Ever since infectious disease transmission mechanisms became known, social isolation has been a strategy to control most epidemics.¹ This strategy has been adopted against 2019 SARS-COV2 pandemic in most countries worldwide, with varied rigorousness depending on the region. What seems to be unanimous is the directive for total social isolation for the elderly and chronicle disease patients. The reasons behind this recommendation are the ever-so-great number of recent publications pointing out the unfavorable evolution of COVID-19 among this population. Wu and McGoogan analyzed more than seventy thousand cases of COVID-19, reporting that the mortality rate by COVID-19 was 10.5% for cardiovascular disease patients and 6% for hypertensive patients.² These rates were higher than the 2.3% rate noticed in the same sample by the general population. In the same publication, death rate was 8 and 14.8% for individuals between 70 and 79 years old and over 80 years old, respectively. Patients with cancer presented an even higher risk of morbimortality.³

Home-based rehabilitation strategies with or without remote monitoring have already been classified as an urgent matter with regard to patients’ engagement in rehabilitation programs.⁴ Telemedicine strategies have been used with this purpose.⁵ A meta-analysis including 11 studies concludes that it is at least as effective as a center-based rehabilitation in improving modified risk factors and aerobic capacity.⁶

In pandemic times, keeping chronic disease patients at home with their compensated illnesses is an extremely important clinical and epidemiological measure. Physical exercise becomes imperative in this process. Given the circumstances, remote-based guiding and surveillance strategies supported by technological resources are the only possible tools.⁹ This study aims at evaluating the engagement of center-based rehabilitation patients in a tele- oriented exercise program at home (TOEP).

The data distribution was tested using the Kolmogorov-Smirnov test. Continuous variables related to the characteristics of the population were expressed in median and interquartile interval and compared through U-Mann-Whitney test. Age comparison and frailty between training plans was made using the Kruskal-Wallis test. The categorical variables were expressed in percentage and compared through chi-square test or Fisher exact. The variations in weekly training rate (WTR) pre-quarantine and along the five-week TOEP were compared using the Friedman test. Pairwise comparison post-hoc between weeks was made by Dunn's test. Variations in attendance were tested considering a WTR ≥3 per week throughout the weeks and compared by the McNemar test.

It was considered satisfactory engagement WTR≥3 per week in at least 4 out 5 weeks of training. A multivariate logistic regression model was created to determine independent engagement predictors containing age and variables with an error probability alfa ≤10% in the univariate analysis (chi-square and Mann-Whitney U). The statistical significance was defined by an alfa <5% probability error. The statistical analysis was conducted using a SPSS program (SPSS 22.0 for Windows, IBM SPSS, IL, US). This research was approved by the Hospital Federal Cardoso Fontes ethical and research committee under the protocol 36149020.6.0000.8066 and 4.258.930. All the procedures are in accordance with the Helsinki declaration 1975, updated in 2013.

Table 1 presents the characteristics of the sample and engagement rate by gender and clinical conditioning. By comparing individuals who participated or not, there was no difference in age, gender-prevailing illnesses and training characteristics. Frailty was the only different variable, with participants frailer than the non-participants.

The distinction between patients in exercise plans A, B, and C enabled effective distinction according to age and patient functionality (Table 2). Individuals classified as plan C were significantly younger than the others. With regard to frailty, group distribution provided the expected distinction, confirmed by the analysis of the Rockwood scale¹⁰, so there was no overlapping in the group distribution.

TOEP had 91.8% engagement among participant patients. With respect to WTR, in the face-to-face physical training program previously adopted by patients, the average was of 2.7±0.1 sessions per week (Figure 2). Since the implementation of home-based exercise program, the same previous average of 2.8±0.2 sessions of weekly training were kept. It was possible to notice no evolution each week. In the beginning, there was a reduction in WTR followed by a rise in the second week, for values higher than the previous average, which was sustained until the end.

WTR≥3 trains per week was observed in 27.9; 77.0; 60.7; 67.2 and 72.1% of participants in weeks 1 and 5, respectively. Variations were significant between weeks 1 and 2 (p<0.001) and weeks 2 and 3 (p=0.007).

While comparing the fifth week with the previous training period (pre-quarantine) 29.5% of patients reduced 13.1% kept and 57.4% had a significant increase in WTR.

Multivariate analysis is show on Table 3. DM was the only independent predictor of engagement equal or higher than three training sessions per week within at least 4 weeks in the program. Figure 3 illustrates the evolution of WTR in stratified patients through the presence/absence of DM.

In this study, after moderated engagement in the remote rehabilitation program (63.9%), participants’ involvement was considered good. By the end of the fifth week, 91.8% kept in touch with the program. Several rehabilitation centers interrupted their face-to-face activities during the pandemic and invited their patients to join remote rehabilitation programs,^11,12 but in the light of the authors’ knowledge, this is the first publication that describes patient engagement and commitment to the home-based tele-oriented exercise program.

The highest multicentric register so far (1,653 patients with heart failure) reported an engagement of 85.6% right at the beginning of the program.¹³ At the end of the 24 weeks, only 55% of the patients kept in touch with the telemonitoring system. Stampehl et al.¹⁴ presented that at the end of 31 days, there were 66.7% of participant patients engaged in the program. Unfortunately, the DIAL study,¹⁵ which included 1,518 patients with heart failure, excluded physical exercise from its engagement criterion.

Although engagement criteria and monitoring plan may vary across studies, in both cases a larger rate of engagement has been related to a lower number of events in this population.

Beyond the satisfactory engagement rate, the main finding in this study is the efficiency in keeping patients exercising. A 2.9 days per week WTR average was observed, with more than 70% of patients exercising more than 3 days a week after 5 weeks of quarantine, which can be considered a good result. Besides, more than half of the patients exercised 3 or more days/week in 4 out of 5 weeks, and 57.4% were exercising more than they did before isolation. Some studies have already evaluated the rate of exercising during telemonitored home-based rehabilitation sessions. Kraal et al.¹⁶ and Laustsen et al.¹⁷ after 12 weeks of training, reported WTR 2±0.6 and 2.6±0.5 days/weeks, respectively. Another group has published a similar result of WTR 2.5±0.3 days/weeks within 12 weeks using a cell phone based exercise plan.¹⁸

The presence of diabetes was the only independent predictor of exercise engagement within the analyzed period. Only 18.8% of the patients with diabetes were able to exercise 3 times a week in 4 out of 5 weeks. The low engagement to exercise programs by patients with diabetes in different countries has been known for years,^19,20 and their rate vary around 60% of inactivity after adjustments. Reasons for that include difficulty to engage and fatigue, among others.²¹ Many studies have used telemedicine exercise plans to boost physical activity engagement in patients with diabetes,^22,23 successfully. Duruturk and Özköslü²⁴ performed a random study including 44 patients with diabetes where participants were offered a 6-week home-based exercise program (an average of 2.66 sessions per week), with the support of a physiotherapist by video-conference. Participants not only showed significant improvement in fitness, but also improved glycemic control and reduced symptoms of depression.

Diabetes is a risk factor for COVID-19 mortality.² Thus, we believe that isolation may be recommended for a longer period for this population,²⁵ even after flexibilization may reach the general population. On the other hand, sedentarism and low physical exercise engagement are risk factors for the development of macro and microvascular events in patients with diabetes.²⁶

The difficulty for full individualization of TOEP exercise prescriptions may be a limiting factor for its efficacy. However, TOEP was a fast-solution plan in order to keep patients engaged in physical activities, while allowing them to manage their clinical conditions. To evaluate patients’ points of view regarding the program would help understand its efficacy. This type of analysis demands the use of mixed methods of investigation. Considering the urgency of the program, there was no available time to develop an evaluation tool that could reflect perception and individual satisfaction.

Moreover, to ensure efficacy, it would have been necessary that patients go through a pre- and post-intervention for cardiopulmonary performance. In these regards, the exercise plan has data of previous evaluations for each patient and will soon be reevaluated. WTR is the main measure of attendance and was based on patients’ personal feedback. Pre-pandemic frequency was based on the program in which patients were enrolled, and not in attendance.

In this small sample, the development of a fast-tracking remote rehabilitation program, comprised by center-based rehabilitation concepts and data, was well-received by the participants. The exercise plans were adequate, and patients were able to maintain good exercise rates after 5 weeks of quarantine. Patients with diabetes showed lower engagement and deserve special attention in future exercise plans. In pandemic times, developing efficient and safe tele-rehabilitation plans must be regarded as a scientific urgent matter.