People awaiting lung transplantation (LTx) are a unique subset of the chronic lung disease population who undergo pulmonary rehabilitation. Candidates have end-stage lung disease, are represented by a high proportion of interstitial lung disease diagnoses and often present with high exertional oxygen requirements, disease progression, exacerbations, other acute events, hospitalizations and palliative care intervention for symptom management during rehabilitation. ¹ Pre-habilitation is essential for frail surgical populations facing a major physiological stressor who are at high-risk for functional decline and a prolonged hospital stay. ² Although physical/phenotypic and cumulative deficit/index frailty, characterized as low physiological reserve and increased vulnerability to stressors and adverse outcomes is common in chronic lung disease and solid organ transplant populations, there is no standardized assessment or clear guideline for patient selection and optimization. ³ However, pre-habilitation is recommended in LTx to address modifiable aspects of frailty to improve pre- and post-transplant outcomes. ^1,4 An additional challenge to pre-habilitation in LTx candidates is the unknown timing of transplantation. The duration of pre-habilitation may be very short for people who undergo LTx soon after transplant listing, or may be a prolonged period when acute and chronic health changes can occur. Pre-habilitation provides an opportunity for serial assessment of physical capacity, exercise participation, symptoms and exertional hypoxemia, and changes over time can be communicated to the medical team to inform medical management and wait list status/urgency.  

Prior to the COVID-19 pandemic, pre-rehabilitation of LTx candidates was commonly delivered in-person at a transplant and/or pulmonary rehabilitation centre. Early in the pandemic in-person participation was either stopped or significantly restricted and there was limited guidance and experience with broad clinical implementation of virtual or tele-rehabilitation. Due to a paucity of evidence on optimal exercise prescription in unsupervised environments and limitations in home monitoring, respiratory societies suggested caution when considering home or virtual rehabilitation for LTx candidates. ⁵ However people continued to be listed for LTx and the need for pre-habilitation to optimize function and prepare for surgery remained. We reported a program evaluation of 78 LTx candidates who underwent virtual rehabilitation in the first wave of COVID-19 in 2020 using a third-party remote monitoring App. ⁶ Although there was good patient and provider satisfaction and no reported adverse effects, the functional outcomes (6-minute walk distance and short physical performance battery) and improvements in pre-transplant exercise volumes were lower than traditionally observed in our centre-based rehabilitation program. Physiotherapists identified a lack of exercise equipment and medical grade monitors as a large barrier to rehabilitation in some participants. While changes in exercise and exertional oxygen prescription were adjusted over time through virtual care, the physiotherapists felt that the lack of robust remote assessments and standard home exercise equipment limited their ability to identify an early clinical change, and preferred to bring people on-site to reassess when possible.  

Although there has been loosening of in-person restrictions, transplant programs such as ours will not be able to return to pre-pandemic, exclusive in-person rehabilitation as healthcare institutions continue to support ambulatory virtual care strategies and patients/caregivers express expectations and preferences for a flexible home-based model that reduces travel and time burden. The current issue is how to develop a robust hybrid model of care for the high-risk LTx population that maintains the benefits of virtual rehabilitation while addressing its’ limitations to provide effective, equitable and safe rehabilitation. Defining hybrid rehabilitation including different models of synchronous and asynchronous monitoring, inclusion of core program components and how to tailor to the needs of the patients is needed moving forward. 7

As part of a funded quality improvement project, our LTx rehabilitation program is examining end-user perspectives and experiences of virtual rehabilitation in addition to some in-person delivery. Preliminary survey results show a moderate level of satisfaction with the current hybrid rehabilitation and communication processes, however 40% of LTx candidates would prefer increased in-person options to increase motivation, receive hands-on instruction and decrease isolation. Rehabilitation providers felt that more precise communication, guidance, and processes are needed to set patient expectations and optimize clinical workflows.​ Next steps include the development of an algorithm to guide decision-making and risk stratification for the ratio of in-person and virtual pre-habilitation, considering baseline and changes in functional capacity, oxygen requirements, symptoms, disease stability and severity, exercise volumes, exercise adherence and access to exercise equipment .

Quality indicators for pulmonary rehabilitation were published in the pre-covid period ⁸ and there is limited data on remote exercise testing. ⁹ Our group has reported on the virtual assessment of physical frailty in solid organ transplant (SOT) recipients showing that virtual performance of the Short Physical Performance Battery (SPPB) and a modified version of the Fried Frailty Index (FFI) was feasible and safe. ¹⁰ As a test of walking capacity is a standard measure in pulmonary rehabilitation and guides aerobic exercise prescription, we are currently examining the clinical utility of remote walk tests in LTx candidates under different testing conditions and hope to have preliminary data available next year. Our research group is also performing a systematic review of telerehabilitation and SOT recipients; which will potentially be expanded to SOT candidates. ¹¹

We look forward to contributing to and reading emerging evidence and best practices on providing effective, equitable, safe and patient-centered hybrid rehabilitation for LTx candidates and other high-risk respiratory and surgical populations.

References 

1. Wickerson L, Rozenberg D, Janaudis-Ferreira T et al. Physical rehabilitation for lung transplant candidates and recipients: an evidence-informed clinical approach. World J Transplant 2015;6:517-531.
2. Santa Mina D, Scheede-Bergdahl C, Gillis C et al. Optimization of surgical outcomes with prehabilitation. Appl Physiol Nutr Metab. 2015;40:966-9.
3. Kobashigawa J, Dadhania D, Bhorade S et al. Report from the American Society of Transplantation on frailty in solid organ transplantation. Am J Transplant. 2019;19:984-994.
4. Montgomery E, Macdonald PS, Newton PJ et al. Frailty in lung transplantation: a systematic review. Expert Rev Respir Med. 2020 Feb;14(2):219-227.
5. Dechman G, Aceron R, Beauchamp M et al. Delivering pulmonary rehabilitation during the COVID-19 pandemic: A Canadian Thoracic Society position statement.Canadian Journal of Respiratory, Critical Care, and Sleep Medicine 2020; 4:232-235.
6. Wickerson L, Helm D, Gottesman C et al. Telerehabilitation for lung transplant candidates and recipients during the COVID-19 pandemic: program evaluation. JMIR Mhealth Uhealth 2021;9:e
7. Heindl B, Ramirez L, Joseph L et al. Hybrid cardiac rehabilitation - The state of the science and the way forward. Prog Cardiovasc Dis. 2022 Jan-Feb;70:175-182.
8. Dechman G, Cheung W, Ryerson CJ et al.Quality indicators for pulmonary rehabilitation programs in Canada: A Canadian Thoracic Society expert working group report. Canadian Journal of Respiratory, Critical Care, and Sleep Medicine 2019; 3:199-209.
9. Holland AE, Malaguti C, Hoffman M et al. Home-based or remote exercise testing in chronic respiratory disease, during the COVID-19 pandemic and beyond: A rapid review. Chron Respir Dis. 2020 Jan-Dec;17:1479973120952418.
10. Ferreira M, Chowdhury N, Wickerson L et al. Feasibility of Virtual Assessment of Physical Frailty in Solid Organ Transplant Recipients: A Single Center, Observational Study. Int J Telerehabil 2022;14:e
11. Ferreira M, Mathur S, Doré I et al. Telerehabilitation in solid organ transplant recipients: effects of telerehabilitation on physical function, mental health and health-related quality of life - A systematic review. PROSPERO 2022 CRD42022337985 Available from:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022337985.