but not foot-specific factors, were independently associated with chronic plantar heel pain. Of these 4 factors, 3 (waist girth, multisite pain, and pain catastrophizing) were central or systemic associations. J Orthop Sports Phys Ther 2021;51(9):449-458. Epub 7 May 2021. doi:10.2519/jospt.2021.10018.

The Impact of Pulmonary Rehabilitation on 24-Hour Movement Behavior in People With Chronic Obstructive Pulmonary Disease: New Insights From a Compositional Perspective.

BACKGROUND: Physical activity levels are low in people with chronic obstructive pulmonary disease, and there is limited knowledge about how pulmonary rehabilitation transforms movement behaviors. This study analyzed data from a pulmonary rehabilitation trial and identified determinants of movement behaviors. METHODS: Objectively assessed time in daily movement behaviors (sleep, sedentary, light-intensity physical activity, and moderate- to vigorous-intensity physical activity) from a randomized controlled trial (n = 73 participants) comparing home- and center-based pulmonary rehabilitation was analyzed using conventional and compositional analytical approaches. Regression analysis was used to assess relationships between movement behaviors, participant features, and response to the interventions. RESULTS: Compositional analysis revealed no significant differences in movement profiles between the home- and center-based groups. At end rehabilitation, conventional analyses identified positive relationships between exercise capacity (6-min walk distance), light-intensity physical activity, and moderate- to vigorous-intensity physical activity time. Compositional analyses identified positive relationships between a 6-minute walk distance and moderate- to vigorous-intensity physical activity time, accompanied by negative relationships with sleep and sedentary time (relative to other time components) and novel relationships between body mass index and light-intensity physical activity/sedentary time. CONCLUSION: Compositional analyses following pulmonary rehabilitation identified unique associations between movement behaviors that were not evident in conventional analyses.