Telemedicine (TM) (see Table 1) finds its application most commonly in chronic heart failure (HF).1–3 TM can be useful during exercise training (ET) as a tool to control stability of the clinical status of patients and to supervise training sessions. These goals can be achieved by monitoring clinical symptoms (dyspnoea, fatigue, oedema, chest pain, palpitations, etc.) and monitoring parameters (electrocardiogram [ECG], heart rate, blood pressure, bodyweight, saturation, respiration) in order to anticipate potential destabilisation of HF patients and thus ensure safety of telerehabilitation (TR).4,5 Many HF patients remain physically inactive despite the proven benefits of ET.6,7 Table 2 shows factors that adversely affect comprehensive outpatient cardiac rehabilitation. It seems that the introduction of TR may help eliminate most of the factors that result in the currently low number of patients undergoing outpatient-based rehabilitation programmes, and it may thus increase the overall proportion of patients undergoing cardiac rehabilitation.
This article will present the opportunities offered by TM in terms of ET in HF patients. Figure 1 shows the proposed position of ET within TM concepts for HF patients. Previous papers reporting experience with TR have mainly included low-risk patients, with only a few studies including medium-risk patients or not excluding HF patients from the studied low-risk group.8,9 In a study by Koudi et al., who demonstrated the feasibility of transtelephonic electrocardiographic monitoring of an outpatient cardiac rehabilitation programme (phase III) in public gyms, only 17% patients suffered from HF. Squires et al. reported transtelephonic monitoring of a single-lead ECG with on-demand two-way voice communication during cardiac rehabilitation programme for patients suffering from coronary artery disease (36 subjects were classified as high-risk patients, and three suffered from HF) performed in patient homes or remote hospital sites. In these studies, TR was not compared with outpatient cardiac rehabilitation programmes, and the effectiveness and safety of TR were not evaluated separately in small subgroups of HF patients. To date, only a few studies have been specifically performed to evaluate TR in HF patients.10,11 Smart et al. reported home-based cardiac rehabilitation in patients with HF initiated after four months of hospital-based ET; this study showed that TR maintained the improvement achieved during previous rehabilitation in hospital settings.10 One randomised study focused on TR in HF patients, demonstrating that home telemonitored cardiac rehabilitation is equally effective1 and provides similar improvement in health-related quality of life compared with a standard outpatient-based cardiac rehabilitation.11
Telerehabilitation Based on Heart Rate Monitoring
Patients were provided with exercise diaries and heart rate monitors for recording heart rate data in a format that was downloadable to a computer. Patients were contacted weekly by telephone or email to report their progress; heart rate monitors and exercise diaries were returned every four to six weeks.10
Telerehabilitation Based on Transtelephonic Electrocardiographic Monitoring
Transtelephonic electrocardiographic monitoring kits contained a telemedicine 12-lead electrocardiographic unit, a telephone modem, a computer receiver with special operating software and a laser printer. Twelve-lead ECGs of patients with worrying symptoms were transmitted by qualified trainers in realtime by standard telephone lines and were evaluated by the medical staff at the receiving centre. As soon as the ECG diagnosis was made, the cardiologist contacted the exercise trainer and provided all the necessary instructions for intervention.8
Telerehabilitation Based on Tele-electrocardiogram
Monitoring and Supervision Using a Remote Exercise
The equipment used for TR consisted of a special remote device, a mobile phone and the monitoring centre with computer receiver with special operating software. The remote exercise training device enabled recording of ECG data from three precordial leads and their transmission via a mobile phone to the monitoring centre. The mobile phone was also used for voice communication. Before the beginning of the training session, patients used the mobile phone to answer a series of questions in terms of their current condition and prescribed medications. Patients then transmitted resting ECG data to the monitoring centre. If no contraindications to training were identified, patients were given permission to start the training session. The remote exercise training equipment was used to monitor and control the training in any place where the patient elected to exercise. The device had pre-programmed training sessions for each patient individually (defined exercise duration, breaks, timing of ECG recording). The planned training sessions were executed with the device indicating what should be performed with sound and light signals. The timing of automatic ECG recordings corresponded to peak exercise. If the completed training session was uneventful, the patient transmitted the ECG recording via mobile phone to the monitoring centre immediately after the end of every training session. Patients could also transmit the ECG recording at any time for example if they experienced worrying symptoms. The ECG recordings were analysed at the monitoring centre, and the safety, efficacy and accuracy of a particular patient rehabilitation programme were assessed. Using the data on heart rate during exercise and the patient™s subjective evaluation of the perceived exertion, consultants were able to adjust the training workload appropriately or, if necessary, to discontinue the session.11
Telerehabilitation Based on Realtime
Electrocardiographic and Voice Transtelephonic
Monitoring of Cardiac Rehabilitation
The transtelephonic monitoring system included a four-channel oscilloscope for electrocardiographic (single lead) visualisation and on-demand simultaneous two-way verbal communication between the patients and the monitoring centre. Patients were provided with transtelephonic electrocardiographic transmitter (battery powered, realtime transmission of the ECG) and a headset with earphones and microphone. Patients were instructed on how to apply the bipolar electrocardiographic lead system. The system operated over commercial telephone lines and allowed simultaneous monitoring of up to four patients. The system allowed all patients to participate in a conference telephone call, which enabled them to interact with other members of the group, as well as with the monitoring staff to facilitate teaching and group therapy.9
Adherence to Telerehabilitation
All authors reporting on TR programmes agree that adherence to TR seems to be superior to adherence to outpatient cardiac rehabilitation.9–11
Safety of Telerehabilitation
Studies on TR showed that regular telesupervised ET in HF patients was safe. Neither death nor a major complication or event has been recorded that could be attributed to TR.10,11
Advantages of Telerehabilitation
TR is an attractive form of comprehensive cardiac rehabilitation. The greatest advantages of TR include convenience and easy accessibility for HF patients. In addition, TR fosters greater patient independence compared with hospital-based exercise training, and may reduce the necessary patient commuting time, time off from work and overall costs.2,3,9–11
Limitation of Telerehabilitation
The limitations of TR may include technical and technological problems and lack of willingness on the part of patients to co-operate.
Proposed Model of Telerehabilitation
On the basis of research data, a preliminary programme of comprehensive cardiac TR for HF patients can be proposed. Indications and contraindications to TR are in line with the published guidelines on ET for HF patients.12–15
Staff and Equipment
In order to perform TR, the following components are necessary: TR monitoring staff and a TR monitoring system. The TR monitoring staff should include a physician, a physiotherapist, a nurse and a psychologist. The TR-monitoring system should comprise a telemedicine electrocardiographic unit, a remote device for tele-ECG-monitored and supervised exercise training, a telephone modem or mobile phone, a computer receiver with adequate operating software and a laser printer.
TR should consist of two phases: an initial phase, conducted either at hospital sites or within existing outpatient programmes, and a basic phase, which is conducted at home.
The Initial Telerehabilitation Phase
The components and goals of the initial phase include a baseline clinical examination to allow reliable evaluation of clinical status and functional capacity, education, individual planning of exercise training depending on patient exercise tolerance as established during tests, and a few (three to six) monitored educational exercise sessions.
Education is a critical step to prepare the patient for TR. All patients should participate in an education programme designed and run by the TR staff. Patients should be taught how to measure heart rate, blood pressure and weight, how to self-evaluate worrying signs and symptoms and the level of perceived exertion according to the Borg scale, how to perform the ET and how to operate the telemonitoring equipment. The partners of patients should also be trained on how to give first aid in case of an emergency.
Planning the Exercise Training
The chosen workload should reflect individual effort tolerance in terms of perceived exertion according to the Borg scale and the training heart rate range established individually for each patient depending on patient-specific parameters (heart rate and physical effort) achieved during exercise tests. Within the TR programme, patients can perform a varied range of exercises, e.g. walking, Nordic walking and cycle ergometer training. After successful completion of the initial phase, patients should be given the telemonitoring device.
The Basic Telerehabilitation Phase
During each exercise training session, the basic TR phase should include the following two steps: the training consent procedure required to initiate each exercise training session and the training session.
The Training Consent Procedure
Before the training session, each patient should answer a series of questions via a mobile phone in terms of his or her current condition (factors should include fatigue, dyspnoea, oedema, blood pressure, body mass and medications taken). Subsequently, patients should transmit resting ECG data to the TR monitoring centre. If no contraindications are detected, patients can be given consent to start the training session.
The Training Session
ET should be performed in accordance with the published standards for HF patients.13–15 Recommended monitoring models are TR based on realtime electrocardiographic and voice transtelephonic monitoring of cardiac rehabilitation and TR based on tele-ECG-monitoring and supervision using a remote exercise training device.9,11
One of the most important requirements is to ensure the safety of home-based TR. The available data show that the benefits of regular ET significantly outweigh its potential risks. The safety of cardiac TR depends on special attention to appropriate risk stratification in candidates for rehabilitation; observing contraindications to ET; consideration of concomitant HF device therapy, including cardiac pacing, cardiac resynchronisation therapy (CRT) and implantable cardioverter defibrillators (ICDs); education (self-evaluation); individually planned training for each patient, including subjective assessment of perceived exertion; using a special training consent procedure before each session, with consent being granted via mobile phone only after the clinical symptoms and transmitted resting ECG have been analysed at the monitoring centre; analysing perceived exertion and ECG immediately after or during each training session (depending on the TR programme); ET approval by patients; and the presence of another who always accompanies the patient during exercise and is able to provide first aid and call professional medical help in case of an emergency.
Based on published studies, it can be concluded that TR in HF patients could be equally effective as and provide similar improvements in health-related quality of life to standard outpatient cardiac rehabilitation. In addition, adherence to cardiac rehabilitation seems to be better during TR. Due to disease-related limitations, TR seems to be a viable alternative for comprehensive cardiac rehabilitation in HF patients. Further studies are needed to confirm the utility of this type of rehabilitation in routine clinical practice, including its cost-effectiveness. Because of the diversity of technological systems, it is necessary to create a platform to ensure compatibility between the devices in telemedicine.
- Shaw DK, Heggestad-Hereford JR, Southard DR, Sparks KE, American Association of Cardiovascular and Pulmonary Rehabilitation Telemedicine Position Statement, J Cardiopulm Rehabil, 2001;21:261–2.
- Meystre S, The current state of telemonitoring: a comment on the literature, Telemed J E-Health, 2005;11:63–9.
- Winters JM, Winters JM, A telehomecare model for optimizing rehabilitation outcomes, Telemed J E-Health, 2004;10:200–12.
- Maric B, Kaan A, Ignaszewski A, Lear SA, A systematic review of telemonitoring technologies in heart failure, Eur J Heart Fail, 2009;11:506–17.
- Mortara A, Pinna GD, Johnson P, et al., Home telemonitoring in heart failure patients: the HHH study (Home or Hospital in Heart Failure), Eur J Heart Fail, 2009;11:312–8.
- Piepoli MF, Davos C, Francis D, ExTraMATCH Collaborative. Exercise training meta-analysis of trials in patients with chronic heart failure (ExTraMATCH), BMJ, 2004;328:189–92.
- O'Connor ChM, Whellan DJ, Lee KL, Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial, JAMA, 2009;301(14):1439–50.
- Kouidi E, Farmakiotis A, Kouidis N, Deligiannis A, Transtelephonic electrocardiographic monitoring of an outpatient cardiac rehabilitation programme, Clin Rehabil, 2006;20:1100–4.
- Squires RW, Miller TD, Harn T, et al., Transtelephonic Electrocardiographic Monitoring of Cardiac Rehabilitation Exercise Sessions in Coronary Artery Disease, Am J Cardiol, 1991;67:962–4.
- Smart N, Haluska B, Jeffriess L, Marwick TH, Predictors of sustained response to exercise training in patients with chronic heart failure: A telemonitoring study, Am Heart J, 2005;150:1240–7.
- Piotrowicz E, Baranowski R, Bilinska M, et al., A new model of home-based telemonitored cardiac rehabilitation in patients with heart failure: effectiveness, quality of life and adherence, Eur J Heart Fail, 2010; 12(2):164–71.
- Dickstein K, Cohen-Solal A, Filippatos G, et al., ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008 The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM), Eur J Heart Fail, 2008;10:933–89.
- Working Group on Cardiac rehabilitation & Exercise Physiology and Working Group on Heart Failure of the European Society of Cardiology. Recommendations for exercise training in chronic heart failure patients, Eur Heart J, 2001;22:125–35.
- Myers J, Principles of exercise prescription for patients with chronic heart failure, Heart Fail Rev, 2008;13:61–8.
- Pina IL, Apstein CS, Balady GJ, et al., Exercise and heart failure: a statement from the American Heart Association Committee on Exercise, Rehabilitation and Prevention, Circulation, 2003;107:1210–25.