JMIR Publications

ABSTRACT

Background:

Pulmonary rehabilitation (PR) is a cornerstone of chronic obstructive pulmonary disease (COPD) management; however, access to traditional center-based PR (CBPR) remains limited. To overcome these barriers, digital and remote delivery models—collectively referred to as pulmonary telerehabilitation (Tele-PR)—have been increasingly implemented. Nevertheless, Tele-PR encompasses different intervention models that vary significantly in terms of technology use, level of supervision, and mode of interaction, and the impact of these variations on treatment effectiveness, program consistency, and long-term sustainability remains poorly understood.

Objective:

This systematic review and meta-analysis aimed to compare the effectiveness and safety of Tele-PR versus CBPR in adults with COPD. Given that Tele-PR is not a uniform intervention, remote interventions were stratified by intensity of supervision and mode of delivery to examine heterogeneity across approaches.

Methods:

A systematic review and meta-analysis were conducted in accordance with the PRISMA 2020 and PRISMA-S guidelines. Searches were performed in PubMed, Embase, the Cochrane Library, and the Web of Science from inception to December 10, 2025 to identify randomized controlled trials comparing Tele-PR or home-based pulmonary rehabilitation (HBPR) with CBPR in adults with COPD. Random-effects meta-analyses were conducted using the Hartung–Knapp–Sidik–Jonkman method. Between-study heterogeneity was assessed using τ², I², and 95% prediction intervals (PIs). Risk of bias was evaluated with the Cochrane Risk of Bias 2 tool, and certainty of evidence was graded using the GRADE approach.

Results:

Seventeen randomized controlled trials involving 1,854 participants were included. Following intervention, Tele-PR and CBPR showed comparable average effects on exercise capacity, as measured by the 6-minute walk distance (k=9; n=950; MD –5.37 m, 95% CI –15.68 to 4.95; P=.26; τ²=103.97; I²=28.2%; 95% PI –31.82 to 21.08 m). Although pooled effects were not statistically significant, substantial heterogeneity was observed across remote delivery models. Subgroup analyses linked digitally supported, synchronously supervised Tele-PR to narrower PIs and less between-study variance across several outcomes, indicating greater consistency in treatment effects across different settings, while revealing that low-technology HBPR yielded more variable outcomes, particularly in symptom burden. At long-term follow-up (≥6 months), between-group differences in functional and symptom outcomes diminished, and short-term improvements in exercise capacity were ultimately unsustained in terms of daily physical activity levels.

Conclusions:

Tele-PR can achieve clinical outcomes comparable to those of CBPR in improving exercise capacity and health status. Further analyses suggest that digitally supported Tele-PR and HBPR represent two clinically distinct intervention paradigms with differing efficacy profiles. A new conceptual "supervision gradient" framework may explain variations in the consistency of efficacy across remote rehabilitation models. Future remote rehabilitation strategies should prioritize integrating real-time supervision and long-term behavioral maintenance components to address the limitations of purely home-based models and sustain treatment benefits over time. Clinical Trial: PROSPERO registration: CRD42025633252. https://www.crd.york.ac.uk/PROSPERO/view/CRD42025633252