Cognitive Telerehabilitation: A “Powerful Alternative” for Patients With COPD

Photo Credit: Ridofranz

Cognitive telerehabilitation was a suitable alternative to pulmonary rehabilitation for older patients with severe COPD who can’t tolerate exercise.

In a randomized trial published in Advances in Respiratory Medicine, researchers compared pulmonary telerehabilitation (PtR) and cognitive telerehabilitation (CtR) for older patients with severe chronic obstructive pulmonary disease (COPD).

Pulmonary rehabilitation is highly effective and can improve QOL, exercise capacity, and dyspnea in patients with COPD. The study authors also noted that cognitive rehabilitation methods, such as motor imagery and action observation, are being applied in rehabilitation to simulate motor actions and engage mirror neurons, which can promote brain plasticity.

“Motor imagery is an active cognitive process whereby the representation of a particular action is internally reproduced (simulated) in the working memory without any explicit motor output. Importantly, researchers suggest that motor imagery provides a projection onto the action representation process by projecting an internal action representation,” Amine Ataç, Dr Öğr Üyesi, and colleagues wrote. “Action observation involves the deliberate and structured observation of a movement.”

Motor imagery and action observation have shown efficacy in fields like neurology, orthopedics, and burn care, but data regarding their application in lung diseases are limited.

“It is important to investigate methods such as motor imagery and action observation, which are methods that can be used during periods when active exercise is difficult, since peripheral and respiratory muscle dysfunction, and low QOL, along with decreased movement of the patients, prolonged bed rest, and lack of motivation, may occur in elderly patients with COPD,” the authors wrote.

Cognitive Versus Pulmonary Rehabilitation

The researchers conducted their study with 26 patients at a pulmonary hospital in Türkiye. Patients were aged between 45 and 80 years, diagnosed with C or D group COPD, did not use assistive devices, scored at least 24 on the Standardized Mini-Mental state examination, and had no orthopedic, neurological, or cardiovascular comorbidities.

Patients had no contraindications for moderate-intensity exercise. In addition, the participants did not experience current or recent (in the last four weeks) COPD exacerbations.

The study authors randomly assigned patients 1:1 to receive either pulmonary or cognitive telerehabilitation. Patients undergoing PtR participated in supervised videoconferences three times per week for eight weeks total. The exercises included warm-ups, breathing exercises, active breathing techniques, aerobic exercise, resistance training, and a cool-down period.

Meanwhile, a physiotherapist sent participants in the CtR group a video containing detailed instructions, including motor imagery and active observation methods.

“Patients were asked to watch each exercise in the videos and then visualize them in their minds, following the instructions in the video while seated,” and colleagues explained. “During the action observation method, each exercise was replayed in the video for 90 seconds and a break was made between each exercise for 30 seconds. In the motor imagery method, patients were asked to imagine each exercise as if it were real for 45 seconds and then to rest for 15 seconds as per the commands in the videos.”

Near the end of the session, the videos prompted patients to do the same breathing exercises and active breathing techniques as the PtR group.

The study’s primary outcome was exercise capacity, as measured by the 6 minute walking test (6MWT). Secondary outcomes included:

• Peripheral muscle strength (electronic hand dynamometer);
• Dyspnea (Modified Medical Research Council Dyspnea Scale);
• Blood lactate levels;
• Activities of daily living (London Chest Activity of Daily Living Scale);
• QOL (St. George’s Respiratory Questionnaire);
• Anxiety and depression (Hospital Anxiety and Depression Scale); and
• Respiratory muscle activities.

COPD Outcomes Improve

Both groups experienced significant improvements in the 6MWT (P<0.05), as well as peripheral muscle strength, COPD Assessment Test symptom scores, activities of daily living, and QOL (P<0.05).

Blood lactate levels also fell in both groups, though the change was not statistically significant. Both groups also showed increases in muscle strength, without superiority in either group.

“While it is expected that muscle strength increase will occur with pulmonary rehabilitation, muscle strength increase occurred in our study by applying the motor imagery and action observation method without active muscle strengthening exercises,” Dr. Ataç and colleagues said.

Of note, dyspnea and cognitive impairment declined significantly in the CtR group (P<0.05) but not in the PtR group.The researchers concluded that CtR, applied in addition to PtR and without active muscle strengthening, had more comprehensive benefits for their patients.

“Cognitive telerehabilitation can be a powerful alternative rehabilitation method in severe respiratory patients who cannot tolerate active exercise programs and/or have problems with transfer to the hospital,” Dr. Ataç and colleagues wrote.