It corresponds to a descriptive and retrospective study that describes the implementation, satisfaction, and perspective of users of a telerehabilitation program for oncosurgical patients during the COVID-19 pandemic. We follow the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines[12] (supplemental file 1).
The inclusion criteria correspond to adult oncosurgical patients candidates for predominantly minimally invasive elective surgery with or without neoadjuvant users of a public hospital in the city of Santiago who entered a telerehabilitation program between August 2020 and June 2022. Regarding the exclusion criteria, patients admitted to the telerehabilitation program with incomplete histories were considered.
User satisfaction and insights
To evaluate user satisfaction, a survey was used which was answered at the end of the program. This survey contained nine items on a Likert scale with five response options ranging from "very dissatisfied" to "very satisfied." Likewise, the survey had a space for observations that aimed to collect the perspectives and general comments, in order to receive feedback aimed at improving the patient-centered approach in relation to the new implemented telerehabilitation service (supplementary file 2).
Additionally, sociodemographic and clinical history such as sex, marital status, age, diagnosis, weight and height, neoadjuvant, comorbidities, the Eastern Cooperative Oncology Group (ECOG)[13] and the American Society of Anesthesiologists (ASA)[14].
Telerehabilitation program
Patients with confirmed oncological diagnosis and scheduled surgery were referred from the surgery service to different essential pre-surgical appointments for patients (anesthesia, nutrition, physical therapy, nursing, and geriatrics if it corresponded to an older person), making them coincide to limit additional and unnecessary hospital visits during the pandemic. Patients were referred to pre-rehabilitation to physical medicine and rehabilitation, a service that in response to the COVID-19 pandemic, adapted the face-to-face pre-rehabilitation program in force until before the pandemic to a telerehabilitation modality.
The program consisted of 8 sessions that were carried out by two physiotherapists with expertise in the subject, which were executed in a time of approximately 45 minutes, 2–3 times a week where the first was face-to-face and the remaining 7 sessions were executed remotely in real time through a video call from a smartphone or a Zoom platform, depending on the technological resources available to each patient.
The program had the following elements:
1. Evaluation: In a first face-to-face session, if the patient met the inclusion criteria for admission to the telerehabilitation program and voluntarily agreed to participate, information about the contents and objectives of the program was provided. Likewise, the sociodemographic/clinical history and an evaluation of functional variables were evaluated, (these variables were evaluated again at the end of the program in which the participants had the option of doing it remotely limiting visits to the hospital due to the risk of contagion). The functional variables evaluated were physical capacity, for which the Sit-to-stand test (STST)[15] in 1 minute. ; balance, assessed with the five-times-sit-to-stand test (FSTST)[16] which measures the time it takes a person to stand and sit five times from a sitting position; Independence in activities of daily living (ADLs) in which the Barthel index was used. [17]This scale with 10 items, identifies the independence or dependence of the subject in different ADLs; and finally fatigue was evaluated for which the Brief Fatigue Inventory (BFI)([18], an instrument that evaluates the intensity, quantity and impact of oncological fatigue.
Additionally, in this initial session, the technological resource with which the patient was going to perform the telerehabilitation was verified, receiving a sheet with indications for the remote connection. They received a work kit for the execution of the remote sessions as well, which contained: a set of elastic bands of yellow, red and blue colors (Theraban® the hygienic Corporation, Akron, USA); a volumetric incentive, (Coach 2®Incentive Spirometer/22-4000);a printed guide with support materials and a booklet for recording daily activities carried out, including basic daily activities.
2. Breathing exercises: From the first session, localized breathing exercises were taught with emphasis on diaphragmatic work. Patients were also instructed in the use of a volumetric incentivizer.
3. Mixed exercise plan: This considered modifiable clinical risk factors, perceived needs, and was personalized based on the baseline condition of each patient evaluated in the first session. At the beginning of each remote session, to ensure physical fitness for exercise, the patient was asked to assess temperature, heart rate by paying attention to warning signs such as chest pain, generalized weakness, shortness of breath, feeling fatigued, or other relevant sign. The exercise plan was elaborated according to safety considerations based on the recommendations of the international guidelines established for the oncology population[19, 20] To assess the perceived effort during each session, the Borg scale (scale 6–20) was used[19, 20]
Details of the intervention were published in the study by Lorca et al 2022[4]
When the patient corresponded to an elderly person with mobility and balance problems, it was requested as a requirement to have the presence of a family member or a caregiver during the telerehabilitation session to guarantee safety.
4. Education and counseling: In an educational session, patients received instructions for self-care, such as favoring physical activity and a 30-minute daily walk considering physical distancing during the pandemic.
Additionally, patients were educated to use the application of a step counter and heart rate recording from their smartphones as a support strategy to promote aerobic walking exercise, complying with the safety measures established during the pandemic. The program set a goal of reaching 10,000 steps a day.
Likewise, as reported [21]), education emphasized the importance of smoking cessation, reduction of alcohol consumption and sleep hygiene as a relevant strategy for telerehabilitation.
With the aim of improving adherence, as an additional resource used in similar telerehabilitation programs [22, 23]), patients were monitored weekly with a phone call to verify compliance with exercises at home. Additionally, patients were encouraged to fill out the daily log sheet of their daily activities and exercises by committing them to the program.
This study was approved by the scientific ethics committee of the Eastern Metropolitan Health Service (November 24,2021). No informed consent was used due to the retrospective nature of the study. Confidentiality was guaranteed regarding the identity of the users, using a correlative number for each registered patient. No information was provided to third parties outside this investigation.