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Abstract

Background

Exercise-based rehabilitation is an integral aspect of chronic condition management. However, the traditional in-person delivery of rehabilitation to condition-specific groups limits service accessibility. This study examined the feasibility of a disease-agnostic physiotherapy-led telerehabilitation programme for people with various chronic conditions.

Methods

A mixed-methods single-arm feasibility trial was conducted examining the feasibility of the Telerehabilitation and Exercise for Chronic Conditions (TECC) programme for people with chronic conditions, a disease-agnostic physiotherapy-led telerehabilitation programme. The 6-week programme comprised weekly physiotherapy-led synchronous group exercise sessions, weekly synchronous education sessions, and a social component, all delivered via videoconferencing. Asynchronous recordings were also made available. Primary outcomes included recruitment, retention, adherence, satisfaction, adverse events, and participant experiences via focus groups.

Results

Sixteen participants were enrolled during the 4-week recruitment period, with 14 commencing the intervention. Eleven participants (68.8%) were retained at follow-up. The mean number of participants who attended the synchronous exercise, education, and social sessions were 7 (50.0%), 5.2 (37.1%), and 1.3 (9.3%), respectively. No serious adverse events were reported. High satisfaction levels (93.8%) with the overall TECC programme were expressed by those who completed the programme. The TECC programme was an acceptable and beneficial experience for participants.

Conclusions

The TECC programme can be a feasible, pragmatic rehabilitation delivery method. However, attendance was poor, and the social component was of limited interest. Intervention amendments and refinements are necessary to improve participant attendance and adherence before progressing to more expansive delivery and evaluation.

Trial Registration

ClinicalTrials.gov (NCT06388499).

Keywords

chronic conditions telerehabilitation exercise feasibility physiotherapy

Introduction

Chronic conditions impose a significant burden on individuals, society, and healthcare systems worldwide.^1–3 These conditions typically require long-term management leading to increased health service utilisation, healthcare costs, death and disability rates, and reduced quality of life and function levels.^4,5 Chronic conditions will continue to pose a persistent challenge to our healthcare services in the future given their increasing prevalence and our ageing population.^6–8

Engagement with exercise-based self-management rehabilitation programmes empowers patients to independently manage their health and wellbeing, reducing health service utilisation and expenses.^9–12 Previous research has shown that these programmes are effective for a range of chronic populations, increasing participants’ physical function and quality of life.^13–15 While evidence supports the efficacy of these programmes, they are traditionally delivered in clinical settings and can be costly, time-consuming, and inaccessible for many individuals.^16–19 This often results in poor uptake and engagement levels.^20,21

The delivery of rehabilitation remotely using telecommunication technologies such as videoconferencing, emails, telephone calls and recorded videos, also known as telerehabilitation, offers a promising alternative healthcare service delivery method. This convenient, cost-effective service delivery method could potentially increase accessibility to, and engagement with, rehabilitation.^22–25 In addition to this, telerehabilitation is non-inferior to traditional in-person rehabilitation for improving clinical outcomes in various chronic populations, and participants report high levels of satisfaction and positive experiences following engagement with these programmes.^22,26–28

Previous research exploring telerehabilitation has focused on condition-specific programmes such as pulmonary telerehabilitation delivered specifically to people with chronic respiratory diseases. However, the structure and content of rehabilitation programs for various chronic populations are strikingly similar, typically consisting of progressive resistance and cardiovascular exercise training as well as educational material focused on health management, despite the variances in underlying diseases.^12,29 Disease-agnostic programmes, delivered to groups of people with different chronic conditions, could be a more pragmatic service delivery method allowing for economies of scale and increased clinician flexibility by optimising resource utilisation, improving efficiency, and providing more flexible care to a diverse population.^30–33 Disease-agnostic programme delivery could reduce the challenges of staff shortfalls leading to gaps in service delivery by encouraging clinicians to be flexible and expand their knowledge to a broader range of populations, thus reducing the reliance on specialised expertise for specific conditions.³⁴ Recent evidence supports the development of disease-agnostic programmes catering for a wide range of chronic conditions.^30,31,35 However, this previous research has focused on traditional in-person delivery of these programmes. Therefore, we aim to examine the feasibility of a disease-agnostic physiotherapy-led exercise-based telerehabilitation programme for people with a range of chronic conditions, known as the Telerehabilitation and Exercise for Chronic Conditions (TECC) programme. The primary aim of this study is to examine the feasibility of the intervention by examining recruitment and retention, adherence, adverse events, and satisfaction with the intervention. A secondary aim is to examine the effect of the intervention on physical function and quality of life.

Materials and methods

Design

A mixed-methods single-arm feasibility trial was conducted to examine the feasibility of the TECC programme for people with chronic conditions. This study was conducted and reported in accordance with the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement extension for pilot and feasibility trials.³⁶ Ethical approval was granted by the Health Service Executive (HSE) Southeastern Area Research Ethics Committee in Ireland. The trial protocol was previously registered on ClinicalTrials.gov (NCT06388499) and Open Science Framework.³⁷ The protocol was reported in accordance with the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist.³⁸

Development of the TECC programme

The design of the TECC programme and feasibility trial was informed by discussions with key stakeholders including physiotherapists and physiotherapy managers involved in rehabilitation service provision and people with various chronic conditions.^39,40 Four focus groups were conducted with people with chronic conditions (n = 18) exploring their perspectives and preferences for telerehabilitation programmes.³⁹ Two focus groups exploring the attitudes and preferences of clinicians involved in rehabilitation delivery for chronic populations (n = 10) were also conducted.⁴⁰ One further focus group was conducted with clinical specialist physiotherapists and managers (n = 6) to inform the recruitment and screening processes for the feasibility trial and to further refine the TECC programme. The eligibility criteria (Table 1) and recruitment pathway were informed by the input from clinicians and current national and local policies and procedures in Ireland.⁴¹ As per current national HSE policies and procedures in Ireland for virtual rehabilitation programme delivery,⁴¹ it was recommended that participants be required to sign a disclaimer to agree voluntary participation in the exercise sessions at their own risk before participating in the TECC programme. The exercise component of the programme was developed by the research physiotherapists and guided by existing rehabilitation programmes and clinician guidance.^40,42–44 Stakeholders also noted the value of including self-management educational content in telerehabilitation programmes, which informed the TECC programme design.^39,40 A social component was also included in the TECC programme based on stakeholder input.

Table 1.

Eligibility criteria.

Inclusion criteria	Exclusion criteria
• Community-dwelling adults (aged ≥18 years old) with a confirmed diagnosis of any chronic cardiorespiratory, neurological, or musculoskeletal condition. We used the ICD-10-CM definition of a chronic condition being one lasting greater than 12 months and resulting in the need for ongoing medical intervention and limiting self-care, independent living, and social interaction.⁴⁵	• Adults who were medically unstable as deemed by the referring physiotherapist or who had uncontrolled medical conditions limiting participation in exercise interventions including uncontrolled hypertension or recent acute cardiovascular events, uncontrolled atrial fibrillation, suspected underlying malignancy, etc.
• Medically stable and appropriate to participate in the exercise-based programme independently and safely as deemed by self-declaration. Subsequent screening using the PAR-Q⁴⁶ identified any additional concerns which would require a discussion with one’s GP prior to signing the disclaimer and participating in the programme	• Significant orthopaedic, psychological, neurological, or cognitive conditions or mobility difficulties that prevented participation in seated or standing exercise interventions as deemed by the referring physiotherapist
• Access to an appropriate technological device with an internet connection and email address to facilitate participation in the telerehabilitation programme
• Willing to provide informed consent to participate in the study
• Good level of spoken and written English

Participants and setting

Adults with various chronic conditions, including chronic cardiorespiratory, neurological and musculoskeletal conditions, were informed of the study by treating physiotherapists from community sites in Ireland and the networks of the research team from April to May 2024. An outline of the study was provided and those who expressed interest in participating were screened for eligibility based on the pre-defined criteria (Table 1) by the research team.

Recruitment took place over a 4-week period during which all participants who expressed interest were provided with an information sheet (Supplemental File 1), electronic consent forms (Supplemental File 2), and a series of electronic baseline evaluation measures to assess their suitability. Baseline measures were sent via email and included a baseline demographic questionnaire, Physical Activity Readiness Questionnaire (PAR-Q) form,⁴⁵ Activities-Specific Balance Confidence (ABC) Scale⁴⁶ (Supplemental File 3), and Euro-QoL-5D-5L (EQ-5D-5L)⁴⁷ which were completed using Microsoft Forms. Eligible participants were then sent orientation documents (Supplemental File 4) via email which contained information including a telehealth set-up checklist and the BORG Rate of Perceived Exertion (RPE) Scale self-monitoring test to guide appropriate exercise intensity.⁴⁸ Participants were also invited to a synchronous online one-to-one orientation session with the primary author (CBW), which was conducted via videoconferencing using Microsoft Teams software. The purpose of the orientation session was to support and guide participant set-up for the telerehabilitation sessions, complete baseline data collection and to conduct the 30-second chair stand test (30-CST) to measure baseline physical function levels for each participant. Table 2 outlines the study schedule and includes the pre- and post-intervention outcome measures administered along with the timepoints at which the measures were administered.

Table 2.

Study schedule diagram.

Timepoint	Study period
	Enrolment	Allocation	Post-allocation
	0	0	6 weeks	8 weeks
Enrolment
Informed consent	X (n = 16)
Eligibility screen	X (n = 16)
Allocation		X (n = 14)
Intervention
TECC programme
Assessments
Activities-Specific Balance Confidence (ABC) Scale	X (n = 16)
Physical Activity Readiness Questionnaire (PAR-Q)	X (n = 16)
Baseline Questionnaire	X (n = 16)
30-second chair stand test (30-CST)	X (n = 16)			X (n = 8)
EURO-QoL-5D questionnaire	X (n = 16)			X (n = 11)
Client Satisfaction Questionnaire-8 (CSQ-8)				X (n = 11)
Focus groups				X (n = 11)

n = number of participants.

Intervention

The TECC programme comprised of a 6-week disease-agnostic exercise-based telerehabilitation programme for people with chronic conditions delivered by a chartered physiotherapist. The programme has been described using the TIDieR (Template for Intervention Description and Replication) checklist to ensure good reporting and intervention description⁴⁹ (Supplemental File 5). The programme consisted of weekly synchronous exercise sessions followed by a social component, and synchronous educational webinars to promote self-management of health and well-being. Recordings of the exercise and education sessions were made available to participants each week via email. Participants were advised to perform additional exercise sessions at their own convenience to supplement the synchronous exercise sessions and facilitate adherence to physical activity guideline recommendations. Participants were advised to record any engagement with the recorded exercise and education sessions via electronic self-report logbook (Supplemental File 6).

Exercise component

Synchronous group exercise sessions led by a physiotherapist, were delivered weekly via videoconferencing using Microsoft Teams software. The exercise sessions included a 10-minute warm-up, 30- to 40-minute main exercise session which included resistance, aerobic, balance and flexibility training, and a 5-minute cool down. We initially planned to deliver the exercise sessions to two exercise group levels based on baseline functional mobility levels. It was planned that one group would perform seated-based exercises while the other group would perform standing-based exercises. Allocation to either exercise group was based on the ABC scale score with participants scoring below the threshold of 67% allocated to the seat-based exercise group.⁵⁰ However, based on the ABC scale scores, all participants enrolled in this trial were allocated to the standing-based exercise group. Therefore, the planned seated-based exercise class was not required. Exercises were instructed and demonstrated by a physiotherapist with instructions for suitable regressions and progressions for each exercise also provided. Participants were informed of the use of the BORG RPE Scale⁴⁸ before the programme to guide appropriate exercise intensity during exercise performance. Participants were encouraged to exercise at an intensity of 11–14 on the BORG RPE scale during the exercise sessions.

Educational component

Participants were invited to attend one 45-minute synchronous educational webinar each week to promote self-management of health and well-being. These webinars were delivered via videoconferencing using Microsoft Teams software by relevant healthcare professionals. The webinar topics, guided by recommendations from the HSE Living Well with a Chronic Condition Framework⁵¹ and the Stanford Chronic Disease Self-Management Programme,⁵² are listed in Table 3.

Table 3.

Educational component schedule.

Week	Webinar topic	Professional background of session facilitator
1	Exercise & Physical Activity	General Practitioner
2	Goal Setting	Physiotherapy
3	Nutrition and Diet	Nutrition & Dietetics
4	Managing Your Mental Health	Psychology
5	Managing Fatigue and Sleep	Physiotherapy
6	Living with a Chronic Condition	Dietetics

Social component

At the end of each weekly synchronous group exercise session, participants had the opportunity to engage in a 10- to 15-minute synchronous online social interaction with other participants in the group via videoconferencing. The social component could be guided by the research team with theme-driven discussions based on the educational topics explored in the webinars, or unregulated and left to participants to discuss subjects of their choice.

Data collection

Primary outcomes

The primary outcomes of interest used to examine the feasibility of the programme were recruitment and retention rates, adherence to the programme (i.e. attendance), satisfaction, adverse events and qualitative data relating to participant experiences of the programme (Table 4). The retention rate was based on the completion of the post-intervention CSQ-8 satisfaction measure, EQ-5D-5L, and participation in the focus group in the post-intervention phase. The adherence rate was measured based on the average number of participants who attended the synchronous group exercise sessions. Adverse events were assessed using an electronic questionnaire and were defined as any problems or injuries experienced during the study that were deemed by the participant to be more likely resulting from participation in the programme, rather than resulting from disease progression. Serious adverse events were defined as any medical occurrence resulting in death, threat to life, hospital admission or significant disability.

Table 4.

Measurement method for each outcome of interest.

Outcome of interest	Method of measurement
Recruitment rate	Number of participants recruited over a 4-week recruitment period
Retention rate	Percentage of enrolled participants who complete the post-intervention assessments and focus groups
Adherence with TECC programme	The average number of participants who attended the synchronous group exercise sessions. Data relating to the mean number of synchronous exercise, education and social sessions attended by participants was also reported
Satisfaction with overall TECC programme	CSQ-8 (4-point Likert scale employed across questions with 4 indicting high satisfaction and 1 indicating low satisfaction, total scores range from 8 to 32)
Satisfaction with individual components of TECC programme	NRS (score of 10 = ‘extremely satisfied’, score of 1 = ‘extremely not satisfied’)
Adverse events	The number of adverse events that occurred during the intervention period as reported via electronic questionnaire completed by participants via Microsoft Forms in the post-intervention assessment period
Acceptability and experiences	Qualitative data collected via semi-structured focus groups
Physical function	30CST administered by the researcher (CBW) via videoconferencing using Microsoft Teams. The 30-CST is a reliable, safe and feasible measure of function and lower limb strength when administered via telehealth.^53,54 The 30-CST was administered in accordance with guidance from a manual for the administration of performance-based tests via telehealth.⁵⁴
Self-reported quality of life	EQ-5D-5L completed electronically via Microsoft Teams. The EQ-5D-5L questionnaire measures self-reported health-related quality of life across 5 dimensions using a 5-point Likert scale. The measure also includes a visual analogue rating scale to measure the participants’ self-reported health level quantitatively. The EQ-5D-5L is a reliable and valid measure that is appropriate for use across a broad range of populations and settings.⁵⁵

CSQ = Client Satisfaction Questionnaire, NRS = Numerical Rating Scale, CST = Chair Stand Test.

Qualitative data relating to participant experiences was collected using semi-structured focus groups which were conducted via videoconferencing using Microsoft Teams during the post-intervention period. Two focus groups were conducted by the primary author (CBW) with five and six participants in each group (female n = 7, male n = 4). Both groups lasted approximately 40 minutes. The questions were informed by an interview guide which was based on the research and clinical experience of the authors (Supplemental File 7). The interview guide included open-ended questions to explore the participants’ experiences participating in the TECC programme. Focus groups were recorded and automatically transcribed using Microsoft Teams software.

Secondary outcomes

The secondary outcomes of interest related to the clinical impact of the programme, including changes in self-reported quality of life and objective physical function, following the TECC programme (Table 4).

Statistical analysis

Descriptive statistics were used to describe the characteristics of the participants at baseline using proportions, percentages, ranges, means and standard deviations. Visual plots and the Shapiro-Wilk test of normality were used to assess numerical data for skewness. Primary feasibility and adherence outcomes were reported using proportions and were also evaluated using a traffic light system as reported in the feasibility trial protocol.³⁷ The traffic light system includes red (stop until solutions found), amber (amend and proceed) and green (proceed) thresholds which indicate progression criteria to evaluate progression to a main trial.⁵³ A preliminary analysis of clinical outcomes involved evaluating mean differences (with associated 95% confidence intervals) between pre-and post-intervention scores. Paired t-tests were conducted to calculate the significance of the results. Data analysis was conducted using SPSS software (v29.0.2.0) and supported by Microsoft Word and Excel for organisation and storage.

Qualitative data analysis was conducted using open inductive coding through line-by-line reading of the transcripts of the focus groups using the principles of grounded theory. Focus group data was video recorded and transcribed using Microsoft Teams software. The first author (CBW) checked the transcripts and edited minor errors relating to sound quality and accent variation, by comparing the transcripts to the video recordings. Transcripts were sent to participants to ensure accuracy and participants were invited to send any comments or edits to the research team within 1 week of receiving the transcripts. The transcripts were initially reviewed by CBW to familiarise with the data. Transcripts were then coded by CBW to identify themes. Microsoft Word and Excel software was used to facilitate data analysis, organisation and storage.

Results

Primary outcomes

Recruitment and retention

A total of 16 participants were recruited within the 4-week recruitment window, and initially enrolled to take part in the study (Table 5). All participants were allocated to the standing-based exercise group based on their ABC scale scores. Therefore, the seated-based exercise class group did not proceed. Eleven (68.8%) of the 16 participants had more than one chronic condition diagnosis, while the remaining five (31.3%) reported a diagnosis of one chronic condition. Thirteen participants reported a diagnosis of a cardiorespiratory condition, four participants reported a diagnosis of a neurological condition, and seven participants reported a diagnosis of a chronic musculoskeletal condition.

Table 5.

Participant characteristics.

Sex
Female	11 (68.8%)
Male	5 (31.3%)
Age (years; mean (SD))	62.8 (10.8)
Residential area
Rural	9 (56.3%)
Urban	7 (43.8%)
Chronic medical conditions
Single chronic condition diagnosis	5 (31.3%)
Cardiorespiratory	3
Neurological	2
Musculoskeletal	0
Multimorbidity (presence of two or more chronic conditions)	11 (68.8%)
Cardiorespiratory	10
Neurological	2
Musculoskeletal	7
Other	3
History of previous telerehabilitation participation
Yes	11 (68.8%)
No	5 (31.3%)

Two individuals withdrew from the study before commencing the programme due to medical reasons (including an exacerbation of a neurological condition). Three individuals withdrew from the study during the intervention phase for personal and medical reasons (including family bereavement and exacerbation of respiratory and musculoskeletal conditions). Three participants were unable to complete the post-intervention 30CST outcome measure due to medical reasons (including two acute musculoskeletal injuries that occurred independent of the intervention and one hospital admission due to an acute respiratory infection). A total of 11 participants (n = 7 female, n = 4 male), of the 16 who enrolled, (68.8%) completed the 6-week intervention, post-intervention CSQ-8 and EQ-5D-5L measures and focus groups.

Adherence

All participants who commenced the programme attended the orientation session before commencing the intervention. Attendance rates are detailed in Supplemental File 8. The mean attendance rates at each of the synchronous exercise, education, and social sessions were 7 (50%), 5.2 (37.1%), and 1.3 (9.3%) participants, respectively. The recordings made available to watch asynchronously were viewed by several of the 14 participants who commenced the intervention (exercise recordings n = 10 (71.4%); education recordings n = 7 (50%)). The mean (SD) number of asynchronous exercise sessions completed by participants each week was 2.2 (1.8). The mean (SD) rate of perceived exertion reported by participants for exercise sessions completed throughout the intervention was 13.7 (1.6) equating to a ‘somewhat hard’ level of perceived exertion.

Of the 14 participants who commenced the programme, the mean number of synchronous exercise sessions attended per participant was three sessions out of a total of six synchronous exercise sessions (50%). Two participants (14.3%) did not attend any synchronous exercise session and subsequently withdrew from the programme. Three participants (21.4%) attended 1-3 synchronous exercise sessions, while the remaining eight participants (57.1%) attended four or more synchronous exercise sessions. The mean number of synchronous education sessions attended per participant was 2.2 sessions out of a total of six synchronous exercise sessions (36.7%). Five of the 14 participants (35.7%) did not attend any synchronous education sessions, with two of these subsequently withdrawing from the programme. Six participants (42.9%) attended 1-3 synchronous education sessions, and three participants (21.4%) attended four or more synchronous education sessions. The mean number of synchronous sessions attended per participant, including both exercise and education sessions, was 5.2 sessions out of a total of 12 synchronous sessions (43.3%). The mean number of optional social component sessions attended per participant was 0.6 sessions out of a total of six (10.0%). Seven of the 14 participants (50.0%) did not attend any of the social component, while the remaining participants (n = 7) (50.0%) attended 1-3 social sessions out of a total of six sessions.

Satisfaction

The CSQ-8 was completed by 11 participants following programme completion. The responses to the CSQ-8 are shown in Supplemental File 9. Total scores ranged from 24 to 32. The total mean score was 30 (SD = 2.4), equating to a rate of 93.8% satisfaction with the overall TECC programme (See Supplemental File 9).

Supplementary File 9 outlines the participant satisfaction levels with each of the programme components. Participants reported high satisfaction levels with the orientation sessions, exercise, and education components, each scoring more than 8/10 on the NRS. However, a low level of satisfaction (3.6/10 NRS) with the social component was reported.

Adverse events

There were no serious adverse events reported by participants in the post-intervention questionnaire. One participant reported some minor knee joint discomfort while performing the exercises included in the programme. As stated previously, three participants withdrew from the study during the intervention phase due to personal and medical reasons that were independent of the TECC programme. Three participants who completed the programme were unable to complete the post-intervention 30CST measure due to medical reasons which were also independent of the programme.

Criteria to evaluate progression to a main trial

The results from the trial have been compared with the traffic light system thresholds set in the trial protocol³⁷ to confirm the viability of progression to a main trial (Table 6). The recruitment (n = 16) and retention rates (68.8%) are placed in the amber threshold while the adherence rate (50.0%) is in the red threshold. The adverse events and satisfaction rate (93.8%) lie within the green threshold.

Table 6.

Traffic light system indicating progression criteria to evaluate progression to a main trial.

Criteria	Outcome	Red (stop)	Amber (amend and proceed)	Green (proceed)
Recruitment rate	16	2 per week (8 in 4 weeks)	4 per week (16 in 4 weeks)	6+ per week (24+ in 4 weeks)
Retention rate	68.8%	<60%	60–70%	≥70%
Adherence rate	50.0%	<60%	60–70%	≥70%
Adverse events	No serious adverse events	>2 serious adverse events	1-2 serious adverse events	No serious adverse events
Satisfaction rate	93.8%	<50% satisfied	50–75% satisfied	≥75% satisfied

Qualitative focus group feedback

The main themes identified from the qualitative focus group data include: 1. Shared aims; 2. Telerehabilitation perceptions; 3. Programme evaluation; and 4. Recommendations for change.

Shared aims

Participants were asked about their experience of participating in a disease-agnostic programme which included a group of participants with various chronic health conditions. Since most had participated in condition-specific rehabilitation programmes such as pulmonary rehabilitation previously, this disease-agnostic programme for a mixed-condition group was a novel experience. All participants, however, expressed no initial concerns about participating in a programme with a mixed-condition group, and noted that they did not encounter any related issues while participating in the programme. Both the exercise and education components of the programme, according to the participants, applied to them and met their needs.

PT-08: ‘I will say initially it (mixed-condition group) was sort of novel because anything I've done similar to this before has all been geared towards COPD that I have. But I didn't have any problem with it, it made no odds (difference) once the exercises that you (facilitator) had put together were suitable for each of the different conditions that people had’.

PT-13: ‘To me personally, it didn't matter really. I didn't know what was wrong with people, what conditions they had, it didn't really matter’.

Participants expressed that, although variations in their underlying medical conditions existed, all participants were striving towards the same goal of enhancing their overall health and well-being. Participants expressed appreciation for the variety of content covered in the educational component, noting that many of the topics covered would ‘apply to everyone across the board’ (PT-10).

PT-03: ‘Yeah, I just found we were all on the same aim trying to keep ourselves well. So, it was nice. And I don't think it really mattered what (condition) you had; we were all on the same goal’.

PT-10: ‘so many, many things overlap and we're all getting older, there are so many things that apply to you as you age that apply to everyone across the board. I thought they (education sessions) were brilliant’.

Telerehabilitation perceptions

Most participants expressed that they would be satisfied to participate in a similar programme again in the future, indicating that they had a positive experience with the remote online telerehabilitation programme. Some expressed their initial concerns about using technology, and a few participants encountered challenges with technology throughout the programme. All participants did, however, affirm that this would not stop them from taking part in telerehabilitation in the future. It was recognised that participation was facilitated by the support provided by the service provider and family members. After participating in the programme, the participants stated they felt more comfortable using technology.

PT-11: ‘my concern was the technology and being able to access it online and I wouldn't be au fait with a lot of the technology, and I did say to (facilitator) that there was once or twice I wasn't able to get on and but within seconds I emailed (facilitator) and she had it sorted for me. So, for me that was really helpful and now I'd like to think that I'm a bit more au fait with the technology’.

PT-01: ‘We can pass on the word now to say that the online works and don’t be afraid of it, embrace it’.

The majority of the group emphasised how practical and convenient the telerehabilitation programme was, especially with regard to the accessibility of the asynchronous recorded content. The programme's flexibility and the ability to access the content at any time and location were appreciated by participants. There was also discussion on the advantages of the synchronous content. Participants stated that they were motivated to engage with the programme due to the structured nature of the synchronous sessions.

PT-08: ‘… having the online from the comfort of your home, if it's raining you don’t have to worry about getting out somewhere or sitting in traffic for half an hour’.

PT-01: ‘The big thing for me is the recordings…when you’re doing the exercises, if you’re a bit under pressure, you can pause it, you can go back to it whenever you feel like it…you can do your few little jobs, then you come back and you can continue exercising, which is much more beneficial, I think, than being in a class where you have to get everything done within the hour. So, the recordings are great, that's what I found really good’.

Programme evaluation

Participants listed several benefits of participating in the program, and generally expressed satisfaction with the experience. Self-reported physical benefits included improved breathing, and increased strength and energy levels. Some participants reported the exercise component was challenging but manageable, while participants valued the options to modify exercises with regression and progression options to suit their individual needs. It was also observed that the BORG rate of perceived effort scale was helpful in guiding the intensity of the exercise component to cater for individual needs.

PT-02: ‘I find if I'm sitting in the chair, and when I stand up, I find it easier to stand up. I'd be grunting before, but I do less grunting now and stand-up kind of better and easier’.

PT-03: ‘I really enjoyed it, I felt stronger and felt more energetic while I was doing it’.

Participants reported that the education component provided them with a deep understanding of the value of lifestyle modifications and self-management strategies. Participants also cited some practical ‘hints and tips’ which they gained from the educational sessions which they have since incorporated into their lives to self-manage their health and wellbeing.

PT-11: ‘The one thing I think the Doctor who talked the first week and it just seems to be sticking in my head is he talked about exercise snacking. And that’s been, if I’m standing doing the dishes or cooking, going up on my heels and back down, they (exercises) don’t have to be in the chunks that the little ones can also help. So, for me, that was a great suggestion’.

PT-08: Well, that's one of the things I found about all the (education) talks there was something practical in all of them.

Recommendations for change

Poor engagement with the social component of the programme was noted. This was attributed to factors including time limitations, social anxiety, and fear related to the discussion of their medical conditions. Participants offered suggestions to improve this component of the programme in the future including a group introduction session prior to commencing the programme or exercise session, and increased support from the programme facilitator to encourage social interaction among the participants. Some participants noted that they prefer to socialise in-person, and they would rather use the telerehabilitation programme for the exercise and education components rather than for social purposes.

PT-08: ‘I have to say, I probably felt a little bit anxious about the talks (social component) that I didn't actually join in any of them, but it coincidentally I just had stuff on at the same time. So, it was simple for me to say, look great, thanks, good luck, see you again’.

PT-03: ‘Yeah, to me if I'm picking the time for exercise… I'm always making extra lists for myself and jobs that I need to do, but I didn't really have time for the chats, I did well to do the exercise’.

To promote individual, unsupervised exercise performance between the group synchronous sessions, some participants also suggested the availability of a visual print-out of the exercise sessions. There were no further recommendations for enhancements to the education or exercise components of the TECC programme.

Secondary outcomes

The pre- and post-intervention secondary outcome results are presented in Table 7 and Figure 1. Eight participants completed the post-intervention 30CST physical function assessment. There was evidence of improvements (p <0.001) in physical function from pre-intervention to post-intervention, as measured by the 30CST, MD = 3.1 (95% CI 4.4, 1.8). 11 participants completed the post-intervention EQ-5D-5L measure assessing changes in quality of life. There was no evidence of improvement observed in self-reported quality of life from pre- to post-intervention, as measured by the EQ-5D-5L Index values, MD = 0.0 (95% CI 0.3, −0.3) (p-value = 0.664), and Visual Analogue scale (VAS) scores, MD = 3.636 (95% CI 9.5, −2.2) (p-value = 0.195). Figure 1 presents the pre- and post-intervention scores for each EQ-5D-5L dimension used to assess self-reported quality of life.

Table 7.

Secondary outcomes pre- and post-intervention.

Measure	Pre-intervention	Post-intervention	Mean difference (95% CI)	p-value	Effect size (Cohen’s d)
30CST (n = 8)	12.4 (SD = 3.2)	15.5 (SD = 3.7)	3.1 (4.4, 1.8)	<0.001	2.0
Euro-QoL-5D-5L Index values (n = 11)	0.5 (SD = 0.4)	0.5 (SD = 0.4)	0.0 (0.3, −0.3)	0.664	0.0
Euro-QoL-5D-5L VAS (n = 11)	62.7 (SD = 16.6)	66.4 (SD = 17.3)	3.6 (9.5, −2.2)	0.195	0.4

Figure 1.

EURO-QoL-5D-5L outcomes pre- and post-intervention.

Discussion

This study examined the feasibility of the TECC programme, a disease-agnostic physiotherapy-led exercise-based telerehabilitation programme for people with chronic conditions. This study also included a preliminary evaluation of the clinical effectiveness of the programme.

Our findings indicate that the TECC programme is feasible and acceptable among participants; however, our results also suggest that some amendments to the programme are necessary before progressing to a main trial. The recruitment rate did not meet the pre-set thresholds and desired sample size outlined in the trial protocol.³⁷ However, this trial adopted a pragmatic proof of concept approach. Therefore, participants were recruited promptly within a narrow recruitment period and pathway over 4 weeks by physiotherapists in a limited number of clinical settings. The recruitment pathway should be broadened for future trials and an extended recruitment period could enhance recruitment rates. The retention of participants who commenced the intervention phase and progressed to complete the post-intervention assessments was satisfactory, thus showing promise for a future, more expansive intervention and trial.

The adherence rate, as measured by synchronous exercise session attendance, did not meet the a priori traffic light system thresholds that we set in the study protocol.³⁷ It is important to note that this adherence rate was based on the mean attendance at the synchronous group exercise sessions only. Perhaps attendance with the synchronous group exercise sessions was poor due to the availability and convenience of the asynchronous recorded sessions. Most participants reported some engagement with the asynchronous recorded content including both the recorded exercise and education sessions. This reinforces the value of including both synchronous and asynchronous content which has been previously cited by people with chronic conditions.³⁹ However, due to inconsistent engagement with the self-reported logbook and incomplete recording, it is difficult to accurately report adherence to the asynchronous recorded content. Some participants engaged in other exercise rehabilitation classes during the intervention period which may also have contributed to the poor attendance rate at the synchronous group exercise sessions. Therefore, the adherence rate reported for comparison with the traffic light system threshold should be interpreted with caution. Future research should evaluate adherence to the asynchronous programme content to include a more accurate representation of participant adherence to the overall programme. Consideration should also be given to intervention amendments that could engage participants more effectively and improve participant attendance. A largely positive, enjoyable, and beneficial experience was reported by those who participated in the telerehabilitation programme. The programme was also safe, with no serious adverse events reported, convenient and flexible.

Furthermore, a preliminary evaluation of the clinical effectiveness of the TECC programme demonstrated evidence of improvements in objective physical function following participation. However, evidence of improvements in self-reported quality of life was not observed. Although further evaluation would be needed to establish the clinical efficacy of the programme, results from the initial evaluation are promising.

Participant satisfaction with the TECC programme was remarkably high. The orientation video call, exercise, and education components were reported by participants to be particularly useful and enjoyable. However, despite previous research promoting the inclusion and importance of opportunities to facilitate social interaction during telerehabilitation programmes,³⁹ the social component of the TECC programme was reported to be substantially less useful for participants. This was reflected by the poor uptake and engagement with the social component during the programme with 50.0% of participants not attending any social session and the remaining participants attending less than half of the social sessions. The qualitative data suggests that this was attributed to various factors such as time limitations and participant fear and anxiety regarding the nature of the social interaction. This mirrors previous findings of Cahalan et al.⁵⁴ who also reported poor attendance at the optional social component of a telehealth intervention because of similar reasons. Previous qualitative findings of Barry Walsh et al.³⁹ highlighted participants’ desire for the inclusion of a social component within telerehabilitation programmes. However, this research was completed shortly after the COVID-19 pandemic, a time when there was limited opportunity for in-person social interaction due to cocooning and social distancing requirements. Perhaps now that in-person social events and activities have recommenced as usual, people can engage in social activities elsewhere and no longer desire these opportunities to be included in telerehabilitation programmes. Proposed improvements to the social element of the TECC programme such as the inclusion a group introduction session prior to commencement of exercise sessions, or increased support from the programme facilitator to encourage social interaction, should be explored with potential participants in advance of any such amendments.

Overall, the encouraging findings from this study endorse previous literature supporting the convenience, feasibility, acceptability and clinical effectiveness of telerehabilitation interventions for a wide range of chronic populations.^22,26,55,56 Additionally, the present study adds a novel finding to the existing research suggesting that these positive results are also obtained with the delivery of a disease-agnostic telerehabilitation programme to a mixed-condition group. Furthermore, our research shows that this method of healthcare service delivery to a heterogeneous group is acceptable among people with chronic conditions. Previous evidence suggests that disease-agnostic programmes for people with various chronic conditions have the potential to maximise resource utilisation allowing for greater economies of scale when compared to traditional rehabilitation service delivery methods focusing on condition-specific populations.¹⁸ Given the increasing prevalence of chronic conditions and particularly the increasing incidence of multimorbidity (the co-occurrence of two or more chronic conditions),⁵⁷ our results are promising and may encourage this novel and pragmatic approach to healthcare service delivery which may help to manage the increasing challenges and demands being placed on our healthcare services.

There are some limitations to this research that should be acknowledged. The sample size included in this study was relatively small and did not reach the target sample size set in the trial protocol.³⁷ However, the sample included participants diagnosed with a wide variety of chronic conditions spanning chronic cardiorespiratory, neurological and musculoskeletal conditions. Based on the ABC scale scores all participants were allocated to the standing-based exercise group, therefore the planned seated-based exercise class was not required. Furthermore, some of the included participants were unable to complete the post-intervention physical function assessments due to medical reasons; therefore. the number who completed the assessments of physical function was smaller. Some participants engaged in other exercise rehabilitation classes during the intervention period. Data relating to engagement with the asynchronous content was collected through self-report by participants. However, participant logbook records were inconsistent and largely incomplete, undermining the accuracy of adherence rates reported. The primary author was involved in programme delivery and data collection. Therefore, this data may have been subject to an increased risk of bias due to the lack of blinding.

The results of this preliminary evaluation are encouraging and suggest that the TECC programme is safe and satisfactory and progression to further evaluation may be warranted. However, amendments and improvements must first be made to improve recruitment, retention and adherence rates before progression to a main trial. Our findings are promising and indicate that this novel method of rehabilitation service delivery for people with chronic conditions could potentially be a pragmatic, viable, and effective approach to healthcare service delivery.

To our knowledge, this is the first original research study exploring the feasibility of a disease-agnostic physiotherapy-led exercise-based telerehabilitation programme for people with chronic conditions. While further evaluation is needed, our initial evaluation suggests that the TECC programme is a safe and acceptable intervention. However, participant attendance and adherence to the programme was poor. Therefore, consideration needs to be given to solutions and intervention amendments that focus on improving the recruitment and retention of participants and their adherence to synchronous content. The social component was of limited interest and was poorly attended by participants. Improvements to this component of the intervention also need to be considered. The results serve as a foundation for the future development of telerehabilitation interventions. Further amendments and progressive refinement of the programme need to be considered before embarking on a full-scale evaluation.⁵⁸

Supplemental Material

Supplemental Material - A physiotherapy-led disease-agnostic telerehabilitation programme for people with chronic health conditions: A mixed-methods feasibility trial

Supplemental Material for A physiotherapy-led disease-agnostic telerehabilitation programme for people with chronic health conditions: A mixed-methods feasibility trial by Caoimhe Barry Walsh, Roisin Cahalan, Niamh Julian, Rana S. Hinman, and Kieran O’ Sullivan in Physiotherapy Practice and Research

Footnotes

Acknowledgements

The authors would like to thank those who participated in this study for their contributions, gatekeepers at recruitment sites for their contribution and support with participant recruitment, and the healthcare professionals involved in the delivery of the educational component of the TECC programme.

ORCID iDs

Caoimhe Barry Walsh

Kieran O’ Sullivan

Ethical approval

Ethical approval was granted by the Health Service Executive (HSE) Southeastern Area Research Ethics Committee. All participants provided informed consent via electronic consent forms.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Health & Medical Research Council Investigator Grant (#2025733), Irish Research Council (GOIPG/2022/1854).

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental material

Supplemental material for this article is available online.

References

Hajat

Stein

. The global burden of multiple chronic conditions: a narrative review. Prev Med Rep 2018; 12: 284–293.

Jennings

. Preventing chronic disease: defining the problem. 2014.

Darker

Whiston

Brendan

. Chronic disease management in Ireland: perspectives from patients and clinical stakeholders-implications and recommendations for the Irish healthcare system. 2015.

Hacker

. The burden of chronic disease. Mayo Clin Proc Innov Qual Outcomes 2024; 8: 112–119.

Sav

Salehi

Mair

, et al. Measuring the burden of treatment for chronic disease: implications of a scoping review of the literature. BMC Med Res Methodol 2017; 17: 1–14.

Mitchell

Walker

. Global ageing: successes, challenges and opportunities. Br J Hosp Med 2020; 81: 1–9.

Mathers

Loncar

. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med 2006; 3: e442.

Hernández

Reilly

Kenny

. Investigation of multimorbidity and prevalent disease combinations in older Irish adults using network analysis and association rules. Sci Rep 2019; 9: 14567.

de Iongh

Fagan

Fenner

. A practical guide to self-management support: key components for successful implementation. 2015.

10.

Richardson

Franklin

Moy

, et al. Advances in rehabilitation for chronic diseases: improving health outcomes and function. Bmj 2019; 365: l2191.

11.

Hoffmann

Maher

Briffa

, et al. Prescribing exercise interventions for patients with chronic conditions. CMAJ (Can Med Assoc J) 2016; 188: 510–518.

12.

Mulligan

Wilkinson

Chen

, et al. Components of community rehabilitation programme for adults with chronic conditions: a systematic review. Int J Nurs Stud 2019; 97: 114–129.

13.

Bolton

Bevan-Smith

Blakey

, et al. British Thoracic Society guideline on pulmonary rehabilitation in adults: accredited by NICE. Thorax 2013; 68: ii1–ii30.

14.

Price

Hoggart

Olukoga

, et al. Guidelines for pain management programmes for adults: an evidence-based review prepared on behalf of the British Pain Society. London: The British Pain Society, 2013.

15.

Long

Mordi

Bridges

, et al. Exercise-based cardiac rehabilitation for adults with heart failure. Cochrane Database Syst Rev 2019; 29: CD003331.

16.

Resurrección

Moreno-Peral

Gomez-Herranz

, et al. Factors associated with non-participation in and dropout from cardiac rehabilitation programmes: a systematic review of prospective cohort studies. Eur J Cardiovasc Nurs 2019; 18: 38–47.

17.

Cox

Oliveira

Lahham

, et al. Pulmonary rehabilitation referral and participation are commonly influenced by environment, knowledge, and beliefs about consequences: a systematic review using the Theoretical Domains Framework. J Physiother 2017; 63: 84–93.

18.

Desveaux

Goldstein

Mathur

, et al. Barriers to physical activity following rehabilitation: perspectives of older adults with chronic disease. J Aging Phys Act 2016; 24: 223–233.

19.

Oates

Niranjan

Ott

, et al. Adherence to pulmonary rehabilitation in COPD: a qualitative exploration of patient perspectives on barriers and facilitators. J Cardiopulm Rehabil Prev 2019; 39: 344–349.

20.

Hinde

Bojke

Harrison

, et al. Improving cardiac rehabilitation uptake: potential health gains by socioeconomic status. Eur J Prev Cardiol 2019; 26: 1816–1823.

21.

Jones

Taylor

Gowler

, et al. Systematic review of interventions to improve patient uptake and completion of pulmonary rehabilitation in COPD. ERJ Open Res 2017; 3: 00089.

22.

Hinman

Campbell

Kimp

, et al. Telerehabilitation consultations with a physiotherapist for chronic knee pain versus in-person consultations in Australia: the PEAK non-inferiority randomised controlled trial. Lancet 2024; 403: 1267–1278. DOI: 10.1016/S0140-6736(23)02630-2.

23.

Subedi

Rawstorn

Gao

, et al. Implementation of telerehabilitation interventions for the self-management of cardiovascular disease: systematic review. JMIR Mhealth Uhealth 2020; 8: e17957.

24.

Hwang

Gane

Morris

. No transport? No worries! Cardiac telerehabilitation is a feasible and effective alternative to centre-based programs. Heart Fail Rev 2023; 28: 1277–1284.

25.

Selzler

Wald

Sedeno

, et al. Telehealth pulmonary rehabilitation: a review of the literature and an example of a nationwide initiative to improve the accessibility of pulmonary rehabilitation. Chron Respir Dis 2018; 15: 41–47.

26.

Lawford

Bennell

Kimp

, et al. Understanding negative and positive feelings about telerehabilitation in people with chronic knee pain: a mixed methods study. J Orthop Sports Phys Ther 2024; 54: 1–27.

27.

Cottrell

Galea

O’Leary

, et al. Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: a systematic review and meta-analysis. Clin Rehabil 2017; 31: 625–638.

28.

Appleby

Gill

Hayes

, et al. Effectiveness of telerehabilitation in the management of adults with stroke: a systematic review. PLoS One 2019; 14: e0225150.

29.

Desveaux

Beauchamp

Goldstein

, et al. Community-based exercise programs as a strategy to optimize function in chronic disease: a systematic review. Med Care 2014; 52: 216–226.

30.

Health Information Quality Authority . Health technology assessment of chronic disease self-management support interventions. 2015.

31.

Barker

Holland

Lee

, et al. A rehabilitation programme for people with multimorbidity versus usual care: a pilot randomized controlled trial. J Comorb 2018; 8: 2235042X18783918.

32.

Boehmer

Abu Dabrh

Gionfriddo

, et al. Does the chronic care model meet the emerging needs of people living with multimorbidity? A systematic review and thematic synthesis. PLoS One 2018; 13: e0190852.

33.

Kehoe

Skelly

Moyna

, et al. The effect of participating in MedEx Wellness, a community-based chronic disease exercise rehabilitation programme, on physical, clinical and psychological health: a study protocol for a cohort trial. Contemp Clin Trials Commun 2020; 19: 100591.

34.

Wilkinson

Higgs

Stokes

, et al. How to best develop and deliver generic long-term condition rehabilitation programmes in rural settings: an integrative review. Front Rehabil Sci 2022; 3: 904007.

35.

Hevey

Wilson O’Raghallaigh

O’Doherty

, et al. Pre-post effectiveness evaluation of Chronic Disease Self-Management Program (CDSMP) participation on health, well-being and health service utilization. Chronic Illn 2020; 16: 146–158.

36.

Eldridge

Chan

Campbell

, et al. CONSORT 2010 statement: extension to randomised pilot and feasibility trials. bmj 2016; 355: i5239.

37.

Barry Walsh

Cahalan

Julian

, et al. A physiotherapy-led disease-agnostic telerehabilitation programme for people with chronic health conditions: a mixed-methods feasibility trial protocol. Open Science Framework 2024. DOI: 10.17605/OSF.IO/4NWC9.

38.

Chan

A-W

Tetzlaff

Altman

, et al. SPIRIT 2013 statement: defining standard protocol items for clinical trials. Ann Intern Med 2013; 158: 200–207.

39.

Barry Walsh

Cahalan

Hinman

, et al. Exploring attitudes of people with chronic health conditions towards the use of group-based telerehabilitation: a qualitative study. Clin Rehabil 2024; 38: 130–142.

40.

Barry Walsh

Cahalan

Hinman

, et al. Exploring attitudes of physiotherapists towards the delivery of group-based telerehabilitation and their acceptability of mixed-condition group programmes for people with chronic health conditions: a qualitative study, 2024. Manuscript submitted for publication.

41.

NCP Respiratory . Guidance for setting up a virtual pulmonary rehabilitation programme, 2023.

42.

de Souto Barreto

. Exercise for multimorbid patients in primary care: one prescription for all? Sports Med 2017; 47: 2143–2153.

43.

Association of Chartered Physiotherapists in Cardiac Rehabilitation . Standards for physical activity and exercise in the cardiovascular population. London: Association of Chartered Physiotherapists in Cardiac Rehabilitation London, 2015.

44.

NHS Coventry and Warwickshire . Cardiac rehabilitation circuit training programme, 2021.

45.

Chisholm

Collis

Kulak

, et al. PAR-Q validation report: the evaluation of a self-administered pre-exercise screening questionnaire for adults. Victoria, Canada: BC Ministry of Health and Health and Welfare 1978.

46.

Powell

Myers

. The activities-specific balance confidence (ABC) scale. J Gerontol A Biol Sci Med Sci 1995; 50: M28–M34.

47.

Herdman

Gudex

Lloyd

, et al. Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res 2011; 20: 1727–1736.

48.

Borg

. Borg's perceived exertion and pain scales. Champaign: Human Kinetics, 1998.

49.

Hoffmann

Glasziou

Boutron

, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. Bmj 2014; 348: g1687.

50.

Lajoie

Gallagher

. Predicting falls within the elderly community: comparison of postural sway, reaction time, the Berg balance scale and the Activities-specific Balance Confidence (ABC) scale for comparing fallers and non-fallers. Arch Gerontol Geriatr 2004; 38: 11–26.

51.

Chronic Conditions Working Group . Living well with a chronic condition: framework for self-management support national framework and implementation plan for self-management support for chronic conditions. COPD, Asthma, Diabetes and Cardiovascular Disease 2017.

52.

Hudon

Chouinard

M-C

Diadiou

, et al. The Chronic Disease Self-Management Program: the experience of frequent users of health care services and peer leaders. Fam Pract 2016; 33: 167–171.

53.

Avery

Williamson

Gamble

, et al. Informing efficient randomised controlled trials: exploration of challenges in developing progression criteria for internal pilot studies. BMJ Open 2017; 7: e13537. DOI: 10.1136/bmjopen-2016-013537.

54.

Cahalan

Meade

Mockler

. SingStrong—a singing and breathing retraining intervention for respiratory and other common symptoms of long COVID: a pilot study. Can J Respir Ther 2022; 58: 20–27.

55.

Cox

McDonald

Mahal

, et al. Telerehabilitation for chronic respiratory disease: a randomised controlled equivalence trial. Thorax 2022; 77: 643–651.

56.

Hawley-Hague

Lasrado

Martinez

, et al. A scoping review of the feasibility, acceptability, and effects of physiotherapy delivered remotely. Disabil Rehabil 2023; 45: 3961–3977.

57.

Navickas

Petric

V-K

Feigl

, et al.

Multimorbidity: what do we know? What should we do?

J Comorb 2016; 6: 4–11.

58.

Skivington

Matthews

Simpson

, et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. bmj 2021; 374: n2061.

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