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PhD Protocol COPD & IPF

COPD patients' experience and benefits after virtual rehabilitation compared with hospital outpatient and municipality a
by

Jose Cerdán

on 8 February 2018

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Transcript of PhD Protocol COPD & IPF

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Intro to COPD
PhD Project Protocol
Effects, efficacy & cost-effectiveness of tele-rehabilitation with IPF & COPD patients vs standard treatment. 3 randomized trials.
José Cerdán
Cand.IT-E-buss, MSC- & BSC Physiotherapy
COPD general statistics, forecast and solutions.


200,000 to 400,000 people with COPD 50,000 with severe COPD in DK.
Cigarette smoke causes 85-90% of cases
Reduced quality of life
Objective of the today´s treatment
Stop the progression of the disease
Prevent acute exacerbation
Improve quality of life
Reduce symptoms
Reduce mortality

In any case worsening of dyspnea directly correlated with their lung´s maturity
Rehabilitation of COPD
Quitting smoking
Physical training
Medical treatment
Nutritional education
Patient education
Psychosocial support
Pulmonary rehabilitation improves
Physical training condition
Walking distance
Functionality
General condition
Quality of life
Long-term survival
¨
The only parameter that is not altered by rehabilitation is the lung function measured by FEV 1
Four Basic Stage of COPD
1-Mild: FEV1/FVC <0.70 and FEV1 80% predicted value*
2-Moderate: FEV1/FVC <0.70 and 50% FEV1 <80% predicted value*
3-Severe: FEV1/FVC <0.70 and 30% FEV1 <50% predicted value*
4-Very Severe: FEV1/FVC <0.70 and FEV1 <30% predicted value* or FEV1 <50% predicted value plus chronic respiratory or heart failure
Telemedicine, Telemonitoring & biotelemetry
KMD In their report, "Chronic illness - a digital community diagnosis” concludes that telemedicine can help to facilitate everyday life for patients with chronic diseases and may be used for continuous monitoring and control
Telemonitoring:
the use of information technology to monitor patients at a distance in a medical practice, meaning monitoring patients who are not at the same location as the health care provider.
data transmission between the patient’s home and health provider located in the hospital
data move rather than people.
includes both objective (from sensors) and subjective (from questionnaires) collection of parameters regarding patient's health and comfort
Telemedicine:
clinical practice for diagnosis, review, or management undertaken synchroneusly or asynchronously through the medium of information and telecommunications technologies
Biotelemetry:
a transmission of biologic or physiologic data from a remote location to another location for data interpretation and decision-making collection
(decision support system)
of such data that can be then filtered to define the statistics doctors may check on a daily or weekly basis to determine the best course of treatment
Challenges applying telemedicine
Delegation of clinical tasks to nonmedical personnel:
Responsibility transition is out of place in health care organization nowadays.
New legal and organizational framework has to be designed
Healt Care Provider´s lack of confidence in telemedicine equipment

User acceptance of tele-rehabilitation services is one of the essential barriers to deploy telemedicine applications
Standardized and commercialized telemedicine test methods for COPD
Today it is possible to telemonitor in COPD patients their lung capacity, oxygen saturation, pulse and weigh

Spirometry O2 Saturation-Pulse






Weigh Body Fat Percentage
Up & Go test
Incremental shuttle walk test (ESWT)
Test: Endurance shuttle walk test (ESWT)
6 min Walk Test
Sub Mximal Ergo Bike test
R-S-S-T standard, times / 30 sec:
Methods to test IPF & COPD
Objective Physio Test Methods
OBJECTIVE
SUBJECTIVE
Medical Research Council Dyspnea Scale
The Borg CR10 scale
Quality of life questionnaires
Respiratory & workload disability
Chronic Respiratory Questionnaire (CRQ)
St George’s Respiratory Questionnaire for COPD patients (SGRG-C)
Medical Outcomes Study Short Form (SF-36)
EuroQol
Self-Efficacy
COPD Self Efficacy Scale (CSES)
Activity of Daily Living
COPD:
Instrumental Activity of Daily Living (IADL) questionnaire
IPF:
Kings Brief ILD questionnaire (KBILD)
Anxiety
Hospital Anxiety and Depression Scale (HADS)
Organization and physiotherapy treatment offered to COPD individuals
CENTER
COPD Degree & Exarcerbation
Rehabilitation
"Exercise on prescription" to practice in patients closed environment or by becoming a member of a
fitness center

Level 1
(General practice): Mild and Moderate COPD, FEV1 ≥ 50% of predicted value. MRC: 1-2:
•Patient
encouraged exercising
: for example
walking, cycling and nordic walking, participate in activities where large muscle groups are activated
. It is
not necessary
to provide
supervised training
in this patient group.
Municipal-ambulatory training center (Sundhedscenter)

Level 2
(Alternating): Severe COPD, 30% <FEV1 <50% of predicted value. MRC: 3
•Patients should exercise at least
3-4 times/ W
, including
2 times under supervision
in connection with attendance to group training

Aerobic training
intensity corresponding to between 60 to 80% of the maximum oxygen uptake.
•Training program extends over at least
7 weeks
.
•Focus on
energy-saving behavior
and the use of aids (eg walkers),

Group workout
consisting on:
warm up
; Individual
walk training
. Exercise intensity 70 to 80% of estimated maximum oxygen uptake;
Cycling
with strain;
Strength
specific training for
leg muscles
as quadriceps, hamstrings and calf;

Relaxation
/ relaxation

Write diary
of both training focus and home workouts.
Municipal- personalized home Training (by Sundhedscenter)
Level 2
(Alternating): Severe COPD, 30% <FEV1 <50% of predicted value. MRC: 3
Level 3
(Lunge Medical outpatient): Very Severe COPD, FEV1 30% of predicted value. MRC: 4-5

Customized
home physical training
program

•Physiotherapist evaluates
patients resources
(physically and psychically) and patients
close environment
Hospital ambulatory center
Level 2
(Alternating): Severe COPD, 30% <FEV1 <50% of predicted value. MRC: 3
•Physical training
2 times/W
.
•Teach primarily the right
walking speed
and how to
tackle the respiratory distress
arising in connection with physical exertion.
•Learn how to
use a stopwatch
and the
Borg scale
and how to fill the
exercising diary


Training group
of approx. 10 patients.
•Procedure of the training:
Warming up
10 minutes,
Individual training
:
walking
speed (+ recording time), Individual
cycling
(bike training with a resistance that feels heavy (approx. 40 revolutions / minute)).
level is raised
the
next training
day.
Hospital (internated)
Level 3
(Lunge Medical outpatient): Very Severe COPD, FEV1 30% of predicted value. MRC: 4-5
•quickly as possible start of physical training

Train with additional oxygen
if blood oxygen saturation below 92%.
•Patients who have oxygen at home, has to be trained with oxygen.

Respiratory techniques
(expiration / inspiration ratio 2:1 and
huffing and cough techniques

Exercise combined with walk training, strength and endurance training
.
CENTER
COPD Degree & Exarcerbation
Rehabilitation
CENTER
COPD Degree & Exarcerbation
Rehabilitation
CENTER
COPD Degree & Exarcerbation
Rehabilitation
CENTER
COPD Degree & Exarcerbation
Rehabilitation
MUNICIPALITY
HOSPITAL
Fitness C.
Physiotherapy treatment using telerehabilitation
TELEREHABILITATION???
trialled an
in-home videoconferencing system
to determine the feasibility of delivering rehabilitation services remotely to
aged clients
and arrived to the conclusion that to implement telerehabilitation more widely in older people
there are barriers
to be overcome relating to patient limitations, staff issues and the logistics of the sys-tem.
77% of 44 admitted patients were considered unsuitable
for telerehabilitation due mainly to
hearing
and/or
vision impairment
, client/carer
anxiety
,
lack of space
in the home, and
cognitive impairment
. telerehabilitation was particularly challenging because of the complexity of cases, with many requiring “hands-on” therapy.
The system was a eHABTM device mainly used remotely for physical consultations conducted by physiotherapists, occupational therapists and speech pathologists.
Peel NM et al 2011
Tousignant et al 2011
have studied the
satisfaction of patients
and physiotherapists with telerehabilitation
after knee replacement
. In a
randomized controlled clinical trial
,
22
elderly
patients
with
new knee
offered
telerehabilitation 2 times/w for 8 weeks
. The
control
group consisted of
20
elderly
patients
with in operated new knee. They got the usual offer of home exercise as many times as physiotherapists estimated that it was necessary. Both groups of patients (
Tele and Control
) were
satisfied
with the services received and
no significant difference
was
observed between them
. Moreover, the
physiotherapists’ satisfaction with regard to goal achievement, patienttherapist relationship, overall session satisfaction, and quality and performance of the technological platform was high
. The results in this study show that
in-home telerehabilitation seems to be a promising alternative
to traditional face-to-face treatments.
Eriksson L et al 2011
investigated the experience of
10 patients
who
received video-based physiotherapy
at home for
2 months
after a
shoulder joint replacement
. Videoconferencing took place via the patient’s home broadband connection at a bandwidth of 256–768 kbit/s. The
patients’ experiences
of interactive video-based physiotherapy at home after shoulder joint replacement indicated that they
felt safe
,
competent and strengthened in their daily exercise routine
.
Access to frequent support and feedback, continuity, reinforced communication, specific body knowledge and being at home were aspects contributing to an enhanced recovery competence
. The findings also illustrated the extensive character of physiotherapy treatment.
After the present study, telerehabilitation
physiotherapy has been permanently
incorporated
into a new standard of physiotherapy
in the region of Norrbotten
in Sweeden
Eriksson L et al 2009
explore the
benefit of video communication in home rehabilitation after shoulder joint replacement
and compared it to referral for physiotherapy in the conventional way. They arrive to the conclusion that despite some limitations, there
seem to be clear benefits from physiotherapy at a distance with a telemedicine technique that allows patients to obtain access to physiotherapy at home
. They express also that the
challenge
to refine physiotherapy at a distance may be the development of indirect
techniques to bring the therapists hands ‘through the wires’
, by the use of robotics,
or to develop the physiotherapist role in order to compensate for not being in the same room as the patient
. It would be interesting to see more studies about physiotherapy at a distance, both long term follow-ups and studies on its cost effectiveness.
Tousignant M et al 2010
examined how efficiently is
tele-rehabilitation
for patients
after

total knee aloplastic operation
. They observed in their study a
high patient compliance
, suggesting that the
technology was not a barrier
. The study showed that both
patients and therapists
were
satisfied
with tele-rehabilitation. There were almost the
same effect
for patients treated with
telerehab
than than the ones treated with
face-to-face
rehabilitation, but the results indicated that
face-to-face
training gave a
better effect on

ADL
level. Before the project started there were
resistance from therapists
to train patients on long distance, but many of them
changed their mind
on the approach during the execution of the project.
.... But what about physiotherapy treatment using telerehabilitation with IPF & COPD patients?
Song B et al 2010
design and
test a decision support system
(DSS) which observes and
controls physical ergometer training sessions of COPD patients
. Based in systematic literature review and expert interviews they
build
a
knowledge base for the DSS
. They establish and
standardize nine production rules
and
develop software that autonomously controls training sessions
on a ergometer-bicycle
on the basis of vital signs
data. The system was tested in a
lab environment
with
few subjects
, but
no studies where done on the effects of such training
method with COPD patients regarding quality of life and physical status. It is thought that
such system can be used in a telerehabilitation set up
There is no study concerning teletraining IPF patients, but...
In my opinion
For my PhD I propose
2
Design A New Physical Tele Rehabilitation Application for patients with COPD (NPTRA-COPD)
Characteristics:
Patient-centered-design /Empowerment of COPD patients with a self-management policy
New organization design
Relevant evidence-base medicine on COPD-physical rehabilitation
Digitalization & Standarization of:
Training programs (With Virtual Reality, Agent-Avatar Case)
Evaluation methods (Objective with Augmented Reality/ Subjective with Web applications)
3 phases
1
Development of a new virtual exercise program for severe COPD patients where health care specialist will have the opportunity to empower patients with a part-self managed physical telerehabilitation-tool & program.
Testing phase where the new telerehabilitation program will be tested with real patients
Evaluation phase where the results of the testing phase will be analyzed and evaluated for publication in international papers.
3


based on the following hypotheses:

1. Physical functions are equal or improved for virtual rehabilitation compared with conventional rehabilitation.
2. Self-efficacy, activities of daily living and health-related quality of life are equal or improved for virtual rehabilitation compared with conventional rehabilitation.
3. Prevalence of anxiety and depression are equal or reduced after virtual rehabilitation compared with conventional rehabilitation.

Research type:
Trial study (20 patients)
Compare COPD patient's physical functions after virtual rehabilitation at homes with conventional outpatient rehabilitation (Singel Case Study)
The project will be designed as a
prospective randomized controlled trial
where the aim is to
investigate the effects of telerehabilitation compared with ambulatory rehabilitation in IPF & COPD patients stage 4
(gold standards).
Design
Men and women aged over 45 years
COPD stage 3 or 4, according to GOLD criteria(39) and in stable phase.
Mild or moderate exacerbation
FEV1 <60%
pH >7.35
Compliant patient that can return home (assessed by the investigator)
There is a written informed consent
Inclusion Criteria:
The patient has significant musculoskeletal disorders, which limits his/her function levels to a degree that is not caused by dyspnea.
The patient has unstable angina pectoris or hemodynamically significant aortic valve stenosis (Because of risk of cardiac ischemia and syncope).
The patient have stated dizziness, significant sensory or motor disabilities, dementia or terminal malignant disease
Severe co morbidities (unstable heart disease, irregular diabetes, known malignant disease, another illness that makes the patient inappropriate for participating in the study).
Non-compliant patient (eg. Nursing home residents)
Exclusion Criteria:
Participation in another project within the last 30 days
Mini-Mental State Examination score below 24 points.
Severe vision or hearing impairment.
Non-Danish speaking.
Unwillingness to implement the protocol.
Motor or sensory disease which make walk training impossible
Has experience an exacerbation in the last 4-6 weeks.
Agenda
Intro:
IPF & COPD
Telemedicine
Test Methods
Organization
TeleRehabilitation
Purpose
Design
Patients:
Inclusion criteria
Exclusion Criteria
Project flow
ThE EnD
Thanks for your attention
For more information contact me at:
cerdan@itu.dk
Tel: +4530648283

Pilot 1 COPD
Procedure
Progress
Effect
2
supervised
sessions in group /w ; 8 w
Follow-up after 8 weeks, 5 months, and 8 months
X
y
5 virtual assisted

self training sessions
/w ; 8 w
Follow-up after 8 weeks, 5 months, and 8 months
Test from base line
decreases
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
80 IPF +160 COPD stage 4
Hospital Ambulatory rehab or follow -up
n=120
Virtual rehab
n=120
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
selftraining
selftraining
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
selftraining
selftraining
selftraining
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
selftraining
selftraining
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
11
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
selftraining
selftraining
selftraining
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
selftraining
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
selftraining
selftraining
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
selftraining
Objective Test:
FVC (FVC6)
FVE1
Oxygen saturation
resting Puls
6min Walk
Pedometer 7 days
Subjective test:
IADL
SGRQ
K-BILD
Base
line
Test
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
Project Flow Extended
1.w
2.w
3.w
4.w
5.w
6.w
7.w
8.w
selftraining
virtual assisted

self training sessions


The 2 supervised 2h sessions/w physiotherapy during the period of 8 weeks will be given virtually in a tele-meeting environment with a real physiotherapist and a virtual automated physiotherapist.
Group-training meeting with 4-5 patients at the same time on the screen.
Set up and wear their wireless Puls-Oxymeter and Blood Pressure devices
Biotelemetry data shows in physiotherapist’s terminal and in real time.
Objective:
-Check patient’s progress and status.
-Perform the warm up screening the real-time biotelemetry values.
-Be the social part of the intervention program.
Patient train its individual workout and relaxation part with an automated physiotherapist agent.
Easy training tools as elastics, weights and a fitness-step that will be used in different exercises to reproduce the same effects as an ergometer-bike-training following the rules from Song B et al (37).
The automated physiotherapist agent will then be animated to propose the patient to imitate him performing exercises according to next Rules:
Intervention Group: Virtual Rehabilitation
P
hysical Training F2F
Teaching
11 sessions
Pedagogical videos on the same subjects areas as conventional group
Followed by few questions (to assure patient’s understanding)
If understanding under 80%, the specialist for such subject as (doctor, nutritionist, etc) will be encouraged to get in contact with the patient via telephone or tele-meeting to solve patients misunderstandings on such subject)
At least 2 session/week during the whole 8 months intervention
Patient has to exercise alone at home
Autonomed Virtual Physiotherapist Agent
Guide the patient on how to perform the exercises and following the rules showe in last slide.
A digital diary will be registering automatically the data obtained by the system on patients self performance.
Physical Training F2S
Tabel 1:Knowledge base in the DSS


The program consists of a total of 16 sessions with 2 sessions (2h. each) every week of an 8 week program.
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Control Group: Conventional rehabilitation
P
hysical Training F2F
Teaching
The 11 sessions
1.Introduction to rehabilitation and rehabilitation program
2.Disease understanding
3.Smoking and COPD
4.Treatment
5.Nutrition Guide
6.Living with COPD 1 (most of everyday, breathing techniques, dyspnea management, mm.)
7.Living with COPD 2 (anxiety, stress, everyday life, social networks, sexuality, etc..)
8.Occupational therapy / assistive
9.Social Counselling (support, regulatory, patient associations, etc..)
10.Exacerbations (etiology, management and planning)
11.Follow-up, summary
At least 2 session/week during the whole 8 months intervention
The patient is encourage to exercise at any time with a specific home training program during the whole intervention.
A diary is handled to the patients in order to register the degree of their hometraining.
Self Physical Training
Telemedicine
Hypothesis
Control Group
Intervention Group
selftraining
virtual assisted

self training sessions
1
Test phase where the new telerehabilitation program will be tested with real patients
PhD Plan
year
Develop a new virtual exercise program for severe COPD patients
Evaluation phase: Results of the testing phase will be analyzed, evaluated, discussed & publicated
year
year
Hospital Ambulatory rehab
n=40
Virtual rehab
n=40
Test from base line
x = y
1
Recruitment of patients
Randomization
IPF
n=80
n=160
COPD
n=
40
+
80
=120
Study
Control
Intervention
n=
80
+
160
=240
• IDIOPATHIC PULMONARY FIBROSIS (IPF)

Intro to IPF
IDIOPATHIC PULMONARY FIBROSIS (IPF)


Progressive fibrotic lung disease of unknown cause
_________________ people with IPF in DK.
Median survival of 3-5 years.
Objective of the today´s treatment
Stop the progression of the disease
Prevent acute exacerbation
Improve quality of life
Reduce symptoms
Reduce mortality


Rehabilitation of IPF
No curative treatment exists
Pulmonary rehabilitation recommended
Pulmonary rehabilitation improves
Quality of life
Exercise tolerance
GOLD standars
Problems reported by IPF patients:
Social isolation,
Increased level of dependency
Immobility.
Dyspnea & fatigue lead to reduction in:
Daily physical activities
Exercise tolerance
Muscle strength
Quality of life.
As the disease progresses, worsening of:
Lung function
Gas exchange impairment
Hypoxemia during physical activity leading to a downward spiral
Tousignant et al 2012
Purpose :
Investigate the efficacy of in-home telerehabilitation for people with COPD.
In COPD:

10-20% of the sickest COPD patients consume over 70% of total health expenditure
Authorities worried: Emphasize clinical, prevention-related interventions and development of welfare's solutions to cope COPD in our society.

40% to 50% COPD patients discharged from hospitals are readmitted the following year.
Large economic costs in our society (2001, 600 million dkk in direct hospital care costs in DK, stimation of 3-billion dkk for 2002)
Results:
Clinical outcomes improved for all subjects except for locomotor function in the first participant.
Conclusion:
In-home telerehabilitation for people with COPD is a realistic alternative to dispense rehabilitation services for patients requiring physical therapy follow-up.

Method:
Pre/post-test design without a control group.
Population:3 community-living elders with COPD were recruited in a rehabilitation outpatient group & by direct referrals from pneumologists with COPD outpatients.

Treatment:
15 telerehabilitation sessions conducted by two trained physiotherapists
Test:
Locomotor function (walking performance)
quality of life
Measured in person prior to and at the end of the treatment.
Tele Rehabilitation need:
higher quality studies on the efficacy & cost-effectiveness
long-term effects of TR have to be determined.
BUT:
no scientific research focusing in the treatment of IPF with TR is found
no scientific proof of TR based on COPD patient ´s adherence & security, treatment efficacy & improved quality of life is showed.

Chronic Lung Disease Patients need:
Maintain a high health care qualitative service in the coming decades
Society need:
economically save the national health systems for an expensive bill to treating chronic patients,
take new actions plans in mind ( treat more patients with less human resources)
sustaining & improve today’s health care services.
Success criteria:
maintain a quality of service chronic patients are willing to accept.

Potential solution:
TR seems to be a good welfare action plan.
n=
40
+
80
=120
Pilot 1 COPD
Pilot 2 COPD
Pilot 3 IPF
n=
40
+
40
=80
n=
40
+
40
=80
n=
40
+
40
=80
Pilot 2 COPD
Procedure
Progress
Effect
Follow-up after 8 weeks, 5 months, and 8 months
X
y
5 virtual assisted

self training sessions/
w
; 8 months
Follow-up after 8 weeks, 5 months, and 8 months
Test from base line
Hospital follow-up
n=40
Virtual follow-up
n=40
Test from base line
x = y
self training sessions;
8 months
Pilot 3 IPF
Procedure
Progress
Effect
Follow-up after 8 weeks 5 months, and 8 months
X
y
5 virtual assisted

self training sessions
/w; 8 months
Follow-up after 8 weeks 5 months, and 8 months
Test from base line
Hospital Follow-up
n=12
Virtual rehab
n=12
Test from base line
x = y
self training sessions;
8 months
Objective Test:
FVC (FVC6)
FVE1
Oxygen saturation
resting Puls
6min Walk
Pedometer 7 days
Subjective test:
IADL
SGRQ
K-BILD
Base
line
Test
Objective Test:
FVC (FVC6)
FVE1
Oxygen saturation
resting Puls
6min Walk
Pedometer 7 days
Subjective test:
IADL
SGRQ
K-BILD
Base
line
Test
Pilot 1 COPD
Pilot 2 COPD
Pilot 3 IPF
Pilot 1 COPD
Pilot 2 COPD
Pilot 3 IPF
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
Nr:
exacerbations
visits clinic
Cost:
acute
rehabilitation
medicine
transportation
homecare
Objective Test:
FVC (FVC6)
FVE1
Oxygen saturation
resting Puls
6min Walk
Pedometer 7 days
Subjective test:
IADL
SGRQ
K-BILD
Base
line
Test
Nr:
exacerbations
visits clinic
Cost:
acute
rehabilitation
medicine
transportation
homecare
Recruitment of patients
Randomization
n=80
COPD
n=
40
Study
Control
Intervention
n=
40
1
1
2
2
3
3
4
4
5
6
6
7
7
8
8
9
9
10
10
11
12
12
13
14
16
15
14
13
15
16
5
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
80 COPD stage 4
Hospital Ambulatory rehab
n=40
Virtual rehab
n=40
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
11
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Warming up in group
Individual workout
Individual cyckeltræning
Relaxation
Objective Test:
FVC (FVC6)
FVE1
Oxygen saturation
resting Puls
6min Walk
Pedometer 7 days
Subjective test:
IADL
SGRQ
Base
line
Test
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
Project Flow Extended
1.w
2.w
3.w
4.w
5.w
6.w
7.w
8.w
virtual assisted

self training sessions
virtual assisted

self training sessions
Objective Test:
FVC (FVC6)
FVE1
Oxygen saturation
resting Puls
6min Walk
Pedometer 7 days
Subjective test:
IADL
SGRQ
Base
line
Test
Objective Test:
FVC (FVC6)
FVE1
Oxygen saturation
resting Puls
6min Walk
Pedometer 7 days
Subjective test:
IADL
SGRQ
Base
line
Test
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
Nr:
exacerbations
visits clinic
Cost:
acute
rehabilitation
medicine
transportation
homecare
Objective Test:
FVC (FVC6)
FVE1
Oxygen saturation
resting Puls
6min Walk
Pedometer 7 days
Subjective test:
IADL
SGRQ
Base
line
Test
Nr:
exacerbations
visits clinic
Cost:
acute
rehabilitation
medicine
transportation
homecare
1
1
2
2
3
3
4
4
5
6
6
7
7
8
8
9
9
10
10
11
12
12
13
14
16
15
14
13
15
16
5
80 COPD stage 4
Hospital
follow -up
n=40
Virtual follow-up
n=40
11
Objective Test:
FVC (FVC6)
FVE1
Oxygen saturation
resting Puls
6min Walk
Pedometer 7 days
Subjective test:
IADL
SGRQ
Base
line
Test
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
Project Flow Extended
1.w
2.w
3.w
4.w
5.w
6.w
7.w
8.w
virtual assisted

self training sessions
virtual assisted

self training sessions
Objective Test:
FVC (FVC6)
FVE1
Oxygen saturation
resting Puls
6min Walk
Pedometer 7 days
Subjective test:
IADL
SGRQ
Base
line
Test
Objective Test:
FVC (FVC6)
FVE1
Oxygen saturation
resting Puls
6min Walk
Pedometer 7 days
Subjective test:
IADL
SGRQ
Base
line
Test
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
Nr:
exacerbations
visits clinic
Cost:
acute
rehabilitation
medicine
transportation
homecare
Objective Test:
FVC (FVC6)
FVE1
Oxygen saturation
resting Puls
6min Walk
Pedometer 7 days
Subjective test:
IADL
SGRQ
Base
line
Test
Nr:
exacerbations
visits clinic
Cost:
acute
rehabilitation
medicine
transportation
homecare
Recruitment of patients
Randomization
n=24
IPF
n=
12
Study
Control
Intervention
n=
12
1
1
2
2
3
3
4
4
5
6
6
7
7
8
8
9
9
10
10
11
12
12
13
14
16
15
14
13
15
16
5
20 IPF patients
Hospital
follow -up
n=10
Virtual follow-up
n=10
11
Objective Test:
FVC (FVC6)
FVE1
Oxygen saturation
resting Puls
6min Walk
Pedometer 7 days
Subjective test:
SGRQ
K-BILD
Base
line
Test
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
virtual assisted

self training sessions
Project Flow Extended
1.w
2.w
3.w
4.w
5.w
6.w
7.w
8.w
virtual assisted

self training sessions
virtual assisted

self training sessions
Objective Test:
FVC (FVC6)
FVE1
Oxygen saturation
resting Puls
6min Walk
Pedometer 7 days
Subjective test:
SGRQ
K-BILD
Base
line
Test
Objective Test:
FVC (FVC6)
FVE1
Oxygen saturation
resting Puls
6min Walk
Pedometer 7 days
Subjective test:
SGRQ
K-BILD
Base
line
Test
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
selftraining
Nr:
exacerbations
visits clinic
Cost:
acute
rehabilitation
medicine
transportation
homecare
Objective Test:
FVC (FVC6)
FVE1
Oxygen saturation
resting Puls
6min Walk
Pedometer 7 days
Subjective test:
SGRQ
K-BILD
Base
line
Test
Nr:
exacerbations
visits clinic
Cost:
acute
rehabilitation
medicine
transportation
homecare
Full transcript