What do the American Thoracic Society/European Respiratory Society guidelines recommend regarding the use of robotic‑assisted gait and upper‑limb training as an adjunct to pulmonary rehabilitation in adults with chronic respiratory diseases such as COPD, interstitial lung disease, or post‑surgical patients?

Role of Robotics in Pulmonary Rehabilitation Based on ATS/ERS Guidelines

The ATS/ERS guidelines do not recommend robotic-assisted gait or upper-limb training as part of pulmonary rehabilitation because the evidence base remains insufficient—instead, clinicians should offer patients the choice between center-based pulmonary rehabilitation or telerehabilitation, both of which have moderate-quality evidence supporting their use. 1, 2

Current Guideline Position on Robotics

The American Thoracic Society and European Respiratory Society acknowledge that robotic technologies are "currently being adapted and tested" to support pulmonary rehabilitation, but these interventions remain investigational rather than established treatment modalities. 1 The 2023 ATS Clinical Practice Guideline for pulmonary rehabilitation in adults with chronic respiratory disease does not include robotic mobility assistance as an established modality, reflecting the lack of robust evidence compared to traditional rehabilitation approaches. 2

Evidence-Based Alternatives to Robotics

Telerehabilitation as the Technology-Based Standard

The ATS issues a strong recommendation (moderate-quality evidence) that telerehabilitation is an equivalent alternative to center-based pulmonary rehabilitation for adults with chronic respiratory disease, including COPD, interstitial lung disease, and pulmonary hypertension. 3, 2, 4

• Telerehabilitation achieves similar clinical outcomes to center-based programs with higher completion rates (93% versus 70%) and no safety concerns. 3, 4
• This modality should be offered specifically for patients who cannot access center-based programs due to transportation barriers, rural location, or mobility limitations. 1, 2

Proven Exercise Training Modalities

The ATS/ERS strongly endorses established rehabilitation interventions over unproven robotic approaches: 1

• Interval training and strength training combined with endurance training 1
• Upper limb training as part of comprehensive rehabilitation 1
• Transcutaneous neuromuscular electrical stimulation for patients with comorbidities 1
• Home-based exercise training that is appropriately resourced, which reduces dyspnea and increases exercise performance 1

Essential Components That Any Technology Must Deliver

Any technology-based intervention—whether robotic or otherwise—must deliver all core pulmonary rehabilitation components and cannot be used as a standalone mobility aid: 2

• Structured, progressive exercise training with individually tailored progression 3
• COPD self-management education integrated alongside exercise training 3
• Patient-tailored behavioral support and behavior change strategies 3
• Multidisciplinary team coordination with healthcare professionals from multiple disciplines 3
• Programs lasting 6-12 weeks with maintenance strategies following initial rehabilitation 1

Specific Guideline Recommendations by Disease

For Stable COPD

The ATS issues a strong recommendation (moderate-quality evidence) for pulmonary rehabilitation in adults with stable COPD. 5, 2 This applies to traditional center-based or telerehabilitation models, not robotic interventions.

For COPD Exacerbations

The ATS issues a strong recommendation (moderate-quality evidence) for pulmonary rehabilitation after hospitalization for COPD exacerbation. 5, 2

For Interstitial Lung Disease

The ATS issues a strong recommendation (moderate-quality evidence) for pulmonary rehabilitation in adults with ILD. 5, 2

For Pulmonary Hypertension

The ATS issues a conditional recommendation (low-quality evidence) suggesting pulmonary rehabilitation for adults with pulmonary hypertension. 5

Critical Pitfalls to Avoid

Do not substitute experimental robotic technology for comprehensive pulmonary rehabilitation—technology must deliver all core components including exercise training, education, behavioral support, and nutritional assessment, not just mobility assistance. 1, 3

Avoid using technology as a standalone intervention without the multidisciplinary team approach that addresses the complex needs of patients with COPD and multiple comorbidities. 1

Do not assume technology improves outcomes simply because it is novel—the ATS/ERS emphasizes that robotic technologies are still being tested and lack the robust evidence base of traditional approaches or telerehabilitation. 1

Until robotic mobility assistance demonstrates outcomes equivalent to standard programs in rigorous trials, clinicians should offer patients a choice between center-based pulmonary rehabilitation and telerehabilitation. 2

Maintenance Rehabilitation Considerations

The ATS provides a conditional recommendation (low-quality evidence) that maintenance pulmonary rehabilitation after completing an initial program may be beneficial for adults with COPD. 5, 2 Technology-assisted approaches may be deployed for maintenance, but must maintain all core rehabilitation components. 3