Provided by: American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) | The Centers for Medicare and Medicaid Services (CMS) has posted its proposed regulations for Hospital Outpatient Prospective Payment Services, with formal publication in the Federal Register scheduled for later this month. This proposed regulation provides detailed information regarding cardiac rehabilitation (CR), intensive cardiac rehabilitation (ICR), and pulmonary rehabilitation (PR).
The evidence base for remote pulmonary rehabilitation (PR) has been explored in Canada (1), Australia (2) and other countries. The US has minimal experience in this emerging area of therapy excluding a few clinical trials (3) and isolated commercial models. This is at least in part due to lack of reimbursement, evidence-based guidelines and clinical experience. The COVID 19 pandemic has brought with it physical distancing, shelter in place and the increased risk of infection and sequelae for older people and those with chronic lung disease. This has led to a need and possibly an opportunity for PR programs to consider a remote approach while center-based PR programs are closed, are functioning at reduced capacity, and/or patients are uncomfortable returning to clinical and/or group settings.
Reimbursement for remote PR is not currently provided by Medicare, despite uncertainty regarding safe provision of center based PR during the pandemic. All major US pulmonary organizations have collaborated to request Medicare payment for remote PR. The author suggests that providers contact all other insurers to request authorization for payment of remote PR.
Remote PR should deliver the essential components of pulmonary rehabilitation, including exercise training, education, and behavior change. Remote PR can be one of home exercise under supervision, telerehabilitation, video rehabilitation, and home exercises with the aid of online tools and videos. An Australian study included a phone based intervention with motivational interviewing by trained clinicians (2). Presented below are general resources that focus on helping patients understand the necessary interface with the PR clinician and safety considerations.
Exercise assessment, recommendations and prescription including progression should be derived from evidence based guidelines such as those published by the ATS (4) or the American College of Sports Medicine (5), and adapted by the prescribing provider to be appropriate for the individual patient and for use in a remote setting. The following resources are a compilation of information from various guidelines and PR providers. Importantly, these considerations lack the evidence base of center-based PR and extensive experience in the US. Exercise prescription, in particular, must utilize a collaborative approach by the prescribing clinician, patient and (ideally) family and/or caregiver, and must include safe and appropriate approaches that consider:
An exercise assessment is needed for effective PR, yet is often not included in remote models. A center-based exercise test pre PR should be performed to assess exercise capacity and desaturation, and enable individualized exercise prescription. This may not be possible in all settings but should be included when local infection prevention guidelines permit, and prioritizing patients for walk tests that cannot safely start remote PR without it.
Successful remote PR must also include exercise progression and reassessment with an expectation that the exercise prescription will increase over time. These features of PR should be based on national guidelines such as ACSM, ATS or AACVPR.
It needs to be acknowledged that, for a substantial number of patients with chronic lung disease, remote rehabilitation will not be an appropriate mode of therapy. For those who are judged good candidates, effective remote rehabilitation can be accomplished only with close and continuing contact between the patient and the rehabilitation team. Technological aids such as videoconferencing and remote monitoring may be useful adjuncts.
Suggestions for Remote Pulmonary Rehabilitation
The options below are not an endorsement of a specific approach to remote PR. Any approach or information should only be used by patients with involvement and agreement of their provider. These considerations are not medical advice. The author, CTS, and UCSF make no warranty or representation that these considerations will ensure the health of patients or preclude the possibility of negative outcomes. This is not a comprehensive approach, and it does not contain all available information on the subject matter. This document was prepared based on available information existing at the time of publication and therefore may be superseded by later developments.
Below are general recommendations for exercise in chronic obstructive pulmonary disease (COPD) from the American College of Sports Medicine (ACSM). They require clinical assessment and insights regarding exercise prescription in lung disease from the prescribing clinician.
ACSM FITT Aerobic Recommendations for Those with COPD
ACSM: American College of Sports Medicine
FITT: Frequency, Intensity, Time, Type
ACSM FITT Resistive Exercise Recommendations for COPD and Asthma
Key: RM = repetition maximum, RPE = rating of perceived exertion
These considerations are for the general information of PR professionals and clinicians. Each rehabilitation program, its clinicians and patients must decide which practices if any to implement based on a collaborative approach involving the PR team, medical director and potential patients. Please refer to the ACSM Guidelines for Exercise Testing and Prescription, 10th edition, Wolters Kluwer Health (5) for full information.
Remote Pulmonary Rehabilitation
Information to be provided to patients
Thank you for considering remote pulmonary rehabilitation (PR). Below are a few considerations we would like you to know.
We will be evaluating you for exercise in your home using established questions and tools. We are eager to know what your goals are and what you would like to do differently or improve. Below is information about remote pulmonary rehabilitation and factors that will help it to be safe and effective.
Please let us know if you have questions. And most importantly, if any of the exercises create discomfort before, during or after the PR sessions or any exercise or activity, please let us know immediately. Any pain is a signal to stop doing what you are doing and rest. Muscle or joint pain can occur with exercise. Mild pain often responds to rest, ice (apply to area of soreness for 20 minutes to every 4 hours using an ice pack or frozen peas or corn wrapped in a towel or thick cloth), elevation and mild pain medicine such as acetaminophen (provided you are not allergic to the medication). Alert us for any pain you have. If you experience moderate to severe joint or muscle pain, contact your physician promptly or call your local emergency room. Chest pain requires prompt medical attention normally in an Emergency Room setting.
We will provide you with suggestions for exercise. We want and need your input regarding what you feel you can do fairly easily without discomfort, somewhat severe or severe breathlessness, or other abnormal symptoms. Below are examples of symptoms that should alert you to stop exercising and to get help.
When to Stop Exercise and Seek Help
Monitoring your oxygen saturation level, heart rate and shortness of breath at rest and during exercise is an important and required part of remote pulmonary rehabilitation.
Oxygen is an essential nutrient for muscle, brain, and heart function and for human life. We will need you to purchase and use a ‘finger oximeter’ to measure oxygen saturation at rest before and during exercise. https://www.thoracic.org/patients/patient-resources/resources/pulse-oximetry.pdf These are available at from many suppliers (e.g., Amazon and various local pharmacies).
Your doctor may prescribe oxygen and advise you what ‘flow rate’ or how many liters per minute of oxygen to use at rest and with exercise. We want you to check your oximeter reading (oxygen saturation) and heart rate at rest and during exercise daily. If your saturation level is below 88% (below 90% in people with pulmonary hypertension or pulmonary fibrosis), slow down and rest. Your goal is to keep your oximeter reading at or above this number. Ask your lung specialist or rehabilitation clinician what your goal is for oxygen saturation and heart rate at rest and during exercise. Let him/her know if you need assistance with monitoring oxygen saturation or heart rate.
Shortness of breath is common in persons with breathing disorders. Breathlessness can be frightening, especially if severe. We use the Borg scale to rate your breathlessness and fatigue on a scale of one to ten. Exercise in persons with breathing disorders results in some breathlessness. This breathlessness occurs normally with exercise at a moderate or greater level of work. Mild to moderate breathlessness is normal and usually safe during exercise. If your shortness of breath is greater than 5 or ‘strong’ on the Borg scale, slow down or rest. If you quickly return to your baseline, it’s usually OK to resume exercise at a slower pace. Your goal is 2-3 on the Borg scale or mild to moderate breathlessness with exercise unless your therapists recommend otherwise.
Positions to Relax when you have Shortness of Breath
Safe Exercise at Home
Think about what part of your home is the safest for exercise. This area should be free from electrical cords, long oxygen tubing, throw rugs or furniture that may increase your risk for tripping or falling. If your doctor has advised you to use a cane or walker, you will need to use it for any walking exercises. Think about walking where you can hold on to a countertop or stable, heavy piece of furniture if needed for balance. IF YOU HAVE DIFFICULTY WITH VISION, BALANCE, WEAKNESS, CHEST PAIN, DIZZINESS OR LEG CRAMPING, LET US KNOW RIGHT AWAY.
Ask your provider if you should measure your blood pressure at home before and after exercise. If recommended, ask your provider to let you know what blood pressure range is safe for you and what range you should stop exercising and get help. Have your provider observe you taking your blood pressure to ensure your measurements are accurate.
We ask that you use a stable surface such as a kitchen counter and/or a stable chair with arms and no wheels to hold on to during balance exercises.
Items that can be used for home exercise include your current equipment (discuss this with your rehab staff), and inexpensive additions including a rollator (see photo above), foot peddler (see photo above and Amazon) and elastic bands. If possible, let a family member or friend know when you start and stop exercising at home so that they can be available to help to you in case of problems.
Getting the Most Out of Remote Exercise
You will get more out of home rehabilitation if you keep track of your exercise type, time and/or distance, steps, and your oxygen saturation, heart rate and shortness of breath before and during exercise. Note any abnormal symptoms associated with exercise. Over the course of the program we will work with you to progress your exercise, by gradually increasing the amount you are able to do, while ensuring you remain comfortable. This progression is an important ingredient for the success of your program. We encourage you to invite or involve a family member or caregiver to join you and support your success together. Please discuss with your pulmonary rehabilitation providers any new exercise before your try it.
Daily Exercise Log
Resources for home exercise are important. A few are listed below. These are not for everyone but may offer options for you to get stronger and feel better. Discuss any option you wish to explore with your physician.
Living Well with COPD https://www.livingwellwithcopd.com/
Pulmonary Wellness Foundation https://pulmonarywellness.org/
Live Better from the American Thoracic Society: Pulmonary Rehabilitation Information, Resources and program directory from the American Thoracic Society http://www.livebetter.org/
British Thoracic Society resources
Stay Active and Stay Well from the British Lung Foundation
Resource Pack from the British Thoracic Society
AACVPR Remote PR video
Home Based Rehab: A resource for the development of home-based pulmonary rehabilitation programs from Australia: https://homebaserehab.net/
Better Living with Chronic Obstructive Pulmonary Disease—A Patient Guide: The State of Queensland (Queensland Health) and Australian Lung Foundation. 2008. http://www.lungfoundation.com.au/lung-information/patient-educational-material/better-living-with-copd-a-patient-guide
Telerehabilitation for people with chronic lung disease by Anne E Holland and Narelle S Cox. https://www.thoracic.org/members/assemblies/assemblies/pr/quarterly-bite/telerehabilitation-for-people-with-chronic-lung-disease.php
Blue Marble Health: A digital remote pulmonary rehab program connects clinicians with clients at home using a computer, smartphone, or iPad. This program incorporates recommendations from the AACVPR Guidelines for Pulmonary Rehabilitation Programs. Get started today www.bluemarblehealthco.com/pulmonary-rehab or contact email@example.com
The American Lung Association pilot Zoom-based Better Breathers group focuses on education and support related to lung health and disease. If you or a client would like to join a Zoom-based group that is based in the San Francisco Bay Area, you are welcome to join the group at 12 noon Pacific time on the first Tuesday of every month by internet or phone. Internet link is at https://ucsf.zoom.us/j/2858728213 ; phone number is 669-900-6833, meeting ID 285 872 8213. Please contact firstname.lastname@example.org for more information.
The author gratefully acknowledges Richard Casaburi PhD, MD, Anne Holland PhD, PT and Surya Bhatt MD for their expert review and recommendations.