Skip to content
Frontiers
Search

Mini Review

Frontiers in Rehabilitation Sciences ·

Volume 7 - 2026 | https://doi.org/10.3389/fresc.2026.1706188

Low-cost pulmonary rehabilitation for chronic respiratory diseases: a narrative review

  • Else Saliés Fonseca1
  • Marcelo Velloso2
  • Marcelo Couto Jorge Rodrigues1
  • Karla Medeiros Costa1
  • Claudio Andre Barbosa de Lira3
  • Ana Luiza Lima Sousa4
  • Natasha Yumi Matsunaga Spicacci5
  • Gustavo De Conti Teixeira Costa1*corresponding author
  1. 1Center for Advanced Study and Research in Sports, Federal University of Goiás, Goiânia, Brazil
  2. 2Laboratory for Assessment and Research in Cardiorespiratory Performance, Federal University of Minas Gerais, Belo Horizonte, Brazil
  3. 3Laboratory of Human and Exercise Physiology, Federal University of Goiás, Goiânia, Brazil
  4. 4Arterial Hypertension Unit, Federal University of Goiás, Goiânia, Brazil
  5. 5Functional Health Department, Federal University of Goiás, Goiânia, Brazil
Article metrics0 viewsView details
PDFCiteMetrics

Abstract

Pulmonary rehabilitation (PR) is a cornerstone in the management of chronic respiratory diseases (CRD), but access remains severely limited in low- and middle-income countries (LMICs) because of cost, infrastructure, and workforce barriers. This mini narrative review synthesized evidence on the effectiveness, feasibility, and implementation of low-cost PR strategies designed with minimal equipment and simplified delivery models. Low-cost PR was considered not only as exercise training using minimal or improvised equipment, but as a context-adapted rehabilitation model that preserves essential PR components while adapting to local health-system, workforce, cultural, and socioeconomic constraints. Searches were conducted in PubMed, Scopus, Web of Science, and SciELO (2014–2024); twenty publications were included, comprising randomized controlled trials, quasi-experimental studies, systematic reviews, clinical guidelines, and implementation research. Across studies, low-cost PR consistently improved exercise capacity, symptoms, and health-related quality of life, measured by 6MWT, ISWT, SGRQ, and CAT. Home-based and community programs demonstrated feasibility and safety, often comparable to conventional PR; supervision and structured education enhanced adherence, while properly instructed unsupervised programs also showed non-inferior outcomes. Tai Chi and Nordic walking emerged as culturally adaptable, low-cost alternatives. However, evidence remains heterogeneous and predominantly COPD-focused, with limited data for other CRD and few studies in primary healthcare, restricting generalizability to the broader CRD burden in LMICs. Effective scale-up requires attention to workforce availability, primary healthcare integration, contextual barriers to home-based rehabilitation, digital accessibility, education, equity, and long-term sustainability. Further high-quality trials and implementation studies are needed to consolidate evidence and inform policies that integrate context-adapted, affordable PR into healthcare systems.

Keywords

Introduction

Chronic respiratory diseases (CRD), such as chronic obstructive pulmonary disease (COPD), asthma, and interstitial lung disease, represent a growing global health burden, leading to high morbidity, mortality, and healthcare costs (1–3). Due to their high prevalence, COPD, asthma, lung cancer, and tuberculosis represent important respiratory conditions in the public health scenario (2). Individuals with CRD may experience dyspnea, reduced functional capacity, and impaired quality of life (4).

The main risk factors for CRD include smoking, exposure to pollutants and allergens, occupational risks, poor diet, obesity, and physical inactivity (2, 4). Globally, millions of individuals are affected, with a substantial burden occurring in developing countries (5). In Brazil, COPD accounted for 17% of hospitalizations among adults older than 40 years in 2018, while asthma accounted for 47,897 hospitalizations in 2020 (6). National data reported 148,411 CRD deaths in 2021 and 173,512 hospitalizations between January 2022 and January 2023 (7). In 2019, CRDs affected 454.56 million people worldwide, resulting in approximately 3.97 million deaths and 103.53 million disability-adjusted life years (1, 8–10). In Brazil, the burden associated with CRD continues to be influenced by population growth and aging (5, 10, 11).

In this context, pulmonary rehabilitation is one of the most effective non-pharmacological interventions for chronic respiratory diseases, improving symptoms such as dyspnea and fatigue, enhancing functionality, and reducing healthcare utilization (4, 12, 13). Traditionally, PR programs require specialized assessment facilities, multidisciplinary teams, and individualized plans; however, access may be restricted by costs, travel requirements, limited infrastructure, and service availability (14–16). Alternative models, including telerehabilitation, home-based rehabilitation, community-based programs, and minimal-equipment approaches, have therefore been proposed to expand access (13, 16–22).

Low-cost PR should not be interpreted solely as exercise training performed with inexpensive or improvised equipment. Rather, it may be considered a context-adapted rehabilitation approach that seeks to preserve essential PR components while adapting delivery to locally available infrastructure, workforce capacity, patient circumstances, and healthcare organization (18, 23–25). Depending on the setting, this approach may combine walking, elastic resistance, bodyweight exercise, home- or community-based delivery, hybrid monitoring, structured education, family or peer support, and task-sharing where professionally and legally appropriate (18, 23–26). This broader perspective is particularly relevant in LMICs, where barriers to PR may include limited workforce availability, fragmented referral pathways, transportation costs, geographical inequities, socioeconomic constraints, limited digital access, and discontinuity of care (16, 24, 25, 27).

Therefore, this narrative review aims to synthesize evidence on the effectiveness, feasibility, and implementation models of low-cost PR while highlighting current evidence gaps and priorities for future research.

Search strategy

Literature searches were conducted in PubMed, Scopus, Web of Science, and SciELO for publications indexed between July 2014 and July 2024, using terms related to low-cost, minimal-equipment, or resource-adapted pulmonary rehabilitation, chronic respiratory disease, and implementation in home-based, community, or primary-care settings (search strings in Table 1). Eligible studies were peer-reviewed randomized or quasi-experimental trials, systematic reviews, implementation reports, or clinical guidelines addressing low-cost PR delivered in home-based, community, or primary-care settings, published in English or Spanish between July 2014 and July 2024; studies restricted to inpatient or highly specialized hospital-based delivery without a low-cost, community, or home-based component were excluded. Records were imported into Rayyan (Qatar Computing Research Institute, QCRI, Qatar), and screened independently by three reviewers (MCJR, KMC, ESF), with disagreements resolved by consensus (80% inter-reviewer agreement); a flow diagram summarizing identification, screening, and inclusion is provided for transparency (Figure 1). As a mini narrative review, this synthesis reflects the authors’ interpretation of the available evidence rather than a systematic or quantitative appraisal; no formal risk-of-bias assessment or meta-analysis was performed given the heterogeneity of designs, settings, and outcomes across the 20 included publications (28, 29).

Table 1. – Studies Characteristics

Author, (Date) CountrySample sizePopulationCRD typeIntervention typeDurationOutcomesKey findings
Alison JA, McKeough ZJ, 2014 (12) AustraliaReview of 11 studies - 8 of endurance exercise - 3 of strength trainingStable adultsCOPDMinimal/low-cost PR (primarily walking, sit-to-stand exercise, stepping, elastic resistance band training, and Tai Chi)4 –12 weeks 2 – 6 sessions/ week40 m - 6MWD (95% CI: 13–67), SGRQ–7-point reduction (95% CI: –12 to –3)Minimal-equipment PR improves capacity/HRQoL; comparable to conventional PR
Anastasaki M et al., 2019, (23) Greece40 participants (31 completed) (77.5%) 24 – COPD, 16 - chronic asthmaRural patients with stable CRDCOPD/asthmaCommunity PR with low-cost 30 minutes of outdoor walking, 1 hour of strength and resistance exercise (bands, weights, sit-to-stand, steps, static bicycle), and educational sessions6 week (2×/week; 2 h)Improvement for −0.53 in CCQ (95% CI −0.81 to −0.24), −5.93 in CAT (95% CI −8.27 to −3.60), −23.00 in SGRQ total (95% CI −29.42 to −16.58), reductions in PHQ-9 (−1.10; 95% CI −2.32 to 0.12)Significant improvements in symptom and functional changes, and acceptability among patients and stakeholders, with feasibility/acceptability in primary care
Cerini et al., 2021, (29) Switzerland53 participantsPost-PR COPD patientsCOPDHOMEX home-based resistance-training program (chair and elastic bands), coach supervision6 days/week 20 minutes/day 12 monthsAdherence and acceptability (OR 11.46; 95% CI 1.88–91.48),70% completed; 79% ≥10 months; high acceptability.
Cheng et al., 2023, (38) AustraliaReview of 19 RCTsAdults stable/exacerbationCOPDMinimal-equipment PR (walking, Nordic walking, stair climbing, elastic bands/tubing, hand weights, and body-weight exercises) versus usual care/equipment PR6 to 28 weeks, session 20 to 60 minutes6MWD 85 m (95% CI 37 to 132; I² = 86%), ISWT 168 m (95% CI 19 to 317), HRQoL -SMD 0.99 (95% CI 0.31 to 1.67), dyspnea (mMRC −1.3; 95% CI −1.8 to −0.8)Minimal equipment PR produces measurable gains in exercise capacity and HRQoL versus usual care; no difference versus equipment PR.
De Lima et al., 2022, (33) BrazilReview of 8 RCTs (n=332)Stable adultsCOPDElastic-resistance versus no/machine8–12 weeks (3×/week)Strength - knee extensors (SMD = 0.52; 95% CI = 0.09–0.95; I² = 40%), 6MWT (MD = 10.94 m; 95% CI = −8.65 to 30.53)Elastic bands produce effects comparable to machines; effective low-cost option.
Fagian et al., 2024, (24) Uruguay17 patientsAdultsCOPDTai chi group versus control group (aerobic training, breathing exercises, resistance exercises, and relaxation), Tai chi group additional 20-minute Tai Chi12 weeks (24 sessions)PROMIS (p > 0.05), SGRQ1 month (44 ± 5 versus 46 ± 5; p = 0.742) and 3 months (44 ± 5 versus 40 ± 6; p = 0.916), BODE at 3 month Tai Chi (2 ± 0.6 versus 3 ± 0.4; p = 0.889)Tai chi improved functional capacity, symptoms, and health-related quality of life after PR.
Frei A. et al., 2022, (31) SwitzerlandHOMEX – 1 and HOMEX - 2 with 120 participants each (protocol)Adults, GOLD II–IVCOPDHOMEX minimal-equipment (elastic bands and a chair) + supervision + telephone coaching12 months, 6 days/week 15–20 minutes/day1° Outcome: CRQ-Dyspnea MIC = 0.5 points, and sample size SD of 0.9, with 80% power and α = 0.05. 2° Outcome: 6MWT, 1-min Sit-to-Stand, CRQ, CAT, HADS, exacerbations, cost-effectivenessA long-term protocol is hypothesized to maintain or improve dyspnea, functional capacity, HRQoL, and physical activity.
Habib GMM et al., 2020, (13) UKReview of 13 trials (n=661)Adults in LMICsCOPD, post-TBLow-resource PR with limited equipment12 weeks home-based program 5 days/weekImprovements in dyspnea (mMRC from 3.1 ± 0.7 to 2.2 ± 0.6; p < 0.05) , functional capacity (6MWT from 312 ± 68 m to 356 ± 70 m; +44 m; p < 0.05) and quality of life (SGRQ from 56 ± 11 to 44 ± 10; −12 points; p < 0.05)Low-cost PR program yielded measurable changes in symptoms, functional performance, and HRQoL using a structure feasible for low-resource settings
Holland et al., 2017, (27) Australia166 participantsStable adultsCOPDHome-based versus center PR8 weeks (+12-mo)Improvements in 6MWD (home: +29.4 m, 95% CI 13.8–45.0; center: +10.8 m, −4.5 to 26.2) between-group difference of +18.6 m (−3.3 to 40.7), CRQ-(home: +4.24; center: +2.68)Home non-inferior center-program; neither model sustained benefits at 12 months
Holland et al., 2021, (17) United States, Australia, Canada, and Europe,——CRDATS/ERS “modern PR” workshop—Identification of 13 essential components of PREndorses home/tele-PR when trial-tested and quality assured
Hurst et al., 2021, (41) Australia——COPD/asthmaATS LMIC implementation workshop—Policy and system-level recommendationsPR scale-up prioritized for LMICs
McKeoug Z et al., 2018, (22) Australia14 participantsStable adultsCOPDSun-style tai chi (short-form)8 weeks 2x/weekImprovement in 6MWT distance (95% CI) 28 m (-7 to 63), and SGRQ total score was -4 points (-9 to 0.4).No physical activity level increase at 8 weeks versus control
Moy LM et al., 2021, (26) USA91 adultsAdults GOLD 3–4COPDTai chi versus usual care versus walking24 weeks Tai chi (12 weeks -2x/week + 12 weeks – 1x/week and home exc. 3x/week6MWD effect size 0.25 (95% CI −0.24–0.73; p = 0.10); proportion with 6MWD improvement: 64% versus 39% (p = 0.05); CRQ-Fatigue improvement 59% versus 31% (p = 0.02); CRQ-Mastery improvement 47% versus 20% (p = 0.01)Tai Chi after PR is feasible and safe, and maintenance of PR gains
Ochman M et al., 2018, (28) Poland40 (22 Nordic walking)Transplant candidatesILD/COPDNordic walking PR (hospital+home)12 weeks 6-week cycles (2 weeks hospital + 4 weeks home training)Improvement in the distance 6-MWT (310 m – to 374 m, P = .0378), dyspnea MRC (P = .002), quality of life PCS (p = 0.039), and pain perception (P = .034) in the intervention group.Nordic Walking improves functional capacity, dyspnea perception, and quality of life, with no adverse events reported.
Patel S et al., 2021, (32) UK318+318 matched participantsAdults - GOLD A–DCOPDMinimal-equipment versus gym-based PR16 supervised sessions 8 weeks (2×/week)ISW −3.1 m (−15.6 to 9.4), p = 0.63, CRQ-dyspnea +1.6 (0.4–2.8), p = 0.009, completion PR-gym (73.0%, p = 0.014)Minimal equipment PR non-inferior ISW/CRQ; completion lower with minimal equipment.
Polkey MI, 2018, (35) China/UK120 participantsBronchodilator--naïveCOPDTai chi: 24-form Yang style, 1 h/day, 5 days/week, 12 weeks versus center PR: aerobic + resistance training, 1 h/session, 3 days/week, 12 weeks2-week run-in, 12-week intervention, 12-week follow-upSGRQ 4.5 points (95% CI 1.9–7.0; p < 0.001), 6MWD –22.7 m (95% CI –34.6 to –10.9; p < 0.001), mMRC 0.32 (95% CI 0.15–0.49; p < 0.001)Tai Chi is a viable, low-equipment modality whose benefits persist longer after supervised training compared to PR.
Pothirat C, 2015, (34) Thailand30 patientsAdvanced COPD (GOLD II–IV)COPDCommunity/home PR (walking, breathing, strength)8 weeks supervised 2x/week, strength training (dumbbells, sandbags, and theraband) and walking-based endurance training + 10-12 month home-based6MWD 307.9 ± 87.4 m to 394.4 ± 143.6 m (P < 0.001; MCID reached from month 2 onward), SGRQ (52.1±13.0 to 31.3±20.6), mMRC (3.1 ± 0.9 to 2.3±1.2)Low-cost PR sustained improvements across 12 months in muscle strength, 6MWD, SGRQ, and dyspnea
Pradella CO, 2015, (25) Brazil44 participantsAdults - GOLD (mild to severe)COPDHome PR (walking, stairs, upper limb exercises -1-kg oil can) + calls24-session home-based 8 weeks 3x/weekThe home PR group presented improvement in 6MWT 65.7 ± 83.1 m (p = .039) compared with 5.5 ± 92.9 m in control group, endurance 316.6 ± 81.8 m (p < .001), SGRQHome-based PR using minimal equipment is just as effective as traditional PR and is a viable alternative in low-cost contexts
Ramos EMC, 2014, (36) Brazil45 participantsAdults - Moderate COPDCOPDElastic tubing(ET): Upper and lower limb resistance Lemgruber® elastic tubes versus Conventional training(CT): weights machines (supervised)24 sessions 8 weeks, 3x/week, 60 minutes6MWT CT: +42.2 m (95%CI 11.7–72.7); ETT: +73.4 m (95%CI 37.4–109.4) (p < 0.05.0), strength and quality of life improved in all domains in both groups (p < 0.05),ET training elicited greater 6MWD improvement than conventional training; both increased strength/CRDQ.
Rochester CL, 2023, (37) USA Canada Australia UK82 RCTsAdultsCOPD/ILD/PHCenter and tele/home PR4 weeks –2 monthsCOPD 6MWD (mean difference 43.93 m, 95% CI 32.64–55.21), ISWD +39.77 m (22.38–57.15), dyspnea (+0.72 points, 0.19–1.25), HRQoL (−6.8 points, −9.26 to −4.52), SGRQ −6.8 points (−9.26 to −4.52)Strong recommendations PR in stable COPD, post-exacerbation COPD, and ILD; conditional recommendation in PH; strong recommendation for both center-based PR and telerehabilitation as equivalent options.

Abbreviations: RCTs (Randomized Clinical Trial); UK (United Kingdom); USA (United States of America); PR (pulmonary rehabilitation); COPD (chronic obstructive pulmonary disease); CRD (chronic respiratory disease); HRQoL (health-related quality of life); 6MWD/6MWT (six-minute walk distance/test); ISWT (incremental shuttle walk test); SGRQ (St George’s Respiratory Questionnaire); CAT (COPD Assessment Test); CCQ (Clinical COPD Questionnaire); PHQ-9 (Patient Health Questionnaire-9); BODE (Body mass index–Obstruction–Dyspnea–Exercise).

PRISMA 2020 flow diagram_Selection and review process. Source: Page MJ, et al. BMJ 2021 372:n71. doi: 10.1136/bmj.n71.
Figure 1. PRISMA 2020 flow diagram_Selection and review process. Source: Page MJ, et al. BMJ 2021 372:n71. doi: 10.1136/bmj.n71.

Results

Evidence on effectiveness

This narrative review identified 20 publications evaluating low-cost PR across chronic respiratory diseases, although most studies focused on COPD (12, 30–32). The included evidence comprised randomized controlled trials, quasi-experimental studies, systematic reviews, clinical guidelines, and implementation reports conducted in high-, middle-, and low-income settings (12, 20, 22, 24, 30–35). Low-cost PR programs were delivered in home-based, community-based, primary healthcare, hospital outpatient, and specialized rehabilitation settings, reflecting substantial variation in service organization and resource availability (13, 20, 24, 33, 34).

Although COPD remains the dominant condition represented in low-cost PR research, this focus limits the applicability of current evidence to the broader burden of chronic respiratory disability in resource-constrained settings (22, 23, 36). In LMICs, rehabilitation needs may extend to individuals with post-tuberculosis respiratory impairment, bronchiectasis, post-COVID respiratory sequelae, diffuse parenchymal or interstitial lung diseases, pulmonary hypertension, asthma, occupational lung diseases, and mixed respiratory conditions. These conditions should be considered priorities for future investigation rather than interpreted as being adequately represented among the 20 included publications (23, 24, 36). This limitation is clinically relevant because real-world PR services may manage heterogeneous CRD populations; Rodrigues et al., for example, reported that only 39% of participants in a Brazilian PR cohort had COPD (36).

The methodological profile of the included literature was heterogeneous. Randomized controlled trials contributed evidence of clinical effectiveness, whereas quasi-experimental and implementation studies provided information on feasibility, adherence, and real-world delivery (12, 20, 21, 24, 30–35). Randomized and controlled studies generally reported improvements in functional exercise capacity, symptoms, functionality, and health-related quality of life following low-cost PR interventions (12, 20, 30–35, 37–39). Review-level evidence suggested that minimal-equipment or low-cost PR can provide clinically relevant effects when aerobic training, resistance training, education, and monitoring are adequately structured (13, 22, 23, 40). Several methodological limitations were identified, including moderate methodological quality in some trials, small samples, single-center designs, short intervention periods, and unavoidable performance bias associated with the difficulty of blinding participants and therapists in exercise interventions (12, 13, 22, 30, 33–35, 40).

The intervention components most frequently reported in low-cost PR included walking, elastic resistance, improvised weights, bodyweight exercise, chairs, step-based activities, and structured education for self-management (18, 20, 21, 31, 32, 34, 35, 37–39). Holland et al. described essential components of modern PR, including exercise training, education, self-management support, and strategies aimed at long-term behavior change (18). Walking was frequently used as an aerobic modality because it is inexpensive, accessible, and adaptable to home or community settings (12, 21, 31, 35). Although many studies included individual PR components, fewer programs combined aerobic and resistance exercise according to guideline-based recommendations, with relevant examples including Anastasaki et al. (33), Patel et al. (41), and Pradella et al. (34). Session frequency and duration ranged from two to six sessions per week and from 20 to 60 min per session, reflecting adaptations to patient needs, supervision models, and local resource constraints (13, 20, 22).

Across the included studies, functional capacity improved when evaluated using the six-minute walk test (6MWT) and incremental shuttle walk test (ISWT), while health-related quality of life improved when assessed using the St. George's Respiratory Questionnaire (SGRQ), COPD Assessment Test (CAT), and Chronic Respiratory Questionnaire (CRQ) (12, 20–22, 34, 35, 37–42). Several studies reported changes that met or exceeded commonly used minimal clinically important difference thresholds, including approximately +30 m for the 6MWT, −4 points for the SGRQ, −2 points for the CAT, and +0.5 points for CRQ domains (13, 20–22, 33, 40).

In community- and home-based programs using minimal equipment, Ramos et al. (39) reported a 6MWT gain of +73.4 m with elastic tubing training. Pothirat et al. (31) reported a between-group difference of +65.7 m and, in a long-term community model, an increase from 307.9 ± 87.4 to 394.4 ± 143.6 m, with sustained benefits at 12 months. Ochman et al. (38) reported an increase in 6MWT distance from 310 to 374 m following a low-cost rehabilitation strategy.

Tai Chi-based and home-based programs also produced clinically relevant functional and health-related quality-of-life benefits, suggesting that culturally adaptable and low-resource exercise modalities may complement conventional center-based PR (20, 30, 32, 34, 43). Polkey et al. (32) reported favorable outcomes following Tai Chi, while home-based studies demonstrated non-inferior functional or quality-of-life outcomes compared with center-based PR when appropriate instruction and follow-up were provided (20, 34).

Improvements in health-related quality of life were observed across low-cost PR studies, with reported SGRQ reductions of approximately −6.4 to −9.3 points and CAT reductions of approximately −4 to −6 points (13, 21, 33). CRQ domains improved by approximately 0.6–1.0 points, reaching the commonly used 0.5-point threshold in relevant studies (20). When minimal-equipment PR was compared with conventional or specialist-equipment PR, differences generally remained within non-inferiority margins for functional outcomes, while simple-equipment resistance training produced clinically relevant strength gains (22, 40, 41).

Overall, the available evidence indicates that low-cost PR can improve functional capacity, symptoms, and health-related quality of life, particularly among people with COPD, when programs include structured exercise prescription, education, progression, and monitoring (12, 20, 22, 23, 31–35, 39–41). Nevertheless, the evidence base remains limited by COPD predominance, heterogeneity of intervention protocols, variable supervision models, relatively little primary care research, scarce cost-effectiveness evaluation, and insufficient long-term sustainability data (18, 22–24, 36, 40).

Implementation models

Implementation of low-cost PR has been reported in home-based, community-based, primary care, and specialized outpatient contexts, reflecting adaptation to local resources and health-system capacities (20, 25, 33, 35). Home-based interventions frequently involved walking, elastic resistance, bodyweight exercises, or improvised equipment and were delivered with less center-based professional contact than conventional PR (20, 35).

Nevertheless, the feasibility of home-based PR should not be assumed across all low-resource settings, because adherence and safety may be affected by household, environmental, cultural, and socioeconomic constraints (16, 25). Unsafe walking environments, overcrowded housing, limited privacy, low health literacy, gender-related restrictions, air pollution, climate extremes, family responsibilities, and competing socioeconomic priorities may limit participation in home-based PR (25). Therefore, home-based PR should include context-specific feasibility assessment, flexible exercise options, caregiver involvement when appropriate, safety screening, symptom monitoring, and locally acceptable strategies for exercise progression (20, 23, 25).

Low-cost programs delivered outside specialized centers may reduce geographical and financial barriers and may require less frequent face-to-face professional contact (12, 13, 20, 31, 34, 35). Reduced professional contact, however, should not be interpreted as absence of professional oversight, because PR requires appropriate assessment, individualized prescription, exercise progression, monitoring, and referral pathways for clinical deterioration (18, 23–25).

Sustainable low-cost PR may involve structured task-sharing with physiotherapy assistants, community health workers, primary care nurses, peer trainers, and family caregivers, where such roles are legally recognized and appropriately supervised (23–26, 44). Depending on local organization and professional regulations, community health workers, primary care nurses, rehabilitation assistants, peer supporters, or family caregivers may contribute to education, adherence support, follow-up, and reinforcement of prescribed activities under appropriate supervision (23–26). In Brazil, however, physiotherapeutic methods and techniques are legally reserved for licensed physiotherapists; therefore, PR assessment, prescription, progression, and clinical decision-making should remain physiotherapist-led (44, 45).

Discussion

Research gaps and perspectives

This narrative review indicates that low-cost PR has the potential to improve exercise capacity, symptoms, and quality of life among individuals with COPD and other CRD (21, 22, 30, 42). The predominance of relatively recent publications also reflects growing interest in approaches that reduce dependence on specialized equipment and infrastructure (22–24, 30, 35, 40).

Overall, low-cost PR can achieve outcomes comparable to conventional programs when exercise prescription, education, safety, progression, and monitoring are adequately structured (12, 20, 22, 23). Supervision appears to contribute to adherence and exercise quality, while limited access to rehabilitation remains an important barrier to participation and outcomes (24, 25, 33, 35).

A major limitation of the available evidence is the predominance of studies involving people with COPD, despite the broader spectrum of CRD associated with exercise limitation, dyspnea, reduced participation, and impaired quality of life (22, 23, 36). This predominance restricts generalizability to the broader spectrum of respiratory disability encountered in clinical practice, particularly in LMICs (23, 24, 36). Future low-cost PR research should therefore explicitly examine populations with other high-burden CRD, including post-tuberculosis respiratory impairment, bronchiectasis, post-COVID respiratory sequelae, interstitial or diffuse parenchymal lung disease, and pulmonary hypertension. These conditions are proposed here as priorities for future research in response to the limited disease representation identified in the reviewed evidence, rather than as conditions adequately evaluated among the 20 included publications (23, 24, 36).

Another important consideration is that evidence supporting home-based PR should not be generalized without considering the environment in which patients are expected to exercise (16, 20, 25). In resource-constrained settings, potential barriers may include unsafe walking spaces, limited household space or privacy, low health literacy, family or caregiving responsibilities, environmental exposures, socioeconomic constraints, and other locally relevant cultural or social factors (16, 25). Future implementation studies should therefore assess these contextual determinants explicitly when evaluating feasibility and adherence.

Implementation in LMICs requires adaptation to workforce availability and local health-system capacity, because conventional specialist-led PR models may be difficult to scale in settings with limited rehabilitation infrastructure (23–26).

Decentralized supervision, task-sharing, community health worker involvement, peer support, family-supported rehabilitation, and periodic professional review may provide feasible alternatives when specialist rehabilitation teams are scarce (23–26).

Remote and hybrid monitoring strategies, including telemonitoring and telerehabilitation, may contribute to expanded access, particularly in rural or geographically remote settings (17, 18, 23, 46). However, digital interventions should be adapted to actual patterns of access and literacy because unstable internet connectivity, shared devices, and limited digital skills may restrict participation (25, 46). Where appropriate, lower-bandwidth strategies such as telephone follow-up, text-based communication, asynchronous instructions, printed materials, and caregiver-supported participation may provide practical alternatives to exclusively high-bandwidth platforms (25, 46).

Primary healthcare represents another important implementation setting. Low-cost PR can be delivered within primary healthcare when guided by structured assessment, individualized exercise prescription, education, safety procedures, and follow-up strategies (23, 24, 33, 35). Meaningful integration, however, also requires clear referral and communication pathways between primary care, chronic respiratory disease services, noncommunicable disease programs, hospital discharge pathways, community services, and, where locally relevant, TB/post-TB care (24, 27, 33). Simplified referral processes, feedback to referring clinicians, and continuity after completion of rehabilitation may improve integration and uptake (24, 27, 33).

Behavioral and educational components should remain central to low-cost PR because the benefits of exercise are unlikely to be sustained without self-management, adherence support, and long-term behavior change (18, 23, 25, 47). Programs should provide culturally and linguistically appropriate education addressing symptom monitoring, recognition of clinical deterioration, pacing, physical activity, medication use when relevant, health beliefs, stigma, family engagement, and patient expectations (18, 23, 25, 26, 47).

Equity should also be considered explicitly. Reducing the cost of exercise equipment does not necessarily remove transportation costs, travel requirements, loss of work time, caregiving responsibilities, disability-related barriers, out-of-pocket expenses, or geographical inequalities (24, 25, 27, 36). Future implementation research should assess whether low-cost models actually reach rural, socioeconomically disadvantaged, disabled, vulnerable, or marginalized populations and whether patient and household costs remain barriers despite lower program-level resource requirements.

Long-term sustainability remains insufficiently evaluated. The included studies provide limited evidence regarding cost-effectiveness, resource allocation, and sustainability beyond the intervention period (22, 24, 40). Sustainable implementation may depend on workforce preparation, integration into routine chronic care, stable referral pathways, local adaptation, maintenance rehabilitation, community ownership, and financing models that do not rely exclusively on temporary external resources (24–27). Public, community, academic, or public-private arrangements may warrant evaluation where locally appropriate, but their contribution to sustainability should be assessed rather than assumed.

Future studies should therefore evaluate not only clinical outcomes but also implementation outcomes such as reach, adoption, feasibility, fidelity, acceptability, cost, equity, continuity, and sustainability. However, collectively, the evidence supports a broader interpretation of low-cost PR as a context-adapted rehabilitation strategy, rather than simply an exercise program that uses inexpensive equipment (18, 23–25). Minimal equipment may reduce one barrier to access, but sustainable expansion also requires appropriate workforce models, referral pathways, primary healthcare integration, culturally responsive education, context-sensitive remote delivery, equitable access, and continuity of care (18, 23–27, 46).

Conclusion

This narrative review indicates that low-cost PR can provide meaningful improvements in functional capacity, symptoms, and health-related quality of life, with several home-, community-, and minimal-equipment approaches demonstrating outcomes comparable to conventional PR. However, the evidence remains heterogeneous, with methodological limitations, a predominance of COPD-focused studies, limited representation of other CRD, and scarce evidence regarding cost-effectiveness and long-term sustainability.

Low-cost PR should therefore not be interpreted solely as rehabilitation performed with inexpensive equipment. Rather, it may be understood as a context-adapted approach that preserves essential PR components while adapting delivery to local infrastructure, workforce capacity, healthcare organization, and patient circumstances.

Future studies should examine broader CRD populations and evaluate implementation outcomes in addition to clinical effectiveness. Integration within primary healthcare, structured education, locally appropriate task-sharing, context-adapted referral and follow-up pathways, maintenance strategies, and explicit consideration of equity may represent important components of future low-cost PR models.

Generative AI statement

The author(s) declared that generative AI was not used in the creation of this manuscript.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Footnotes

Edited by: Julia Alleyne, University of Toronto, Canada

Reviewed by: Monsur Habib, University of Edinburgh, United Kingdom

Statements

Conflict of interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding

The author(s) declared that financial support was not received for this work and/or its publication.

Author contributions

EF: Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing. MV: Formal analysis, Methodology, Writing – original draft, Writing – review & editing. MR: Formal analysis, Methodology, Writing – review & editing. KC: Formal analysis, Methodology, Writing – review & editing. CL: Writing – review & editing. AL: Writing – review & editing. NS: Investigation, Methodology, Software, Visualization, Writing – original draft, Writing – review & editing. GC: Methodology, Formal analysis, Writing – original draft, Writing – review & editing.

References

  1. 1. Momtazmanesh S, Moghaddam SS, Ghamari S-H, Rad EM, Rezaei N, Shobeiri P. Global burden of chronic respiratory diseases and risk factors, 1990–2019: an update from the global burden of disease study 2019. eClinicalMed. (2023) 59: 101936. doi:10.1016/j.eclinm.2023.101936
  2. 2. Soriano JB, Kendrick PJ, Paulson KR, Gupta V, Abrams EM, Adedoyin RA. Prevalence and attributable health burden of chronic respiratory diseases, 1990–2017: a systematic analysis for the global burden of disease study 2017. Lancet Respir Med. (2020) 8 (6): 585 – 96. doi:10.1016/S2213-2600(20)30105-3
  3. 3. Viegi G, Maio S, Fasola S, Baldacci S. Global burden of chronic respiratory diseases. J Aerosol Med Pulm Drug Deliv. (2020) 33 (4): 171 – 7. doi:10.1089/jamp.2019.1576
  4. 4. GOLD. Global Strategy for the Prevention, Diagnosis and Management of Chronic Obstructive Pulmonary Disease: 2025. Fontana, WI: Global Initiative for Chronic Obstructive Lung Disease (GOLD) (2025). Available online at: (Accessed July 29, 2025).
  5. 5. Leal LF, Cousin E, Bidinotto AB, Sganzerla D, Borges RB, Malta DC. Epidemiology and burden of chronic respiratory diseases in Brazil from 1990 to 2017: analysis for the global burden of disease 2017 study. Rev Bras Epidemiol. (2020) 23: e200031. doi:10.1590/1980-549720200031
  6. 6. Marques CPC, Bloise RF, Lopes LBM, Godói LF, Souza PRP, Rosa IMS. Epidemiologia da asma no brasil, no período de 2016 a 2020. Res Soc Dev. (2022) 11 (8): e5211828825. doi:10.33448/rsd-v11i8.28825
  7. 7. DATASUS. TabNet Win32 3.2: Morbidade Hospitalar do SUS – por local de internação – Brasil (2023). Available online at: (Accessed November 18, 2023).
  8. 8. Cruz AA, Camargos PA, Urrutia-Pereira M, Stelmach R. Global alliance against chronic respiratory diseases (GARD) Brazil success case: overcoming barriers. J Thorac Dis. (2018) 10 (1): 534 – 8. doi:10.21037/jtd.2018.01.40
  9. 9. Chen P, Li Y, Wu D, Liu F, Cao C. Secondhand smoke exposure and the risk of chronic obstructive pulmonary disease: a systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis. (2023) 18: 1067 – 76. doi:10.2147/COPD.S403158
  10. 10. Oliveira MSD, Montovani EH, Santana MDFED, Ponce De Leon ACM, Marques MC. Mortalidade por doença respiratória crônica no Brasil: tendência temporal e projeções. Rev Saúde Pública. (2022) 56: 52. doi:10.11606/s1518-8787.2022056003672
  11. 11. Malta DC, Duncan BB, Schmidt MI, Teixeira R, Ribeiro ALP, Felisbino-Mendes MS. Trends in mortality due to non-communicable diseases in the Brazilian adult population: national and subnational estimates and projections for 2030. Popul Health Metr. (2020) 18 (1): 16. doi:10.1186/s12963-020-00216-1
  12. 12. Alison JA, McKeough ZJ. Pulmonary rehabilitation for COPD: are programs with minimal exercise equipment effective? J Thorac Dis. (2014) 6 (11): 1606 – 14. doi:10.3978/j.issn.2072-1439.2014.07.45
  13. 13. Habib GMM, Rabinovich R, Divgi K, Ahmed S, Saha SK, Singh S. Systematic review (protocol) of clinical effectiveness and models of care of low-resource pulmonary rehabilitation. NPJ Prim Care Respir Med. (2019) 29 (1): 1 – 4. doi:10.1038/s41533-019-0122-1
  14. 14. Benavides-Cordoba V, Barros-Poblete M, Vieira RP, Mazzucco G, Fregonezi G, Torres-Castro R. Provision of pulmonary rehabilitation in Latin America 18 months after the COVID-19 pandemic: a survey of the Latin American thoracic association. Chron Respir Dis. (2022) 19: 14799731221104102. doi:10.1177/14799731221104102
  15. 15. Incorvaia C, Longo L, Makri E, Ridolo E. Challenges in pulmonary rehabilitation: COVID-19 and beyond. Pol Arch Intern Med. (2022) 132 (11): 16357. doi:10.20452/pamw.16357
  16. 16. Sami R, Salehi K, Hashemi M, Atashi V. Exploring the barriers to pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: a qualitative study. BMC Health Serv Res. (2021) 21 (1): 828. doi:10.1186/s12913-021-06814-5
  17. 17. Bhatt SP, Rochester CL. Expanding implementation of tele-pulmonary rehabilitation: the new frontier. Ann Am Thorac Soc. (2022) 19 (1): 3 – 5. doi:10.1513/AnnalsATS.202109-1082ED
  18. 18. Holland AE, Cox NS, Houchen-Wolloff L, Rochester CL, Garvey C, ZuWallack R. Defining modern pulmonary rehabilitation. An official American thoracic society workshop report. Ann Am Thorac Soc. (2021) 18 (5): e12 – 29. doi:10.1513/AnnalsATS.202102-146ST
  19. 19. Bourne S, DeVos R, North M, Chauhan A, Green B, Brown T. Online versus face-to-face pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: randomised controlled trial. BMJ Open. (2017) 7 (7): e014580. doi:10.1136/bmjopen-2016-014580
  20. 20. Holland AE, Mahal A, Hill CJ, Lee AL, Burge AT, Cox NS. Home-based rehabilitation for COPD using minimal resources: a randomised, controlled equivalence trial. Thorax. (2017) 72 (1): 57 – 65. doi:10.1136/thoraxjnl-2016-208514
  21. 21. Holland AE, Jones AW, Mahal A, Lannin NA, Cox N, Hepworth G. Implementing a choice of pulmonary rehabilitation models in chronic obstructive pulmonary disease (HomeBase2 trial): protocol for a cluster randomised controlled trial. BMJ Open. (2022) 12 (4): e057311. doi:10.1136/bmjopen-2021-057311
  22. 22. Cheng SWM, McKeough ZJ, McNamara RJ, Alison JA. Pulmonary rehabilitation using minimal equipment for people with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Phys Ther. (2023) 103 (5): pzad013. doi:10.1093/ptj/pzad013
  23. 23. Rochester CL, Alison JA, Carlin B, Jenkins AR, Cox NS, Bauldoff G. Pulmonary rehabilitation for adults with chronic respiratory disease: an official American thoracic society clinical practice guideline. Am J Respir Crit Care Med. (2023) 208 (4): e7 – e26. doi:10.1164/rccm.202306-1066ST
  24. 24. Hurst JR, Buist AS, Gaga M, Gianella GE, Kirenga B, Khoo EM. Challenges in the implementation of chronic obstructive pulmonary disease guidelines in low- and middle-income countries: an official American thoracic society workshop report. Ann Am Thorac Soc. 2 021; 18 (8): 1269 – 77. doi:10.1513/AnnalsATS.202103-284ST
  25. 25. De Oliveira TMD, Pereira AL, Costa GB, De Souza Mendes LP, De Almeida LB, Velloso M. Embedding pulmonary rehabilitation for chronic obstructive pulmonary disease in the home and community setting: a rapid review. Front Rehabil Sci. (2022) 3: 780736. doi:10.3389/fresc.2022.780736
  26. 26. Faria ID, Mendes LPS, Schettino RC, Rocha BLC, Alison JA, Velloso M. Knowledge, confidence, and clinical experience of physiotherapists and multiprofessional team on pulmonary rehabilitation. Fisioter Pesqui. (2024) 31: e23007724en. doi:10.1590/1809-2950/e23007724en
  27. 27. Johnston KN, Young M, Grimmer KA, Antic R, Frith PA. Barriers to, and facilitators for, referral to pulmonary rehabilitation in COPD patients from the perspective of Australian general practitioners: a qualitative study. Prim Care Respir J. (2013) 22 (3): 319 – 24. doi:10.4104/pcrj.2013.00062
  28. 28. Sukhera J. Narrative reviews in medical education: key steps for researchers. J Grad Med Educ. (2022) 14 (4): 418 – 9. doi:10.4300/JGME-D-22-00481.1
  29. 29. Chand GB. Narrative inquiry: a critical examination of its theoretical foundations and methodological applications. Far West Rev. (2024) 2 (1): 135 – 52. doi:10.3126/fwr.v2i1.70514
  30. 30. Fagián L, Amilivia G. Taichí como intervención terapéutica en la rehabilitación respiratoria de la enfermedad pulmonar obstructiva crónica. Rev Médica Urug. (2024) 40 (2): e203. doi:10.29193/RMU.40.2.7
  31. 31. Pothirat C, Chaiwong W, Phetsuk N. Efficacy of a simple and inexpensive exercise training program for advanced chronic obstructive pulmonary disease patients in community hospitals. J Thorac Dis. (2015) 7 (4): 637 – 43. doi:10.3978/j.issn.2072-1439.2015.04.13
  32. 32. Polkey MI, Qiu Z-H, Zhou L, Zhu M-D, Wu Y-X, Chen Y-Y. Tai chi and pulmonary rehabilitation compared for treatment-naive patients with COPD. Chest. (2018) 153 (5): 1116 – 24. doi:10.1016/j.chest.2018.01.053
  33. 33. Anastasaki M, Trigoni M, Pantouvaki A, Trouli M, Mavrogianni M, Chavannes N. Establishing a pulmonary rehabilitation programme in primary care in Greece: a FRESH AIR implementation study. Chron Respir Dis. (2019) 16: 1479973119882939. doi:10.1177/1479973119882939
  34. 34. Pradella CO, Belmonte GM, Maia MN, Delgado CS, Luise APT, Nascimento OA. Home-Based pulmonary rehabilitation for subjects with COPD: a randomized study. Respir Care. (2015) 60 (4): 526 – 32. doi:10.4187/respcare.02994
  35. 35. Cerini T, Kunz R, Dalla Lana K, Radtke T, Polhemus A, Puhan MA. Evaluation of the implementation of a home-based exercise training program for people with COPD: a mixed-methods study. Front Rehabil Sci. (2021) 2: 743588. doi:10.3389/fresc.2021.743588
  36. 36. Rodrigues G, Velloso M, Gomes da Silva DJV, Pitta F, Mesquita R. Classification of people with chronic respiratory disease into preserved or reduced functional exercise capacity: a retrospective analysis of associated factors considering baseline characteristics and responses to pulmonary rehabilitation. Physiother Can. (2025) 77: 321 – 8. doi:10.3138/ptc-2023-0068
  37. 37. Moy ML, Wayne PM, Litrownik D, Beach D, Klings ES, Davis RB. Long-term exercise after pulmonary rehabilitation (LEAP): design and rationale of a randomized controlled trial of tai chi. Contemp Clin Trials. (2015) 45: 458 – 67. doi:10.1016/j.cct.2015.09.004
  38. 38. Ochman M, Maruszewski M, Latos M, Jastrzębski D, Wojarski J, Karolak W. Nordic walking in pulmonary rehabilitation of patients referred for lung transplantation. Transplant Proc. (2018) 50 (7): 2059 – 63. doi:10.1016/j.transproceed.2018.02.106
  39. 39. Ramos EMC, De Toledo-Arruda AC, Fosco LC, Bonfim R, Bertolini GN, Guarnier FA. The effects of elastic tubing-based resistance training compared with conventional resistance training in patients with moderate chronic obstructive pulmonary disease: a randomized clinical trial. Clin Rehabil. (2014) 28 (11): 1096 – 106. doi:10.1177/0269215514527842
  40. 40. de Lima FF, Cavalheri V, Silva BSA, Grigoletto I, Uzeloto JS, Ramos D. Elastic resistance training produces benefits similar to conventional resistance training in people with chronic obstructive pulmonary disease: systematic review and meta-analysis. systematic review and meta-analysis. Phys Ther. (2020) 100 (11): 1891 – 905. doi:10.1093/ptj/pzaa149
  41. 41. Patel S, Palmer MD, Nolan CM, Barker RE, Walsh JA, Wynne SC. Supervised pulmonary rehabilitation using minimal or specialist exercise equipment in COPD: a propensity-matched analysis. Thorax. (2021) 76 (3): 264 – 71. doi:10.1136/thoraxjnl-2020-215281
  42. 42. Frei A, Radtke T, Dalla Lana K, Brun P, Sigrist T, Spielmanns M. Effectiveness of a long-term home-based exercise training program in patients with COPD after pulmonary rehabilitation. Chest. (2022) 162 (6): 1277 – 86. doi:10.1016/j.chest.2022.07.026
  43. 43. McKeough Z, Leung R, Wootton S, Cheng S, Alison J. Effect of short-form, sun-style tai chi on physical activity in people with COPD. Eur Respir J. (2018) 52 (Suppl 62): PA5423. doi:10.1183/13993003.congress-2018.PA5423
  44. 44. Brasil. Decreto-Lei n° 938, de 13 de outubro de 1969. Provê sobre as profissões de fisioterapeuta e terapeuta ocupacional, e dá outras providências (1969). Available online at:
  45. 45. Conselho Federal de Fisioterapia e Terapia Ocupacional (COFFITO). Resolução COFFITO n° 80, de 9 de maio de 1987. Baixa atos complementares à Resolução COFFITO-8, relativa ao exercício profissional do fisioterapeuta, e à Resolução COFFITO-37 (1987). Available online at:
  46. 46. Cox NS, McDonald CF, Hill CJ, O'Halloran P, Alison JA, Zanaboni P. Telerehabilitation for chronic respiratory disease. Cochrane Database Syst Rev. (2021) 1 (1): CD013040. doi:10.1002/14651858.CD013040.pub2
  47. 47. Holland AE, Wageck B, Hoffman M, Lee AL, Jones AW. Does pulmonary rehabilitation address treatable traits? A systematic review. Eur Respir Rev. (2022) 31 (165): 220042. doi:10.1183/16000617.0042-2022

Citation

Fonseca, E. S., et al. (2026). Low-cost pulmonary rehabilitation for chronic respiratory diseases: a narrative review. Frontiers in Rehabilitation Sciences, Volume 7. https://doi.org/
Received
Accepted
Published
Volume
7 - 2026

Copyright

© 2026 Fonseca, Velloso, Rodrigues, Costa, de Lira, Lima Sousa, Spicacci and Costa.

License: https://creativecommons.org/licenses/by/4.0/

*Correspondence: Gustavo De Conti Teixeira Costa

Article metrics

Views
0
Downloads
0
Citations
0
Shares
0

Related articles

Original ResearchPhysical therapist management of patients with suspected or confirmed osteoporosis – German translation and contextual adaptation of a clinical practice guideline from the Academy of Geriatric Physical Therapy (USA)Tobias Braun, Maxime Hermanns, Vanessa Haug, Jessica Nau, Bettina Scheffler, Gudrun Diermayr, Gregory W. Hartley, Keith G. Avin, Susanne SaalCase ReportCase Report: An MDT-guided multimodal protocol for large-area stroke plateau — integrating neuromodulation with multimodal assessmentXiao-li Wu, Xiao-qian Xia, Chang-qing Ye, Yun-lei Wang, Xing-zhu Li, Li-xu Liu, Fu-biao Hang, Jing-song Liu, Yi-chuan Song, Yue Zhang, Xiao-xia DuPerspectiveBridging institutional expertise and democratic decentralization: a proposed hub-and-spoke framework for rehabilitation, built on Kerala’s model of community-based disability careBinoy Mathew K V, Maryelizabeth Tidiya Walarine