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Home versus center based physical activity programs in older adults

  • Review
  • Intervention

Authors


Abstract

Background

Physical inactivity is a leading cause of preventable death and morbidity in developed countries. In addition physical activity can potentially be an effective treatment for various medical conditions (e.g. cardiovascular disease, osteoarthritis). Many types of physical activity programs exist ranging from simple home exercise programs to intense highly supervised hospital (center) based programs.

Objectives

To assess the effectiveness of 'home based' versus 'center based' physical activity programs on the health of older adults.

Search methods

The reviewers searched the Cochrane Central Register of Controlled Trials (CENTRAL) (1991-present), MEDLINE (1966-Sept 2002), EMBASE (1988 to Sept 2002), CINAHL (1982-Sept 2002), Health Star (1975-Sept 2002), Dissertation Abstracts (1980 to Sept 2002), Sport Discus (1975-Sept 2002) and Science Citation Index (1975-Sept 2002), reference lists of relevant articles and contacted principal authors where possible.

Selection criteria

Randomised or quasi-randomised controlled trials of different physical activity interventions in older adults (50 years or older) comparing a 'home based' to a 'center based' exercise program. Study participants had to have either a recognised cardiovascular risk factor, or existing cardiovascular disease, or chronic obstructive airways disease (COPD) or osteoarthritis. Cardiac and post-operative programs within one year of the event were excluded.

Data collection and analysis

Three reviewers selected and appraised the identified studies independently. Data from studies that then met the inclusion/exclusion criteria were extracted by two additional reviewers.

Main results

Six trials including 224 participants who received a 'home based' exercise program and 148 who received a 'center based' exercise program were included in this review. Five studies were of medium quality and one poor. A meta-analysis was not undertaken given the heterogeneity of these studies.

Cardiovascular
The largest trial (accounting for approximately 60% of the participants) looked at sedentary older adults. Three trials looked at patients with peripheral vascular disease (intermittent claudication). In patients with peripheral vascular disease center based programs were superior to home at improving distance walked and time to claudication pain at up to 6 months. However the risk of a training effect may be high. There are no longer term studies in this population.

Notably home based programs appeared to have a significantly higher adherence rate than center based programs. However this was based primarily on the one study (with the highest quality rating of the studies found) of sedentary older adults. This showed an adherence rate of 68% in the home based program at two year follow-up compared with a 36% adherence in the center based group. There was essentially no difference in terms of treadmill performance or cardiovascular risk factors between groups.

Chronic Obstructive Pulmonary Disease (COPD)
Two trials looked at older adults with COPD. In patients with COPD the evidence is conflicting. One study showed similar changes in various physiological measures at 3 months that persisted in the home based group up to 18 months but not in the center based group. The other study showed significantly better improvements in physiological measures in the center based group after 8 weeks but again the possibility of a training effect is high.

Osteoarthritis
No studies were found.

None of the studies dealt with measures of cost, or health service utilization.

Authors' conclusions

In the short-term, center based programs are superior to home based programs in patients with PVD. There is a high possibility of a training effect however as the center based groups were trained primarily on treadmills (and the home based were not) and the outcome measures were treadmill based. There is conflicting evidence which is better in patients with COPD. Home based programs appear to be superior to center based programs in terms of the adherence to exercise (especially in the long-term)

摘要

背景

老人之家庭與機構為基礎的身體活動計畫比較

身體不活動為已開發國家老人可預防死因及罹病之主要原因。身體活動可能是心血管疾病及退化性關節炎治療方法之一。身體活動包括簡單在家庭做與在醫院機構監測下做。

目標

比較在家庭做與在醫院機構做身體活動的效果。

搜尋策略

搜尋包括Cochrane Central Register of Controlled Trials (CENTRAL) (1991present), MEDLINE (1966Sept 2002), EMBASE (1988 to Sept 2002) INAHL (1982Sept 2002), Health Star (1975Sept 2002), Dissertation Abstracts (1980 to Sept 2002), Sport Discus (1975Sept 2002) and Science Citation Index (1975Sept 2002)。同時手動搜尋所選文章之參考文獻及徵詢專家。

選擇標準

所有隨機對照試驗及擬隨機對照試驗比較50歲以上老人,在家庭做與在醫院機構做身體運動計畫的效果。參加者需有心血管疾病風險因子或已有心血管疾病、或慢性肺氣腫、或退化性關節炎。並排除一年內有心臟及術後運動計畫者。

資料收集與分析

3位作者獨立選擇及評讀文獻,並由另2位作者進行資料摘錄。

主要結論

6個研究包含224例在家庭做與148例在醫院機構做身體運動病患於分析中。5個研究品質中等,1篇品質低。因異質性而未統合分析。最大研究含60% 病例,研究不活動老人,3篇研究週邊血管疾病間歇性跛行患者。在週邊血管疾病間歇性跛行患者,在醫院機構做身體運動,在走路距離及到跛行時間,比在家庭做效果好,持續到6個月,但訓練影響效果的風險可能高。未有更長期研究。值得注意的是在家庭做比在醫院機構做遵從性較高﹝68% 比36% ﹞,但結論主要來自一篇不活動老人高品質研究,兩組在心血管疾病風險因子及treadmill運動表現相同。慢性肺氣腫有2篇研究,但結論不一,有一篇研究顯示居家運動在3月時多種生理改變指標與在醫院機構做身體活動相似,並可維持到18個月,但在醫院機構組則未維持。另一篇研究在醫院機構做身體活動8週之生理改變指標有改善,但可能是短期訓練效果。 沒有關於退化性關節炎的研究報告。 以上各研究報告均未述及各項運動所須之費用及使用何種健康醫療照顧之工具。

作者結論

短期而言,在醫院機構做身體運動對週邊血管疾病間歇性跛行患者有幫助,但有可能是短期訓練效果,因在醫院機構做主要是treadmill運動,而評估指標是treadmill運動。在慢性肺氣腫結論不一。長期而言,在家庭做比在醫院機構做之遵從性較高。

翻譯人

本摘要由林口長庚醫院余光輝翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

為了改善健康,在家裡還是在醫院機構作運動,哪個比較好?為了回答這個問題,科學家從Cochrane群組發現和分析了6個研究。這些研究測試超過 370名,50歲以上有心臟病(或有心臟病高風險),慢性氣道阻塞疾病(COPD)的患者。這些研究比較在家裡作運動計劃和在醫院機構作運動長達2年。這次審查提供了今日我們擁有最好的證據。在家運動計劃跟在醫院機構之間的區別是什呢?為什麼要研究哪一個好呢?積極的生活有助於 50歲以上患者健康。其中一個重要的好處是能夠更好地做日常活動和步行地更好(身體功能)。有許多方法來增加活動。你可以做一個運動計劃在自己的家裡,隨自己方便與可能比較便宜,且不花錢的健康護理制度。或者你可以加入一個中心或醫院的運動計畫,由訓練有素的醫護人員來訓練你。 大多數時候這些方案都包括在內,不花你什麼,但會花費在醫療照護系統。因此重要的是要知道哪些類型的方案可改善健康更多,哪個方案人們可以長遠持續和哪個計畫是值得花錢的。在本研究中哪個計畫是較好?在有心臟病或高心臟病的風險的患者。 6個月後,大多數研究表明,無論在家裡還是在醫院機構做的運動都可改善身體機能,生活品質,血膽固醇濃度,步行速度和由於血流不暢造成行走後腿部疼痛。當比較兩個運動方案,研究發現,改善結果類似,但在醫院機構可能會提高步行速度和減輕走路後腿部疼痛。一個大型研究顯示,相比於在醫院機構運動,更多的人傾向於以家庭為基礎的方案。在慢性阻塞性肺病病患。大多數研究表明,無論在家裡還是在醫院機構,可改善身體功能,降低血壓,改善一些運動的測試項目。但是,生活品質和其他運動的測試並沒有改善。當比較兩個運動計畫,一項研究表明,在家中3個月的改善跟在醫院機構類似。但在家18個月的運動是比在醫院機構好。另一項研究表明,在醫院機構2個月的效果比在家好,但13個月時就相同。沒有研究著重於費用或使用的醫療照護系統。是否計畫有任何問題?這次review沒有報告到任何問題。什麼是底線?有'銀級的證據,無論在家裡還是在醫院機構運動,都可提高老人健康和生理功能。但是,人們往往堅持在家裡勝過在醫院機構。有心臟病或心臟病高風險的患者顯示在醫院機構短期3個月運動比在家好。在慢性阻塞性肺病患者,仍不清楚是否在家裡運動比在醫院機構更好。還需要更多的研究,以測試對於有退化性關節炎患者哪種計畫較好和成本一般約多少。

Plain language summary

Physical activity programs for older adults

To improve health, is it better to do an exercise programme at home or at a hospital center?
To answer this question scientists from the Cochrane Group found and analyzed 6 studies. These studies tested over 370 people over 50 years old who had heart disease (or high risk of heart disease), Chronic Obstructive Airways Disease (COPD). The studies compared people who did an exercise programme at home to those who did an exercise programme at a hospital or center up to 2 years. This review provides the best evidence we have today.

What is the difference between exercise programmes at home or at a center? Why research whether one is better than the other?
Active living benefits the health of people 50 years and older. One of the important benefits is being able to do your everyday activities better and walking better (physical function). There are many ways to increase activity. You can do an exercise programme at home on your own, at your own convenience and at maybe a cost to you, but no cost to the health care system. Or you can join a programme at a center or hospital run by trained health care professionals. Most times these programmes are covered and do not cost you anything but they do cost the health care system. It is therefore important to know which type of programme improves health more, which programme people will stick with in the long run and which programme is worth the cost.

Which type of programme was better in the studies?
In people who had heart disease or an increased risk of heart disease

After 6 months, most studies show that exercise programmes, whether at home or at a center improve physical function, quality of life, blood cholesterol levels, walking speed and leg pain after walking due to poor blood flow. When comparing the two exercise programmes, the studies found that improvements were similar but that exercising at a center may improve walking speed and leg pain after walking more than at home.

One large study shows that many more people tend to stick with exercising after a home based programme compared with a center programme in the long-term.

In people who had COPD
Most studies show that exercise programmes, whether at home or at a center, improve physical function, decrease blood pressure, and improve some tests for exercise. But quality of life and other tests for exercise did not improve. When comparing the two exercise programmes, one study shows that improvements at home were similar to a center at 3 months. But at 18 months exercising at home was better than at a center. Another study shows that exercising at a center was better than at home at 2 months but the same at 13 months.

No studies looked at costs or use of the health care system.

Were there any problems with the programmes?
This review did not report any problems with the programmes.

What is the bottom line?
There is 'silver-level' evidence (www.cochranemsk.org) that both exercising at home or at a center improves the health and physical function of older adults. But, people tend to stick with exercising at home more than in a center.

People with heart disease or a high risk of heart disease may show more improvements exercising at a center than at home in the short-term (3 months). In people with COPD, it is still not clear whether exercising at home or at a center is better.

More research is still needed to test which type of programme might be better for people with osteoarthritis and what the costs are in general.

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