Telerehabilitation Exercise Program for Postoperative Recovery in Lung Cancer.

Lung cancer remains the leading cause of cancer-related mortality worldwide and continues to impose a substantial burden on healthcare systems. Surgical resection is considered the standard treatment for patients with resectable disease and offers the best opportunity for long-term survival. However, despite advances in surgical techniques and perioperative care, recovery following thoracic surgery is frequently characterized by impaired physical function, reduced exercise capacity, dyspnea, decreased physical activity levels, postoperative pulmonary complications, and deterioration in health-related quality of life.

The physical and functional consequences of lung cancer treatment may persist for months or years after surgery and can negatively affect independence, participation in daily activities, and overall well-being. Postoperative rehabilitation and therapeutic exercise have therefore become important components of comprehensive cancer care. Early physiotherapy interventions aim to prevent postoperative pulmonary complications, facilitate recovery of physical function, reduce symptom burden, and promote a safe return to daily activities. Previous studies have shown that exercise-based rehabilitation following lung resection can improve functional capacity and quality of life while reducing postoperative morbidity.

Despite these recognized benefits, access to structured rehabilitation programs remains limited in many healthcare settings due to geographical, logistical, organizational, and resource-related barriers. This challenge is particularly relevant in publicly funded healthcare systems, where rehabilitation services may not be universally available after hospital discharge. As a result, many patients do not receive adequate follow-up rehabilitation during a critical phase of postoperative recovery.

Telerehabilitation has emerged as a promising alternative model of healthcare delivery that enables rehabilitation services to be provided remotely through digital technologies. This approach has the potential to improve accessibility, continuity of care, adherence to prescribed exercise programs, and patient engagement while reducing travel requirements and healthcare costs. Growing evidence supports the safety, feasibility, and effectiveness of telemedicine and telerehabilitation interventions across a variety of chronic and oncological conditions.

In patients with lung cancer, recent studies have reported encouraging results regarding the use of mobile applications and remotely supervised rehabilitation programs. These interventions have been associated with improved adherence to treatment, enhanced functional recovery, better pulmonary function, increased physical activity levels, reduced symptom burden, and improvements in quality of life. Furthermore, digital rehabilitation strategies may facilitate long-term monitoring and support during the postoperative period, helping patients maintain active participation in their recovery process.

Nevertheless, important knowledge gaps remain. The number of high-quality randomized controlled trials specifically evaluating structured postoperative telerehabilitation programs after lung cancer surgery is still limited. Existing studies have often included small sample sizes, heterogeneous interventions, or mixed cancer populations, making it difficult to establish definitive recommendations regarding the optimal design and clinical effectiveness of telerehabilitation in this population. Additional research is needed to determine whether remotely delivered therapeutic exercise programs can produce clinically meaningful improvements in postoperative recovery and patient-centered outcomes.

The present randomized controlled trial has been designed to address this evidence gap by evaluating the effectiveness of an eight-week telerehabilitation program based on therapeutic exercise in patients undergoing thoracic surgery for lung cancer. Participants allocated to the intervention group will receive a structured and progressive exercise program delivered through a dedicated telerehabilitation platform, combined with regular online clinical follow-up sessions. The intervention incorporates aerobic exercise, muscle strengthening exercises, respiratory muscle training, individualized progression, and continuous monitoring of adherence and symptoms. Participants assigned to the control group will receive the usual postoperative physiotherapy care routinely provided after thoracic surgery.

The study will evaluate the impact of the intervention on key dimensions of postoperative recovery, including functional capacity, dyspnea, physical activity levels, postoperative pulmonary complications, and health-related quality of life. Assessments will be performed before surgery, after completion of the intervention period, and following a short-term follow-up period to explore the maintenance of potential benefits.

The findings of this study may contribute to the development of evidence-based rehabilitation pathways for patients recovering from lung cancer surgery. If effective, this telerehabilitation model could represent an accessible, scalable, and cost-efficient strategy for improving postoperative outcomes and expanding access to rehabilitation services within routine clinical practice.

• Therapeutic Exercise-Based Telerehabilitation (Behavioral): Participants will receive an 8-week telerehabilitation program delivered through the RehBody platform. The intervention includes 24 supervised therapeutic exercise sessions and 8 online clinical follow-up sessions. Exercise sessions incorporate aerobic training, strength exercises, respiratory muscle training, individualized progression, symptom monitoring, and adherence support. Participants will also receive usual postoperative care.
• Usual Postoperative Care (Other): Participants assigned to the control group will receive usual postoperative care routinely provided after thoracic surgery for lung cancer. This includes early mobilization, progressive ambulation according to individual tolerance, deep breathing exercises, active upper-limb and trunk mobility exercises, cough training with wound protection, and discharge recommendations for home-based recovery. No structured telerehabilitation or supervised exercise program will be provided after hospital discharge.

Primary outcomes

• Functional capacity measured by the One-Minute Sit-to-Stand Test (1MSTS) [Baseline (pre-surgery), 8 weeks (post-intervention), and 12 weeks (4-week follow-up).]: Functional capacity will be assessed using the One-Minute Sit-to-Stand Test (1MSTS). Participants will stand up and sit down from a standardized chair as many times as possible within one minute. The total number of completed repetitions will be recorded. There is no fixed maximum value, and higher numbers of repetitions indicate better functional capacity.

Secondary outcomes

• Dyspnea measured by the Modified Medical Research Council (mMRC) Dyspnea Scale. [Baseline (pre-surgery), 8 weeks (post-intervention), and 12 weeks (4-week follow-up).]: Dyspnea will be assessed using the Modified Medical Research Council (mMRC) Dyspnea Scale, a 5-point ordinal scale. Scores range from 0 to 4 (minimum 0, maximum 4). Higher scores indicate greater breathlessness and functional limitation due to dyspnea (worse outcome).
• Physical activity level measured by the International Physical Activity Questionnaire - Short Form (IPAQ-SF), MET-minutes/week. [Baseline (pre-surgery), 8 weeks (post-intervention), and 12 weeks (4-week follow-up).]: Physical activity will be assessed using the International Physical Activity Questionnaire - Short Form (IPAQ-SF). Results will be expressed as total MET-minutes/week (metabolic equivalent of task-minutes per week), with a minimum of 0 and no fixed maximum. Higher values indicate a higher level of physical activity (better outcome). Participants will also be categorized as having low, moderate, or high physical activity levels according to the standardized IPAQ scoring protocol.
• Incidence of postoperative pulmonary complications defined by the European Perioperative Clinical Outcome (EPCO) criteria. [From hospital discharge to 12-week follow-up.]: Postoperative pulmonary complications will be collected from clinical records and defined according to the European Perioperative Clinical Outcome (EPCO) criteria. Complications will be recorded from hospital discharge until the end of the intervention and follow-up period. The outcome will be reported as the number and percentage of participants with at least one postoperative pulmonary complication.
• Health-related quality of life measured by the EQ-5D-5L descriptive system (index value). [Baseline (pre-surgery), 8 weeks (post-intervention), and 12 weeks (4-week follow-up).]: Health-related quality of life will be assessed using the descriptive system of the EuroQol 5-Dimension 5-Level questionnaire (EQ-5D-5L), which covers five dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression) with five levels each. Responses will be converted into an index value using a country-specific value set. A value of 1 represents full health and 0 represents a state equivalent to dead; negative values indicate states considered worse than dead, and the minimum depends on the value set used. Higher values indicate better health status (better outcome).
• Self-rated health measured by the EuroQol Visual Analogue Scale (EQ-VAS). [Baseline (pre-surgery), 8 weeks (post-intervention), and 12 weeks (4-week follow-up).]: Self-rated health will be assessed using the EuroQol Visual Analogue Scale (EQ-VAS), on which participants rate their health on the day of assessment. Scores range from 0 (the worst health you can imagine) to 100 (the best health you can imagine). Higher scores indicate better perceived health status (better outcome).

Sex: All, ages: 18 Years to 80 Years

Inclusion Criteria:

* Adults aged 18 to 80 years.
* Histologically confirmed primary lung cancer (stage 0 to IIIB).
* Patients who have undergone thoracic surgery for lung cancer.
* Medical clearance to participate in an exercise-based rehabilitation program.
* Ability to understand and communicate verbally.
* Access to a smartphone and/or computer with internet connection.

Exclusion Criteria:

* Any medical condition or comorbidity that contraindicates participation in an exercise program.
* Current psychiatric disorder that may interfere with study participation.
* Inability to provide written informed consent.
* Previous thoracic surgery.
* History of another malignancy within the past one year.

• María Jesús Casuso Holgado, Principal investigator, University of Seville