Good afternoon, everyone. Thank you for joining us today for the session titled Pulmonary Rehabilitation, Nuts, Bolts and Lessons Learned. My name is Associate Professor Catherine Granger. I'm based in Melbourne, Australia, where I specialize in exercise for people with chronic respiratory diseases, particularly lung cancer. Before we commence the session, I'd like to acknowledge Dr. Brett Beatty, who was instrumental in setting up this session today, originally going to be the chair, but he's actually speaking at the room just down the corridor at this very same time, so he asked me to chair this session in his absence. But we'd like to acknowledge him for putting together the session. We are going to, we have four brief presentations today. We're going to start with a very powerful patient video, and then we'll take questions at the end of the session for the three of us. So to begin, I'd like to introduce Dr. Rahat Hassan. Dr. Professor Hassan is from the University of Texas. He is the Medical Director of Pulmonary Rehabilitation, the Medical Director of the Lung Transplant Unit at the University of Texas. Welcome and thank you. Good afternoon, everybody. Thank you very much for coming over. Aloha. There we go. So I would like to take two minutes to introduce to you one of my patients. His name is Frank Trahan, and I would like to listen to his testimony and see what he thinks. It's a four-minute video, so bear with him. This patient has severe COPD or had severe COPD about two and a half years ago. He's a 69-year-old gentleman. Frank is full of life. He was a radio DJ. All his life was very colorful, was full of energy. Unfortunately, with severe COPD, he had significant shortness of breath problems, and the lack of breath made him extremely anxious and depressed. He underwent severe exacerbations three times two years ago, to a point that he had to be intubated in one of those exacerbations. Most of these exacerbations were probably because of his anxiety and lack of breathing, and it was not so much because of pneumonia or something. As you know, when the work of breathing is so high, we end up intubating them. Unfortunately, when he got intubated, he was in the hospital for a week, and that's when we seriously told him that this is it. If you want lung transplant, we cannot move forward. After he said yes to us, he went to pulmonary rehab right after that hospitalization, and his life completely changed. He had four exacerbations the prior year. He had zero exacerbations after he went to pulmonary rehab, and that made a phenomenal difference in his quality of life. We got him transplanted. He's now one and a half year out, and here is Frank Trehan for you. He was extremely excited to talk when I told him that this is something that we would like you to share. Would you be? And he was like, absolutely, I want to share that. It's loading, so give me a second. I met him about two and a half years ago. He's a very God-loving man. One day I walked into his room, and he was crying in inpatient rehab, and I asked him, why are you crying? Frank, you're on the list. We are going to get a transplant soon. He said, you don't know when you take breathing for granted, and when that's taken away from you, how of a feeling is that? And that's the reason he was crying, unfortunately, at that time. So he wanted to share this with us and wanted to thank all the pulmonary rehab people who are around. Hello, my name is Frank, and I am a lung recipient at Memorial Harmony Hospital. My journey started about two and a half years ago when I was at stage two of COPD, and when I heard I could possibly get a transplant, I couldn't believe it, because I'd always heard that they didn't give transplants to older people. Okay, so I really didn't think about it, so when I found out I was going to be testing to see if I qualified, I was elated, but I was also a bit nervous, because after watching the videos that they required me to watch, I felt a little overwhelmed and didn't know if I could do it, but I made up my mind that breathing was better than that, so I pushed on and didn't think about not doing it anymore. So once my transplant, well before the transplant, I was ordered, I say ordered, it was recommended that I go to pulmonary rehab, because I was going through lots of anxiety, not to mention I was getting no physical exercise at all, and so I had no problem with that, so I started going to pulmonary rehab quite a while before the transplant, and you know, everything helped me that I went through, because I don't know how to tell that if I hadn't done it, where would I be now, I don't know, but all the oxygen that I didn't need, but had to have because of my mental state, I did, and it helped me, even though I didn't need it, it helped me, and the physical therapy helped me, because it's exercise, or physical, pulmonary rehab. And so once my transplant happened, I was, actually I was going to, I was going to pulmonary rehab when I got the transplant, so I didn't complete that first set of visits, but after I got out of the hospital, after getting the transplant, I of course went back to pulmonary rehab, and I'm telling you, it was what I needed at the time, and it's what I need now. The staff there at pulmonary rehab are wonderful, they love you, they care about you, and they encourage you, and they care about your health, and I love them to death, and they have been wonderful to me, and so helpful, and they keep an eye on you, and encourage you to do what you're supposed to do, and they've been that for me, and they've been, I have nothing but good things to say about them, and everybody needs somebody like that in their lives, and today I'm doing fantastically well. You wouldn't know me if you had seen me a year ago, you would not know me now, and I thank God for it. Please join me in thanking Frank for sharing his story, even though he's not here with us in the room right now. It's a wonderful story, and we're very grateful for him for sharing his words. So I'm going to start our session today talking a little bit about the introduction to pulmonary rehabilitation, I will talk about what pulmonary rehab is, what are the essential components, what are some of the desirable components, and then we'll go on to further details in the next two presentations. As mentioned, my name is Catherine Granger, and I'm from Melbourne, Australia, and from the University of Melbourne and the Royal Melbourne Hospital. Overall the learning objectives for our session this afternoon are to discuss the indications, need selection, program design, and outcomes for pulmonary rehabilitation. That's what I'll cover in the first few minutes of today. We'll then go on looking at the multidisciplinary components of pulmonary rehabilitation. I'll then recontinue talking about the role specifically in people with lung cancer, and then we'll conclude talking about tele-rehabilitation. So to begin, an overview of pulmonary rehab. The definition from the ATS-ERS guideline statement from 2013 still holds true today. Pulmonary rehabilitation is a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies that include but are not limited to exercise training, education and behaviour change that is designed to improve the physical and psychological condition of people with chronic respiratory diseases, to promote long-term adherence to health-enhancing behaviours. Pulmonary rehab can be initiated at any stage of the disease. This may vary depending on the type of patient that you're working with and the type of respiratory condition that they have. Typically in CERPD we see this initiated in periods of clinical stability during or directly after an exacerbation. The overall aims of the program are to reduce symptom burden, maximise exercise performance, promote autonomy, increase participation in activities of daily living, enhance quality of life and promote long-term health-enhancing behaviours. For many of us we'll think of pulmonary rehab for people with CERPD. It was where the research was initially generated and where we have our most robust evidence to support pulmonary rehab. But now we know it's actually beneficial for a range of a variety of different chronic respiratory diseases. Some of those are on the screen here today. You've heard from Frank who is an example of a lung transplant recipient. As I mentioned, I'll be talking a little bit more about lung cancer later in the session today. But there are a wide variety of people with chronic respiratory diseases who suffer from breathlessness who are eligible and will benefit from pulmonary rehab. In the most recent clinical practice guideline by Carolyn Rochester and colleagues, they looked at the strength of recommendations around pulmonary rehab and the quality of evidence supporting those recommendations, the clinical practice recommendations. And as you can see on the screen here, this is an example of a few different respiratory conditions. Initially, for people with CERPD, there is a strong recommendation with moderate quality evidence that people with stable CERPD receive pulmonary rehab. And again, a strong recommendation with moderate quality evidence that people with CERPD following an exacerbation receive pulmonary rehab. Similarly, in ILD, there is a strong recommendation and moderate quality of evidence that people with ILD undertake pulmonary rehab and a conditional recommendation that people with pulmonary hypertension undertake pulmonary rehab. In CERPD, there are a wide variety of expected outcomes and our highest quality evidence to support these outcomes. We see that pulmonary rehab improves exercise capacity, reduces dyspnea, improves quality of life, emotional function, provides social support in that group-based environment, as well as, importantly, reduces hospital readmissions and reduces mortality risk after hospitalization. And as I mentioned, our strongest and largest body of evidence is in the COPD cohort. And many of you will be familiar with this statement back from 2015 in the Cochrane Review, which actually concluded that additional RCTs comparing pulmonary rehab to conventional care in COPD are not warranted. And that's because the evidence is so strong that we know it's beneficial and our patients should receive that treatment. And then other patient groups with chronic respiratory diseases, we understand that there are other benefits. And these vary slightly depending on the patient group that you're working with. I put a few examples on the screen here. In ILD, we know that, and this is from Cochrane Review's meta-analysis data, we know that pulmonary rehab improves exercise capacity, quality of life, and dyspnea. In pulmonary hypertension, we know it improves exercise capacity, quality of life, and reduces mean arterial pressure. And in bronchiectasis, it improves exercise capacity and quality of life. Fairly recently, Anne Holland and colleagues prepared and published this American Thoracic Society document defining the modern era of pulmonary rehab. We've seen pulmonary rehab change dramatically over the last decade. One of the reasons for this is that access and uptake of pulmonary rehab is very challenging. This will not be news to people in the audience, but we know it's an effective treatment, but the actual referral rate is very low, and the patient uptake rate is even lower. So this statement here looks at the modern pulmonary rehab era and defines what is a pulmonary rehab program, and what are the essential components of a program that actually make it be pulmonary rehab, when we're seeing so many different models now being used in clinical practice. So the group convened to achieve consensus on what makes up pulmonary rehab. And they concluded that there are 13 essential components, and I'll talk about those in a moment, and 27 desirable components, depending on your resources and the program that you have available. So these are the essential components, and so any program, whether it's a centre-based program, whether it's tele-rehab, home-based program, web-based program, for example. Any program that meets these 13 criteria will be considered pulmonary rehab. You can see in the first section, it's around, green is around patient assessment. So all programs should include an assessment of a centre-based assessment with a health professional, which includes an assessment before the program of an exercise test, a field-walking test, such as, for example, the six-minute walk test, measures of quality of life, dyspnea, nutritional status, and occupational status. And so these are the essential assessments. You may actually be assessing many other aspects. In terms of exercise training, and I'll talk about these in a little bit more detail in a couple of slides, the essential components are endurance training and resistance training, and there are additional add-ons that you can add on, and we'll talk about those a little bit later as well. It's essential that the program is individually prescribed and individually progressed for that patient, and this is done with a team of health care professionals with expertise in this area. And finally, it's essential that the health care professionals are trained to deliver the model that has been deployed. So exercise training, this is recommended to be performed by a health professional, be individualised to the patient, and based on their initial assessment. And as I mentioned, it's typical that we would have a field-based walking assessment, like the six-minute walk distance. You may also have assessments of muscle strength, for example, with handheld dynamometry and functional-based assessments. So using those assessment findings before the program commences, we would typically use those findings to prescribe an individual exercise program, and we can be as prescribed as possible. We can take the distance walked in six minutes and use that to calculate a modern intensity walking program, for example, down to the number of metres and the time that someone would be walking. And then it's important that that patient is progressed every couple of sessions at least, or monitored every session, so that they continue to progress their exercise training as improvement occurs. In terms of the principles of exercise training, it's important that the training load exceeds their specific requirements, and that the load exceeds what they're doing in their daily life to improve exercise capacity and muscle strength. And we typically include a variety of modes of training to achieve resistance training and endurance training, and the wide variety of benefits needed. In terms of, again, I'm still talking about the essential components here, we would typically see patients exercising two to three times per week in a supervised setting. That could be supervised in a centre-based program, or more recently we're seeing patients who are supervised in the home and using tele-rehabilitation to exercise in the home, and you will hear more about that soon, combined with a home unsupervised program, so that the patient is actually exercising four to five times per week across the duration of the program. For most patients, they'll be exercising at a moderate intensity. There are exceptions to that, particularly in lung cancer, we see more and more some patients are able to exercise at a higher intensity, and there are other patient groups where high intensity is contraindicated. In terms of the type of training, lower limb endurance training is an essential aspect. This could be a continuous-based program, where you're continually exercising for 15, 20, 30 minutes, or interval training, where they're exercising in intervals, probably still moderate intensity, or maybe high intensity, with intervals of lower intensity or rest. And for example, it may be a ground-walking program, a stationary bike program, or treadmill walking. So we often, in our program, would have someone walking for 15 minutes and then doing 15 minutes on the stationary cycle. And then resistance training is the other essential component, where here we're looking at strength training, so it's high weights, which may not be particularly high for that patient, sorry, it is high for that patient, it may not be high for you or I, it might be one kilogram dumbbells, for example, high weights and low repetitions. So they could be done with gravity, with elastic bands, with free weights or the gym weights, depending on what resources you have available. And then there are a variety of desirable components, and so these are not essential, but these are great depending on the patients that you're seeing and the access that you have. You may look at upper limb training, if you're seeing patients with chronic sputum production, sputum retention, they may have airway clearance, there might be education, there may be self-management, et cetera. In fact, tomorrow we're running a session on physical activity counselling and health coaching in COPD that I'm speaking at, so we'll go into physical activity coaching in much more detail at three o'clock tomorrow. And then if you're looking for resources to establish a program or to modify your program, this is a website that is based in Australia, but it's freely available around the world, and it is set up for clinicians who are establishing programs. There's lots of information there, assessment forms, referrals to clinicians, et cetera. It goes into a great amount of detail. For example, here there's examples of pictures for exercise prescription, and it goes down to the fit principles of how many frequency, intensity, type and time. So for people who are starting a program, this may be a helpful resource. And the website also goes into a great amount of detail around education components that you may use for your patients. So on that note, I may hand over to our next speaker, who is going to speak to you about the multidisciplinary components, so just bear with me as we get this on. So I'd like to introduce Ashley Knox. Ashley is a nurse practitioner with a decade of dedicated service in the pulmonary department at MD Anderson. With a wealth of experience in patient care, she has become a trusted expert in managing complex pulmonary conditions. Ashley is committed to quality improvement initiatives that improve health care outcomes. And beyond the hospital, Ashley enjoys quality time with her family. Thank you very much, Ashley. Thank you, Catherine, for that introduction, and thank you, all of you, for having me. It is an honor to be able to present to you today, along with these dynamic clinicians. We were just introduced to pulmonary rehabilitation programs, components, qualifications and outcomes. So now, as we know, pulmonary rehabilitation benefits from a multidisciplinary approach. Therefore, I'm going to talk to you about the effects of psychological diagnosis on the respiratory system, management and treatment from a psychological standpoint, as well as support systems and outcomes. So when we think about dyspnea, it's important to understand all aspects of it. It may be labored, difficult, or uncomfortable breathing. It may vary in sensation and intensity. It's important to understand the exacerbated factors or ameliorating factors. It may be considered acute or chronic. At our institution, what we find is many patients present with multiple comorbidities all at the same time. They may have underlying superimposed pneumonia. They may have drug-induced pneumonitis. They may also have pleural effusion on top of that. They have a COPD exacerbation, which is all debilitating. So when we think about when these patients experience dyspnea, they enter into a vicious cycle, which they may reduce their activity, reduce their exercise, which leads to muscle loss and which leads to muscle loss, which may be debilitating. So what we want to do is we want to start a pulmonary rehabilitation program to break that cycle, increase their activity, which will then increase their muscle strength. Symptom cluster is a common terminology used in cancer patients, and it actually applies here. There's a correlation between COPD, sleep disruption, pain, as well as anxiety and depression. Due to increased CO2 levels, this may elicit a panic response. These patients may experience multiple anxiety attacks, which may disrupt their sleep, may reduce their functionality, as well as increase hospitalizations. So just so I can see if I have y'all's attention, what is the most important aspect of a successful pulmonary rehabilitation program? Give y'all just a few seconds. All right. Y'all got it? Well, I'll just go ahead. And hopefully we will. There you go. There you go. Awesome. Yay. So as I mentioned, pulmonary rehabilitation has a multidisciplinary approach. So all of these actually are applicable. So there's not just one answer choice. Thank you guys for participating. All right. So when we're considering our patients for our pulmonary rehabilitation program, it is important to establish a baseline. As mentioned previously, we may do a six-minute walk test before, during, and after. We may also evaluate with lung function studies. And we also will evaluate these patients with questionnaires to determine how they feel, as well as improvement. There are multiple psychological approaches that may be taken for patients in a pulmonary rehabilitation program. And these are actually thought to be just as effective as pharmacological approaches. We may do cognitive-based therapy, which will help to improve their thought process. Group therapy, which will allow for support from other individuals. And we also may do relaxation and alternative therapy to help with coping mechanisms during this process. Some things that we have used is mindful meditation, yoga, whatever makes the patient comfortable. Psychological interventions have been used for patients with mild to severe anxiety and depression. When patients are more on the moderate to severe, then we may incorporate pharmacological measures, as well as hospitalization if needed. It is important to support these patients with nutrition. So you may consider a nutritional consult. Diagnose and treat any underlying sleep disorders. Help with stress management. Also encourage self-care and independence, which can help with increasing their confidence, all to help positive outcomes. It is important to consider all different diagnoses and promptly treat them, despite usage of psychological measures, pharmacological measures, may be warranted. At MD Anderson, what we find is we usually need to support these patients related to cancer and the treatment effects. It is important to provide social support for these patients. It takes a village to manage patients with chronic comorbidities. So it's important to include their family members, friends, and the treatment plan and provide education. To further expand upon that, this team has developed a new program called To further expand upon that, this study sought to see the importance of including patient and family members with spiritual support. So what they did was they provided social support for both family members and patients. And they used the F-COPE score. What they found is at the end of the treatment, they had better coping and behavioral, they improved by coping and behavioral aspects. This study looked to determine the effects of muscle relaxation on anxiety and depression. After an eight-week pulmonary rehabilitation program, these patients had improved hospital anxiety and depression scores just by exercise. Pulmonary rehabilitation, as I mentioned, is a multidisciplinary approach. In fact, it improves respiratory and peripheral muscle performance, exercise performance. We see improvement with patients with the six-minute walk test. Patients also report improvement in breathlessness as well as quality of life. In conclusion, I hope to have provided evidence on how a multidisciplinary approach, inclusive with psychological components, may improve quality of life and exercise capacity. Anxiety and depression are underdiagnosed and treated. Therefore, early detection of these disorders along with supportive measures may positively impact health outcomes. Thank you. Thank you very much. I'm going to now go into a little bit more detail specifically around lung cancer and the evidence and expected outcomes for people with lung cancer going through pulmonary rehabilitation. There are many factors contributing to why someone with lung cancer may have poor exercise capacity. We know exercise capacity is a very important outcome in lung cancer. And in fact, exercise capacity at time of diagnosis is associated with lower exercise capacity is associated with worse overall and tumor-specific survival in lung cancer. Lung cancer is a complex condition, as is all of the other chronic respiratory diseases that we work with. There are many factors influencing someone's exercise capacity. These can be the lung cancer disease itself and symptoms, the lung cancer treatments that they may be going through and side effects, the cycle of deconditioning that may have happened years before the diagnosis or particularly often will happen after diagnosis if someone's going through treatment, lack of physical activity and sedentary behavior. And we know that many of our patients, not all of them, but many have had a history of lifelong sedentary behavior leading up to diagnosis, as well as aging and comorbid diseases. And all of these interrelate to contribute to a picture of poor exercise capacity for that patient. We can target many of these factors with pulmonary rehabilitation. But it also talks to the importance of individualization of that treatment within pulmonary rehab. Because why someone may be presenting the way they are will vary from patient to patient. There are many times that we can intervene with pulmonary rehab in lung cancer. Along the top row here, you can see an example of someone with early stage lung cancer with operable disease. And along the bottom is an example of someone with advanced disease that's inoperable. Where we see data from studies so far and clinical programs is that pulmonary rehab has been implemented before surgery. There it's often termed prehab or prehabilitation. It's often implemented immediately after or very early after surgery, sometimes commencing with education and advice in hospital after surgery. And then very commonly implemented after surgery where it's a very traditional pulmonary rehab program. For people with advanced disease, lung cancer, it's often implemented before commencing treatment if there's time, certainly during treatment and then after if they've had an acute period of treatment after treatment in the survivorship phase. So we have data to show that exercise and pulmonary rehab is safe across all of those time points in lung cancer and certainly beneficial. Although the target outcomes and the benefits for patients do vary depending on the timing that you're implementing it. I'd like to make a few comments around the operable group with lung cancer and the use of pulmonary rehab initially before surgery. Late last year, a colleague and myself published a Cochrane Review on the topic of exercise training before surgery for lung cancer. So here I'm gonna pull out a little bit of data specifically about the exercise side of pulmonary rehab. The reason I'm gonna talk about exercise is we don't have a huge amount of data on the multimodal pulmonary rehab programs in lung cancer. We're very far behind the COPD literature in lung cancer in this area. And so what we know most of at the moment is the role specifically of the exercise component. In the Cochrane Review, patients were eligible for participation in pulmonary rehab if they were undergoing lung resection. They may or may not have had risk factors putting them at risk of complications after surgery. They may or may not have had COPD. The pulmonary rehab programs were a little bit different to our typical pulmonary rehab programs. And the reason for this is we have a very short period of time before surgery that we can intervene. So they were typically supervised three to five times per week. So that's certainly up on the typical two to three times per week. They were moderate to high intensity, aerobic plus resistance training, although the aerobic exercise is the essential component at this timing. There may be other supplements such as inspiratory muscle training. And the program went around for 30 to 45 minutes and only one to four weeks. And that's usually limited by the time someone's waiting for their surgery, typically in a supervised setting so we can have them training as fast to gain the benefits as quickly as we can. In terms of our outcomes, our primary outcome of this Cochrane review was the risk of developing a post-operative pulmonary complication after surgery. And what we found from the meta-analyses was that there is high certainty that exercise before surgery for lung cancer results in a risk reduction of 55% of someone developing a post-operative pulmonary complication. The number needed to treat is only five. So it's a very powerful treatment to reduce post-operative pulmonary complications. And then there's a variety of secondary outcomes that we found immediately after the program. We expected improvement in exercise capacity, whether you're measuring this with a field-based test or a cardiopulmonary exercise test, potentially improvements in lung function and certainly a reduction in hospital length of stay. And then I'll now make some comments around the post-surgery time point. And this is where we typically see a very traditional pulmonary rehabilitation program implemented for lung cancer. Here I'm presenting some data from a fairly recent Cochrane review by Cavalieri and colleagues. These exercise programs, as I mentioned, these are much more typical that you would see in your practice if you're seeing a variety of people with respiratory conditions. They run two to five times per week. They're moderate to vigorous or high intensity. Certainly aerobic and resistance training, and resistance training here is a critical aspect. They run for much longer, four to 20 weeks at least. And they're usually supervised with the home-based components. They're very similar to the programs you would be familiar with. And we see a wide variety of patient outcomes from these programs after lung cancer surgery. We have moderate to high certainty evidence that these programs improve exercise capacity, regardless of whether you measure this with a cardiopulmonary exercise test or a field-based test. They improve quadriceps force, low certainty evidence that they improve quality of life, and very low certainty evidence that they reduce dyspnea. So I thank you for your attention to the lung cancer aspect. And we're now going to move on to the final component of our session today before we open for questions around telerehabilitation. All right, guys, we're talking about exercise. And I see, I was sitting there, all of us are down, it'll be after lunch and everything. Why don't we all stand up and let's do a little dopamine release here, huh? How about that? Come on, let's do this. It's just gonna take one or two minutes. Let's do that, okay? We all have had our lunch now. The blood was in the belly. We were all feeling sleepy. It's just coming, come on, maybe you can do this. Wonderful, I love it. All right, there we go, just stretch up a little bit. And that's all, we'll talk about exercise. Good, wonderful. All right, woo, now, now we'll concentrate. Okay. So let me tell you a little bit about the advances. Tele-rehabilitation. So thank you for doing that. You guys have been a great audience, great, wonderful. Great job. So basically I'm gonna talk about tele-rehab and advances in pulmonary rehab. I am the medical director of the pulmonary rehab program at Memorial Hermann in Houston, Texas, and also the medical director of the lung transplant. So it's an amazing feeling to see that journey that you saw, Frank, from a patient who was having severe COPD exacerbations, go through pulmonary rehabilitation, get the transplant, and now get back in pulmonary rehabilitation. So this is something that's very, very underutilized, and because all of you guys are here today, I think it is a testimony that this is just gonna get better and better, and then we will do well. And that's why telemedicine is going to be the forefront, in my opinion, I think is going to be leading the pulmonary rehab space with a combination of standard pulmonary rehabilitation. So today we're gonna talk about indications of tele-rehab and different types, compare the tele-rehab data with the standard pulmonary rehab data. We're also gonna talk about the advances in pulmonary rehabilitation, that what else is coming in the future, what we are doing there in Houston, and explore the future technologies that are available. So just to give you a brief definition, that benefits of pulmonary rehabilitation are all well known. We know that the referrals are down. Pulmonologists who actually treat COPD, ILDs, and lung diseases for a living have a less than 20% referral rate. We know that by ATS guidelines. We know that the people who actually get to pulmonary rehabilitation, less than 5% of them actually finish the pulmonary rehabilitation. So it's a huge problem, and plus it's a 1A guidelines in COPD, in ILD, in lung transplant, in cancer, in surgery. So why is it so limiting? And we know that there is a lot of time frame. Who likes to do exercise at five o'clock in the morning? But our job as clinicians and providers is to instill that this is something that really we believe in, and this is something that really works. So to increase and to adapt the technology, I think telemedicine is going to be a very, very fruitful conjunction with the standard rehab. Conventional pulmonary rehab has significant challenges. We all know that, and since the pandemic, the pulmonary tele-rehab has been more often used and very successfully compared to standard rehab, and the six-minute walk distances, the BORC scores, even the anxiety and the depression scores actually have gone significantly down. And so in the most recent guidelines that got published in 2023, it is one of the recommended modalities to have in conjunction with the standard rehab. So that's why we are talking about this. There are three basic types when we talk about tele-rehab. One is the spoke and the hub-and-spoke model, where you have an expert facility like we are, and then we have small satellite centers around the different parts of the region where you can actually have patients come over in these small centers, and you can actually manage them as a tele-rehab. The second one, obviously, is a very common home-based telemedicine that we do. It's very robust in Australia. It's very robust in Britain, but unfortunately in Europe it's used very well. But unfortunately here, we are still behind in the data and adaptation of this technology. So it is a supervised program. You can use either a video conferencing, you can have a group Zoom chat, and then have people do this. That's the second model. And the third model is very self-driven. It's an app-based model. You log in, or a web-based model. You log into this program, and you actually just keep on clicking some things, and you're doing walking for 30 minutes, and then you click Next, and so on and so forth, which is also hard. So I think there has to be a combination of two or three with the standard therapy. That's when it will be successful. When you compare standard rehabilitation, just a Cochrane review in 2021, that included 15 studies and about 2,000 patients compared, and there was no difference in the quality of life, or the six-minute walk distance and BORC scores, which is huge because most of the time when I introduced tele-rehab in my pulmonary rehab center, everyone's skeptical, patients will fall, I don't know, it's a 675-year-old person, they don't know how to use technology, but it's just a matter of education, and just a matter of you being excited about it. It's just a matter of why we don't travel in trains anymore. That's why we use electricity vehicles, or electric EV vehicles now. It's just evolution and transition in technology, and we have to be early adapters as medicine folks. So the completion rate, which was amazing, with tele-rehab versus standard rehab, was 93% versus 70%. Now again, these are skewed numbers, as you very well know, whoever does pulmonary rehab, the completion rate is less than 50% in any pulmonary rehab that I have seen. So these are obviously people who are actually being monitored and being coerced into doing this rehab therapy, and that's why it's 70% in the standard trial, and 93%. But still, this is something that, amazing, there's a 20% difference with a number you need to treat that's great, if you do the absolute risk reduction there. Now the limitations, obviously, we all know, these are very self-explanatory. Older age, lower house income. Sometimes people in lower house incomes may not be so attuned to technology. Again, and this is just a matter of education, I think, and that's why I think this is a future. Now, talking about, I'm gonna shift gears to the advances in pulmonary rehabilitation. Now, one thing that I think is going to take over is virtual reality in PR. Virtual reality in pulmonary rehabilitation is incorporated into standard pulmonary practice, where you actually will have an immersive experience of your multiple sensations that can be used, whether it's a sense of smell, whether actually there's a sense of pleasantness around. You see things that are beautiful, and that's how people will have their anxiety down, their depression down. I think this is a really cool technology that we have been using. One of my friends actually started using VR-based technology in the NHS system in England, and it is a complete hit. NHS is paying for it, and they are using it very, very well. So they gave us this device, and are wanting to do this trial with us. So what is virtual reality? Virtual reality, these are certain definitions that we use. This is a reality which is not real. You are in an environment which we create, or software companies create, where you are there, and you feel that you are actually in a rehab. You can have simulation of other people around you, so that you can have a sense of bounding and community. We can create that. On top of that, you can have your auditory signals where someone can be talking to you. Someone can have, if you're in a garden, we can have air coming in, and you can feel the birds chirping, and so on and so forth, to have that feeling of you actually being outside and driving a bike in Memorial Park, and in Houston, or something like that. So that's something that you can do. Not only that, these are the definitions that the VR technology people use. I'm just having you out there if you're interested. But this is something that was really cool as well. It not only actually helps you with the exercise, and with the mobility, but it actually helps your anxiety, depression, and sense of completion. So what we can do is, with these VR-based technologies, we can give you a task of a virtual garden at the initial stage of therapy, and we'll give you a weight-based watering plant where you can actually go in and keep on watering those plants, and coming along, and then later on, at the end of the day, this is what your completion thing is. It's a dopamine rush. It's a sense of completion. It's a sense of well-being. It's a sense of being productive. This reduces anxiety, reduces depression scores, and this study, when it was done, had great outcomes. And as we all know, we just heard Frank's story, 30% of the people have depression and anxiety, and this is something that really, really helps. And that is why we have those wellness centers out there. We are painting, and so on and so forth. We are trying to relax, and we are just trying to come down, calm down. And that's what VR can actually bring on your fingertips, so you don't have to go outside somewhere to do this. Now, what it looks like for the patient, this is what it looks like for the patient. The patient is there. They are in an immersive environment where they are trying to adapt to different kind of noises, different kind of feelings. You can have a fan blowing, and this is the patient, what they see. They are on a bike, and they are basically just driving around in a park, and just having fun. This is something I think is the future, and I think we should be early adapters, and I wanted to introduce this to you. As far as the home-based pulmonary rehab, unfortunately, we don't have really clear guidelines in the United States. And this is something that I use personally, and I saw that Catherine placed a really, really good modality where she actually had significant websites where you can go in and get that. But in home-based pulmonary rehab, this is something that I got from the British Medical Journal, and I give this to my patients all the time who cannot come to rehab and cannot use virtual. It's a very good, you can Google this. It gives you the FIT format, the F-I-T-T format, the frequency, intensity, the time, and the training that she talks about. And they basically can use this on a daily basis and actually have the same outcomes. So I'm going to stop here. Oh, I think my presentation did not go through, but anyways, I had some other cool stuff. I'm just gonna say that here, that I was using a non-invasive pulmonary rehabilitation in our devices, I'm not sure. And one of the things that we talked about was using a non-invasive machine, a portable machine, we call it Life 2000, which is an FDA-approved machine in the United States. And we use it for COPD patients and patients who have excessive breathlessness of more than 30 breaths a minute. And we use it on them and walk them. We have seen better completion rates, we have seen them reduce anxieties, and we have seen them better adaptation to physical therapy because of reducing the muscle load with the Life 2000. So that's something that we are doing as a study right now in addition to the VR. So we'll stop here and take questions. And that's my QR code if you guys want to contact me. Thank you.

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