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Physical rehabilitation for older people in long-term care

  1. Tom Crocker1,
  2. Anne Forster1,2,*,
  3. John Young1,2,
  4. Lesley Brown1,
  5. Seline Ozer1,
  6. Jane Smith1,
  7. John Green1,
  8. Jo Hardy1,
  9. Eileen Burns3,
  10. Elizabeth Glidewell4,
  11. Darren C Greenwood5

Editorial Group: Cochrane Stroke Group

Published Online: 28 FEB 2013

Assessed as up-to-date: 28 SEP 2012

DOI: 10.1002/14651858.CD004294.pub3


How to Cite

Crocker T, Forster A, Young J, Brown L, Ozer S, Smith J, Green J, Hardy J, Burns E, Glidewell E, Greenwood DC. Physical rehabilitation for older people in long-term care. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD004294. DOI: 10.1002/14651858.CD004294.pub3.

Author Information

  1. 1

    Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Trust, Academic Unit of Elderly Care and Rehabilitation, Bradford, UK

  2. 2

    Leeds Institute of Health Sciences, University of Leeds, Academic Unit of Elderly Care and Rehabilitation, Bradford, UK

  3. 3

    Leeds Teaching Hospitals NHS Trust, Department of Elderly Care, Leeds, UK

  4. 4

    Leeds Institute of Health Sciences, University of Leeds, Academic Unit of Primary Care, Leeds, UK

  5. 5

    University of Leeds, Centre for Epidemiology and Biostatistics, Leeds, UK

*Anne Forster, a.forster@leeds.ac.uk.

Publication History

  1. Publication Status: New search for studies and content updated (conclusions changed)
  2. Published Online: 28 FEB 2013

SEARCH

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Physical function in older people in long-term care

Elder residents of long-term care are amongst the frailest in our population, with significant healthcare and social care needs (Bowman 2004; Continuing Care Conference 2006). Increasing age is associated with increasing disability. In developed countries, long-term care for older people is often provided in institutional settings for those with physical or mental conditions that preclude independent living (Continuing Care Conference 2006). It is reported that care-home residents spend the majority of their time inactive, with low levels of interaction with staff (Holthe 2007; Sackley 2006a).

Decreasing mobility and increasing dependency have many adverse effects. For residents in care homes, it may lead to increased incidence of pressure sores, contractures, cardiovascular deconditioning, urinary infections, and loss of independence (Butler 1998). Sedentary behaviour is adversely associated with chronic disease risk factors and all-cause mortality (Balboa-Castillo 2011; DH 2011). Mobility problems and reduced physical activity compound health difficulties by directly affecting physical and psychological health and reducing opportunities to participate in social activities; social isolation negatively impacts on mood and self-esteem, which can then further adversely affect physical health (Marmot 2003; NICE 2008). Residents identify mobility as of central importance to quality of life and well-being (Bourret 2002), and residents with dementia wish for more day-time activities (Hancock 2006). Physical ill-health and disability are the most consistent risk factors for depression in later life, with reports suggesting that, rather than illness per se, it is the resulting functional limitations, including social participation and meaningful relationships, that increase the risk of depression (Braam 2005; Zeiss 1996).

 

Physical rehabilitation

Physical rehabilitation is defined as those interventions that aim to maintain or improve physical function of an individual. In a care-home setting, this typically involves increasing the physical exertions of an individual (active), although passive rehabilitation involving external stimulation (e.g. whole body vibration) is also in use. The focus of this review is active rehabilitation, which may be in the form of specific exercises or physical activity as a part of some other purposeful or leisure activity. It may be provided in a group format or individually; generic or tailored; and delivered by rehabilitation professionals (e.g. physiotherapist), care staff, or self-directed.

 

How the intervention might work

Physical activity provides positive benefits for people over 65 years old for a range of outcomes: mood (Blake 2009; Windle 2010), decreased disease risk, and overall health (DH 2011). For frail institutionalised older people, systematic reviews indicate that physical training can positively affect fitness for some participants (Chin A Paw 2008; Rydwik 2004a; Weening-Dijksterhuis 2011); the level of effect may be related to level of frailty (Chin A Paw 2008). A recent review of the effects of physical activity for older people with dementia (not all of whom were in institutions) reports some benefits to walking, getting out of chairs, lower limb strength, and flexibility (Potter 2011). Included studies in the reviews were generally small and of variable quality.

 

Why it is important to do this review

Dramatic increases in life expectancy over the last century are likely to result in a significant increase in the demand for long-term care. Between 1985 and 2010 the proportion of the world's population over 65 years old grew by a quarter, from 6.0% (291 million) to 7.6% (524 million), and is expected to increase to 13% by 2035, exceeding a billion people globally (United Nations 2011). However, this prospect of longevity may be associated with a concomitant increase in morbidity and requirement for long-term care in a residential setting. Annual healthcare costs among those living in long-term care (USD 45,400 per annum) are over four times greater than the average for the elderly population in the USA in 1998 (Lubitz 2003). This means that despite much shorter life expectancy, total costs of care for those institutionalised at 70 are much greater than for the rest of the population (Lubitz 2003). Of those aged 65 or over, in the USA in 2004, 1.3 million (3.6%) were living in nursing homes (Jones 2009), while in England and Wales in 2001, 310,000 (3.7%) were living in care homes (ONS 2003). Projections of the use of long-term care are unreliable (US Department of Health and Human Services 2003) as they rely on a variety of factors other than population projections, including finances; changes in the prevalence of disability; and social, technical, and organisational changes to the provision of assistance with independent living, including informal care. However, even if usage rates reduced by a third, approximately 2 million people would require nursing-home care in the USA by 2030, a significant increase on current amounts (Sahyoun 2001).

An encouraging evidence base is being developed about rehabilitation programmes appropriate to the circumstances and needs of older people. In addition, governing bodies world wide are responding to the pressures exerted by current demographic patterns by placing increased emphasis on promoting health and independence in old age, which may result in greater investment in rehabilitation services. This review examines the evidence for the effectiveness of physical rehabilitation for older people in long-term care. This is an update of a Cochrane review first published in 2009; it includes an additional 18 studies and now formally quantifies some of the pooled results using meta-analytical methods.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

To evaluate the benefits and harms of rehabilitation interventions directed at maintaining, or improving, physical function for older people in long-term care through review of randomised and cluster randomised controlled trials.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We included all studies that were randomised controlled trials (RCTs) or cluster RCTs that evaluated physical rehabilitation programmes for older people in long-term care.

 

Types of participants

Older people who reside in a care home or hospital as their place of permanent abode. We defined older people as those aged 60 years or over, and we included all participants in studies where the mean age is 60 or over. The term 'care home' was as defined in a previous review (Ward 2003):

  • provides communal living facilities for long-term care;
  • provides overnight accommodation;
  • provides nursing or personal care; and
  • provides for people with illness, disability, or dependence.

We included studies that addressed a defined subgroup of care-home residents, such as stroke survivors or residents with dementia. We excluded trials in which only a proportion of participants met the inclusion criteria, unless outcome data pertaining to these participants were reported separately.

 

Types of interventions

Physical rehabilitation was defined as those interventions that aim to maintain or improve physical function. We included studies that compared a rehabilitation intervention designed to maintain or improve physical function with either no intervention or an alternative intervention. We excluded interventions that primarily addressed cognitive deficits, mood disorders, or both, unless they also aimed to improve the physical state. We evaluated interventions by content, not by the personnel implementing them (e.g. physiotherapist, occupational therapist). We excluded studies where the intervention and control groups received the same physical rehabilitation intervention with the only differential being a non-rehabilitative component. We reported comparisons of physical rehabilitation versus control (no physical rehabilitation, but including other interventions such as social visits) and comparisons of physical rehabilitation (experimental) versus physical rehabilitation (control), where the experimental intervention is hypothesised by the study authors to be more rehabilitative than the control. During the review process, the review team reached consensus to exclude those trials in which physical exercise was a component of a multifaceted intervention primarily aimed at falls prevention as this topic is addressed in other Cochrane reviews (Cameron 2005; Gillespie 2003).

 

Types of outcome measures

Outcome measures did not form part of the eligibility criteria for studies in this review. Outcomes of interest are listed below.

 

Primary outcomes

  • Function in activities of daily living (ADL) measured either with an independence scale (e.g. the Barthel Index (BI), the Functional Independence Measure (FIM)) or tests of ability in ADL, such as mobility or transfers (e.g. Timed Up and Go (TUG) test, 6-metre walk test). Activities of daily living typically include eating, bathing, dressing, continence, personal care, mobility, and transfers.

 

Secondary outcomes

  • Exercise tolerance (e.g. number of repetitions)
  • Muscle power (e.g. isokinetic and isometric dynamometry)
  • Flexibility (e.g. joint range of movement)
  • Balance (e.g. Berg Balance Scale, Functional Reach test)
  • Perceived health status (e.g. Sickness Impact Profile, Nottingham Health Profile)
  • Mood (e.g. Geriatric Depression Scale)
  • Cognitive status (e.g. Mini-Mental State Examination (MMSE))
  • Fear of falling (e.g. Falls Efficacy Scale)
  • Economic analyses

 

Adverse outcomes

  • Deaths from all causes
  • Morbidity
  • Falls and other serious adverse events

 
Timing of outcome assessment

Our original intention was to focus on those studies that comprised a minimum of one month of follow up. However, only a minority of studies reported any follow up. Therefore, for consistency, the outcomes were assessed at the end of the intervention. We also reported follow up in the narrative synthesis. We anticipated disparity between studies, and this was given due consideration in the review.

 

Search methods for identification of studies

See the 'Specialized register' section in the Cochrane Stroke Group module.

The extensive nature of this topic was reflected in the search of a wide range of resources, both electronic and non-electronic. We searched for trials in all languages and arranged translation of papers published in languages other than English. The search dates given below are those up to which the trials found have been fully incorporated into the review.

 

Electronic searches

We searched the trials registers of the following Cochrane Groups: the Stroke Group (last searched 17 May 2012), the Effective Practice and Organisation of Care Group (last searched 2 April 2012), and the Rehabilitation and Related Therapies Field (last searched 4 April 2012). In addition, we searched the following databases:

  • the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2009, Issue 4) (Appendix 1);
  • the Cochrane Database of Systematic Reviews (searched 21 December 2009);
  • Cochrane Other Reviews (DARE) and Methods Studies resources (The Cochrane Library, 2009, Issue 4);
  • MEDLINE (1966 to 18 December 2009) (Appendix 2);
  • EMBASE (1980 to 18 December 2009) (Appendix 3);
  • Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 21 December 2009) (Appendix 4);
  • Allied and Complementary Medicine Database (AMED) (1985 to 21 December 2009) (Appendix 5);
  • PsycINFO (1967 to 21 December 2009) (Appendix 6);
  • Physiotherapy Evidence Database (PEDro) (searched 4 April 2012);
  • British Nursing Index (1994 to 1 October 2007);
  • Applied Social Sciences Index and Abstracts (ASSIA) (1987 to 21 December 2009);
  • International Bibliography of the Social Sciences (IBSS) (1951 to 21 December 2009);
  • Database of Abstracts of Reviews of Effects (DARE) (searched 21 December 2009);
  • Health Management Information Consortium (HMIC) database (searched 21 December 2009);
  • NHS Economic Evaluation Database (NHS EED) (searched 21 December 2009);
  • Health Technology Assessment (HTA) database (searched 21 December 2009);
  • ISI Web of Knowledge (searched 21 December 2009);
  • Google Scholar (searched 2006 to 14 January 2010);
  • Index to Theses (http://www.theses.com/) (searched 7 January 2010); and
  • ProQuest Dissertations & Theses (PQDT) database (searched 22 December 2009).

For this update, we stopped searching the British Nursing Index, because its collection is similar to CINAHL, and our institution no longer subscribes to it.

We developed the MEDLINE search strategy with the help of the Cochrane Stroke Group Trials Search Co-ordinator and adapted it for the other databases.

On 19 August 2011, we again searched the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, Cochrane Other Reviews and Methods Database, MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED), Applied Social Science Index and Abstracts (ASSIA), International Bibliography of Social Sciences (IBSS), PsycINFO, Database of Abstracts of Reviews of Effects (DARE), Health Management Information Consortium Database (HMIC), NHS Economic Evaluation Database (NHS EED), Health Technology Assessment (HTA) Database, ISI Web of Knowledge, Google Scholar, Index to Theses, and Proquest Dissertations and Theses. We did not fully assess the records retrieved from these searches, but we screened the titles, sought the full text of potentially eligible studies, and assessed them further for eligibility. We added potentially relevant trials to the 'Characteristics of studies awaiting classification' tables.

In addition, we searched the National Research Register (www.nrr.nhs.uk/) in December 2007 (now defunct), and in January 2010 we searched Current Controlled Trials (www.controlled-trials.com) and HSRProj (Health Services Research Projects in Progress, www.nlm.nih.gov/hsrproj/);

 

Searching other resources

In an effort to identify further published, unpublished, and ongoing trials, we:

  1. scanned reference lists of relevant studies;
  2. contacted investigators and subject area experts and requested additional information from authors of relevant trials;
  3. searched the following available proceedings of the Chartered Society of Physiotherapy Annual Congress (1990, 1995, 1997, 2000, 2003, and 2005); and
  4. searched the following available proceedings of the World Congress of Physical Therapy (1953, 1963, 1967, and 1982).

In view of the comprehensive nature of the electronic search we did not handsearch journals. We also contacted the Cochrane Dementia and Cognitive Improvement Group (August 2006) and the Cochrane Health Promotion and Public Health Field, now the Cochrane Public Health Group, (August 2006) who indicated that their own field registers would not contain studies of relevance to this topic.

 

Data collection and analysis

 

Selection of studies

Two review authors independently assessed titles and abstracts (where necessary) of the records identified from the electronic searches and excluded obviously irrelevant studies. We obtained the full texts of all remaining studies, and at least two members of the review team assessed these for eligibility based on the predetermined inclusion criteria. We resolved disagreements at a consensus meeting.

 

Data extraction and management

Two review authors independently extracted and recorded data using a standardised electronic data collection form. A third author combined these data sets; we combined numerical data automatically where there was consensus. We resolved discrepancies by discussion and, where possible, we contacted study authors to provide clarification or additional data if necessary.

For continuous outcome data and ordinal outcome data, we converted the results from all studies into estimated difference in means, and the standard error for this difference.

 

Assessment of risk of bias in included studies

Two review authors independently assessed risk of bias in included studies using The Cochrane Collaboration's tool for assessing risk of bias (Higgins 2011). We assessed risk in the categories of sequence generation (was assignment truly random?), allocation concealment (could group assignment be foreseen and therefore subverted?), blinding of participants and personnel (could participants and care staff identify treatment allocation?), blinding of outcome assessment (could outcome assessors identify treatment allocation?), incomplete outcome data (could attrition or exclusions have resulted in bias?), selective reporting (did authors report all prespecified outcomes) and any other risks of bias, using the criteria provided (Higgins 2011). We assessed the blinding of outcome assessment separately for observed measures of function in ADL (such as the TUG test) and reported measures of function in ADL (such as the BI) as these were entered into meta-analyses and were likely to have involved different assessors and involved different difficulties with blinding. We assessed each category as having low, high, or unclear risk of bias. We resolved any disagreements by discussion and contacted study authors for clarification if appropriate. We did not actively seek pre-study protocols unless they were referenced within a report or had been identified through our literature searches.

 

Measures of treatment effect

We treated ordinal data as if they were continuous. For continuous data, we combined the estimates for each study using the mean difference (MD). For dichotomous data, we combined the estimates for each study using the risk ratio (RR).

 

Unit of analysis issues

In cross-over trials, we only included data from the first period of the trial in meta-analyses to guard against carry-over effects. Where a trial comprised of more than one exercise group (e.g. Christofoletti 2008; MacRitchie 2001), we used the group with the greatest rehabilitative component to compare with the group with the least intervention.

Where cluster randomised studies presented an estimate of effect that properly accounted for the cluster design, this was used. Where this was not the case, we assumed that the intra-cluster correlation coefficient (ICC) was the same as for other studies included in the review for that outcome. We calculated an average ICC for the outcome and corrected the values for each unadjusted study by the design effect (see Higgins 2011). Where the ICC for an outcome was not available from the other included studies we attempted to find an appropriate estimate from external databases (e.g. Elley 2005; Health Services Research Unit 2004; Ukoumunne 1999). Where no appropriate estimate was available, we presented unadjusted estimates. In all cases, we presented sensitivity analyses excluding cluster studies.

 

Dealing with missing data

Because of the long-term nature of the interventions and the frailty of the population, we anticipated a high rate of loss to follow up because of death, deviating from the intention-to-treat (ITT) principle. Where multiple analyses were reported, we used the data that most closely resembled an available case analysis (i.e. all available data are analysed in the intervention groups to which participants were assigned, without imputation of missing data), but we did not exclude studies that had only performed other analyses. However, as described above, we assessed incomplete outcome data as a risk of bias and, as described below, we stratified studies by risk of bias; therefore, we accounted for large deviations from the ITT principle in the analysis. We used the generic inverse-variance approach to facilitate inclusion of studies presenting results in different ways, so we converted standard deviations, confidence intervals, or both, for each group separately to standard errors for the difference in means. Where data were missing, we made every effort to derive the appropriate measure from the available data. For example, we derived data from graphs and converted a variety of measures of time taken to cover set distances and walking speeds to metres per second.

 

Assessment of heterogeneity

We explored heterogeneity through stratified forest plots, quantified in terms of the proportion of the total variation in study estimates that is due to heterogeneity (I² statistic) (Higgins 2002) and tested using the Q statistic, with I² > 50% or P < 0.2 used to identify significant heterogeneity.

 

Assessment of reporting biases

We assessed small study effects, e.g. publication bias, using contour-enhanced funnel plots centred around the null hypothesis and informed by the test of the intercept from a regression of estimates on their standard errors (Egger’s test), with P < 0.1 being used to indicate significant asymmetry.

 

Data synthesis

The included studies were heterogeneous. They examined different types of intervention and evaluated them with a wide battery of outcome measures. Such variety limited the feasibility of conducting meta-analyses. We chose to perform meta-analyses of measures of ADL, our primary outcome, and mortality.

Where we performed meta-analyses, for all outcomes, we presented random-effects meta-analyses because of the anticipated large heterogeneity caused by different populations and interventions involved in the trials. When results were presented at several time points, we used the time closest to the end of intervention unless a better analysis was available at another time point. For continuous or ordinal data, where results were presented in terms of change from baseline or adjusted for baseline, this was used in preference. We used a generic inverse-variance approach for continuous and ordinal data. We used the Mantel-Haenszel approach for dichotomous outcome data.

We originally intended to combine results in a fixed-effect meta-analysis where sufficient homogeneity existed. However, because of the extensive heterogeneity in the interventions, we used a random-effects meta-analysis as our primary approach, but still report the results of fixed-effect models as sensitivity analyses.

There were many different ways of measuring various ADL, so to reduce heterogeneity in the meta-analysis we focused on studies reporting the BI, FIM, Rivermead Mobility Index (RMI), TUG test, and certain measures of walking speed. For walking speeds and timed walks over a fixed distance, we converted the time to walk a fixed distance into speed (m/s) over that distance, to include as many similar studies as possible. However, we decided a priori to only include distances of less than 10 metres, to reduce heterogeneity introduced by very different designs. Of the remaining studies, there were an insufficient number assessing the same outcome to include in further meta-analyses. Those that appeared to assess similar outcomes were often measured in entirely different ways, assessing very different activities requiring varying functional ability. We therefore chose not to attempt to combine these quantitatively, even using standardised mean difference, because they were not actually assessing the same outcome.

For outcomes where a narrative synthesis is provided, we summarised those studies that reported a statistically significant difference in a direction that favoured the intervention or the control (P < 0.05) and those that do not. We described limitations of such comparisons where statistical significance was reached (for example, a within-group comparison only). We provided a narrative exploration of the extent to which included studies demonstrated that their rehabilitative interventions were of benefit to the participants, and we discussed the nature and sustainability of any benefits. Some trials selected extremely frail individuals, and we considered this when assessing these interventions, as preventing or slowing decline may be the treatment goal in this situation.

 

Subgroup analysis and investigation of heterogeneity

For all outcome measures, potential sources of heterogeneity decided a priori were risk of bias (see Risk of bias in included studies); duration of intervention: for the BI, FIM, death and walking speed less than three months compared with three or more months, and for the TUG test and RMI less than six months compared with six or more months; mode of delivery (group, individual or group and individual); mean age of participants (less than 85 years compared with 85 years or more); and the percentage of participants in the study who are female (less than 80% compared with 80% or more). For ADL outcome measures, we also specified the level of function at baseline as measured by the relevant outcome measure (above or below the median function). For walking speed, we also included the fixed distance walked (less than six metres compared with six metres or more), in case this was a source of heterogeneity. We investigated these through subgroup analysis.

Our original intention, if sufficient data existed, was to conduct analyses on the basis of methodological quality and the effect of dropouts, but this was replaced by risk of bias. We also specified age, pathology-specific interventions, mode of delivery, and residential category. However, we neither conducted analyses based on pathology-specific interventions, because insufficient data exists, nor conducted analyses based on residential category, because we replaced this with measured function at baseline (see Differences between protocol and review).

We wanted to consider type of intervention as a potential source of heterogeneity, e.g. physiotherapy, strength training, mobility training, balance training, occupational therapy, but the interventions were often complex, containing many combinations of the above, and with great variation within each broad type. Given the small number of studies available for each meta-analysis, there were insufficient studies of each type to explore this interesting aspect further.

 

Sensitivity analysis

For all outcomes included in a meta-analysis, we presented a fixed-effect sensitivity analysis. For dichotomous outcomes, we also calculated odds ratios and risk differences. Where a meta-analysis included studies that were cluster-randomised, we presented a sensitivity analysis excluding such studies.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of studies awaiting classification; Characteristics of ongoing studies.

 

Results of the search

Several searches contributed to this review. The results of the searches are outlined in a PRISMA diagram in Figure 1. Searches from the original review in 2007 and searches from December 2009 produced approximately 30,000 references, from which 67 studies fulfilled the eligibility criteria and were included in this review. An additional search (August 2011) produced 7969 references, from which there are 27 potentially eligible studies awaiting classification.

 FigureFigure 1. Review update flow diagram

The original review included 49 studies from a search that produced over 20,000 references. The search from December 2009 produced 10,621 references, from which 26 new articles fulfilled the eligibility criteria and were included in this update. This represented 18 new studies (22 articles) and an additional four articles that report on two existing studies. Four studies remain awaiting classification from this search because the articles were unavailable. The characteristics of Included studies and Excluded studies are discussed below. We conducted an additional search in August 2011. Because of the scale of this review and updates to the methods (introduction of an electronic database and meta-analyses), we did not fully assess the results of these searches (i.e. we did not include any new studies). Of the 7969 references, an additional 25 new studies (28 references) and five new references across two existing studies (Resnick 2009; Rosendahl 2006) are awaiting classification (see the 'Characteristics of studies awaiting classification' tables). These studies awaiting classification are likely to be classified as included or ongoing in future updates of the review.

 

Included studies

Across 67 studies, the included studies randomised a total of 6300 participants, prior to any attrition. We give a general overview below; further details can be found in the 'Characteristics of included studies' tables.

 

Design

Forty-eight studies randomised individuals into experimental groups; the remaining 19 used cluster designs, when they randomised facilities, not individuals (Brittle 2009; Brown 2004; Choi 2005; Faber 2006; Gillies 1999; Kerse 2008; Lee 2009; McMurdo 1993; McMurdo 1994; Mihalko 1996; Morris 1999; Peri 2008; Resnick 2009; Rosendahl 2006; Sackley 2006; Sackley 2008; Sackley 2009; Sung 2009; Taboonpong 2008). One study followed cluster randomisation of exercise type with randomisation of individual participants to exercise or control conditions (Faber 2006). Nine studies stratified participants before randomisation to ensure even distribution of certain participant characteristics between groups, for example, older, more sick, or less mobile individuals (Baum 2003; Bautmans 2005; Lazowski 1999; MacRitchie 2001; Makita 2006; Mulrow 1994; Przybylski 1996; Santana-Sosa 2008; Sihvonen 2004). Five studies used a 'matched pairs' design, where participants were systematically matched on characteristics of interest and then randomly allocated into intervention groups (Au-Yeung 2002; de Bruin 2007; Dorner 2007; Schoenfelder 2000; Schoenfelder 2004). Of the cluster randomised trials, two studies stratified facilities (Rosendahl 2006; Sackley 2006), and two matched facilities (Morris 1999; Peri 2008) prior to randomisation.

Five trials used a counterbalanced cross-over design, where all participants received all conditions, but the order in which they were received was randomised. In three of these, the outcome measures were measures of performance during single-session interventions, such as number of repetitions (DeKuiper 1993; Lang 1992; Riccio 1990), while in two they followed long-term interventions that risked carry-over of treatment effects between periods (Ouslander 2005; Pomeroy 1993). Four trials also used a semi-cross-over design (Baum 2003; Brown 2004; Kinion 1993; Sauvage 1992) where participants allocated to the control group also received the intervention. However, in Sauvage 1992 this was a post-hoc design following attrition from the intervention group.

Of the cluster trials, six (Brittle 2009; Kerse 2008; Peri 2008; Resnick 2009; Sackley 2006; Sackley 2009) explicitly reported statistical analyses that were adjusted for the effect of clustering.

 

Eligibility criteria

All of the studies except Przybylski 1996 stated some eligibility criteria, which on average limited eligibility to half of all residents. This often related to the safety and feasibility of including such participants in the planned intervention or the likelihood of it showing an effect, and in 27 studies, it limited the focus to populations with specific functional limitations.

 
General eligibility criteria

Thirty studies had a minimum age limit (typically 65 years). Thirteen studies excluded participants that were engaged in physical therapy or activity. Six studies required participants to have been a resident for a minimum time that varied between one and four months; seven studies specified an expected duration of stay for at least as long as the intervention. Six studies excluded those with challenging behaviours, including abusive and aggressive behaviour.

 
Physical functioning or disorders

Overall, 45 studies excluded residents with insufficient physical function or physical disorders. The ability to walk or be mobile was a requirement of 22 studies, of which two disallowed the use of walking aids; one allowed one carer to assist; five specified at least six metres and two at least five metres; one, 250 feet; and one, five minutes. Alternative requirements included the ability to independently stand (three studies), stand or transfer with assistance (five studies), or to be independent in all but one basic activity of daily living (ADL) (one study). Thirteen studies excluded participants on the basis of musculoskeletal disorders or other physical impairments, including paralysis and amputation.

 
Cognitive functioning and communication

In total, 39 studies only included participants with a minimum level of cognitive function, often citing the ability to follow simple instructions; an additional four studies excluded participants because of communication-specific difficulties. Exclusion criteria were often stated as severe dementia or severe cognitive impairment, but where specific measures were given, these varied widely. Nine studies excluded participants on the basis of their Mini-Mental State Examination (MMSE) score: Five required a minimum score between 20 and 23, indicating participants were cognitively intact or had mild dementia; one excluded those scoring less than 50% (typically 15); and three excluded those scoring less than 10 or 11, indicating severe dementia. Four studies excluded those with very low communication and physical skills using the Parachek Geriatric Rating Scale.

 
Other health conditions

A variety of other health-related criteria were reasons for exclusion. Sixteen studies ruled out participants on the broad grounds of medical contraindications or at the discretion of a physician. Twenty-two studies excluded individuals with acute or unstable conditions, while 19 studies excluded those with a terminal condition or short life expectancy. Eight studies excluded individuals on the basis of recent medical events, for example, a fracture within the past six months. Twenty-seven studies identified a variety of specific diseases as reasons for exclusion, often including cardiac disorders (14 studies). Medical implants, including pacemakers and hip replacements, or specific medications were exclusion criteria in six studies. Seven studies excluded those with significant visual impairments. Four studies excluded individuals with psychological or psychiatric disorders.

 
Focus on specific conditions

While most studies required participants to have some minimum level of physical or mental functioning, 27 studies only examined participants with some form of impairment or limitation. These included a degree of dependence in ADL (Brittle 2009; Karl 1982; Meuleman 2000; Mulrow 1994; Rosendahl 2006; Sackley 2009), stroke-related dependence in ADL (Sackley 2006), dementia and dependence in ADL (Christofoletti 2008; Pomeroy 1993), dementia (Buettner 1997; Stevens 2006; Tappen 1994), Alzheimer’s disease (Cott 2002; Rolland 2007; Santana-Sosa 2008; Tappen 2000), mental illness (Stamford 1972), those who were physically restrained (Schnelle 1996), incontinence (Alessi 1999; Ouslander 2005; Schnelle 1995; Schnelle 2002), visual impairment (Cheung 2008), those at a risk of falling (Choi 2005; Donat 2007), and those with poor balance and weak muscles (Sauvage 1992). Finally, in the feasibility study of Sackley 2008, staff purposively selected residents with a range of functional, cognitive, and continence impairments prior to randomisation.

 
Representativeness of participants

Approximately half of the population of participating facilities were eligible for entry into the trials, but only one quarter participated. Twenty-two studies reported the total population of the participating facilities, and the number of those who were eligible for participation. Across these, the total population included 14,384 (median = 423) individuals, 6853 (47.6%, median = 204) were eligible, but only 3426 (23.8%, median = 104) of whom were allocated to groups in the trials; 1618 (11.2%, median = 63) did not consent to participate, and in 14 trials, residents were excluded for other reasons, including insufficient capacity within the trial or individuals becoming unavailable (e.g. illness) before the trial began (total = 1849 (12.9%), median = 7).

 

Sample size

Included studies randomised a median of 56 participants into their trial prior to any attrition. This ranged from just 12 participants (Sauvage 1992 ) to 682 (Kerse 2008) (lower quartile = 28, upper quartile = 107). Only 18 studies included 100 or more participants (Chin A Paw 2004; Faber 2006; Fiatarone 1994; Kerse 2008; Lee 2009; Makita 2006; Morris 1999; Mulrow 1994; Ouslander 2005; Peri 2008; Przybylski 1996; Resnick 2009; Rolland 2007; Rosendahl 2006; Sackley 2006; Sackley 2009; Schnelle 2002; Stevens 2006). Twenty-four studies randomised fewer than 35 participants; of these, eleven studies were particularly small with 20 or fewer participants (Baum 2003; Brill 1998; Gillies 1999; Karl 1982; Lang 1992; Naso 1990; Santana-Sosa 2008; Sauvage 1992; Schoenfelder 2000; Stamford 1972; Urbscheit 2001). One study (Sauvage 1992) was especially problematic, reporting data from just 10 individuals. Starting with 12 participants, they allocated 6 each to the intervention and control groups. On losing two intervention participants, they allowed four control participants to complete the intervention. Therefore, they reported data for eight intervention participants and six control participants. Sample size calculations were performed for 17 studies (25%), although recruitment did not always achieve the target.

 

Setting

Studies were undertaken in various countries and long-term care settings.

 
Location

Most studies were conducted in North America: 31 took place in the USA and five in Canada. Within Europe, eight were conducted in the UK, two each in Belgium and The Netherlands, and one each in Austria, Denmark, Finland, France, Spain, Sweden, Switzerland, and Turkey. Throughout the rest of the world, there were three studies from Hong Kong, and two studies each from New Zealand and South Korea, with single studies from Australia, Brazil, Japan, and Thailand.

 
Care setting

Most often, studies were undertaken in nursing and residential care homes, with 45 studies and 25 studies including facilities from these categories, respectively. In addition, four studies were undertaken exclusively in hospitals where participants were long-term residents (Clark 1975; Dorner 2007; Pomeroy 1993; Stamford 1972).

 

Participants

We present a brief synopsis of the characteristics of participants here. We give further in the 'Characteristics of included studies' tables. See also Eligibility criteria.

 
Sex

Overall, 76% of participants were women. Seven studies only had female participants (Cheung 2008; Crilly 1989; Makita 2006; Riccio 1990; Sihvonen 2004; Sung 2009; Yoder 1989), while two studies had exclusively male participants (Sauvage 1992; Stamford 1972).

 
Age

Data indicated that in each study the mean age was greater than 65 years. The grand mean (composite standard deviation (SD)) participant age was 83 (8) years across studies reporting such data. Reported means ranged from 69 years (Clark 1975; Stamford 1972) to 90 years (Bruunsgaard 2004). Only six studies reported a mean age of under 75 years, five of which were small (less than 25 participants) (Clark 1975; Karl 1982; Santana-Sosa 2008; Sauvage 1992; Stamford 1972), and one was of average size (54 participants) (Christofoletti 2008). Three studies did not report mean age, two of which reported age range (Naso 1990; Pomeroy 1993). In total, 36 studies reported age range, and among these, the total range was from one participant aged 44 (Sackley 2006) to a participant aged 105 (Tappen 2000). Only five of these studies included any participants aged less than 60, and all but one included participants aged over 90 (Clark 1975), with 13 of the 36 studies including centenarians.

 
Physical status

The physical status of participants varied widely within and between studies that reported this. Eight studies reported the Barthel Index (BI) mean (SD) at baseline as 49.1 (27.5) (Sackley 2006), 51.5 (24) (Sackley 2008), 55.5 (21) (Brittle 2009), 58.8 (13) (Dorner 2007), 58.8 (21.1) (Sackley 2009), 58.9 (29.5) (Resnick 2009), 65.6 (21) (Rosendahl 2006), 71 (10) (Santana-Sosa 2008), and 88 (12.5) (Peri 2008) out of 100, where 100 indicates independence in 10 basic ADLs. Four studies reported the Katz ADL index, with mean (SD) values of 1.9 (1.3) (Fiatarone 1994), 3.1 (1.3) (Rolland 2007), 4.7 (0.5) (Christofoletti 2008), and 5.8 (0.4) (Bautmans 2005) out of 6, where 6 indicates independence in six basic ADLs. Five studies reported the proportion of participants who used mobility assistance devices (e.g. cane, wheelchair) as 10% (Chin A Paw 2004), 19% (Donat 2007), 45% (Mihalko 1996), 60% (Sihvonen 2004), and 83% (Fiatarone 1994); as reported above, three studies had excluded such participants, and one study only included participants requiring assistance to stand.

 
Cognitive status

The cognitive status of participants varied widely within and between studies that reported this. Twenty-one studies provided mean MMSE scores at baseline, four of which had a mean score less than 10, indicative of severe dementia (Buettner 1997; Cott 2002; Schoenfelder 2000; Tappen 1994); nine studies' participants had a mean score between 10 and 20, indicative of moderate dementia (Alessi 1999; Christofoletti 2008; Ouslander 2005; Rosendahl 2006; Santana-Sosa 2008; Schnelle 1995; Schnelle 1996; Schnelle 2002; Tappen 2000); five studies' participants had a mean score between 20 and 25, indicative of mild dementia (Baum 2003; Dorner 2007; Fiatarone 1994; Mulrow 1994; Resnick 2009); while three studies' participants' mean score was in the cognitively intact range (25 to 30) (de Bruin 2007; Faber 2006; Schoenfelder 2000). Overall, mean MMSE scores ranged from 6 (Cott 2002) to 26.9 (de Bruin 2007), while for individual participants they ranged from 0 to 30.

 
Chronic comorbidities

The majority of participants had at least one significant comorbidity, with many having multiple comorbidities based on the 29 studies that reported on this. Commonly reported comorbidities included arthritis, osteoporosis, Alzheimer's disease, stroke, cardiovascular disease, respiratory disease, incontinence, and depression. Three studies reported the mean (SD) number of comorbidities that participants had as 2.9 (3.1) (Lee 2009), 4.9 (2.2) (Kerse 2008), and 5.6 (3.6) (Tappen 2000), while the similar Charlson Comorbidity Index was reported to average 3.8 (2.2) in Ouslander 2005.

 

Interventions

To provide a convenient overview, we categorised interventions according to key components. We describe individual programmes in the 'Characteristics of included studies' tables. Details of the groups that experimental interventions were compared with in all studies are provided in the below 'Comparison conditions' section.

While most studies featured only one experimental intervention, two studies featured two different experimental physical interventions. Faber 2006 compared 'functional walking' and 'in-balance' exercise interventions, while Morris 1999 compared the 'fit for your life' exercise regime and the 'self-care for seniors' nursing rehabilitation programme. Therefore, 69 interventions are described across the 67 studies.

 
Physical components

The most common physical components were strength training and walking. Forty-nine interventions included exercises targeted at basic components of physical fitness, such as strength or flexibility (rote exercise), while 40 interventions included practice of basic ADLs, such as walking or transfers, and 21 interventions featured other recreation or leisure activities, such as ball games or dancing.

 
Rote exercise

Strength training, for example, using elastic resistance bands or weights, featured in 42 interventions. Balance (motor skill) exercises, such as tandem stands, were features of 21 interventions; flexibility (range of motion) exercises featured in 17 interventions; and endurance training featured in seven. Other less common features include relaxation and breathing exercises (three interventions) and posture training (two interventions).

 
Basic ADL practice

Mobility training (walking or wheeling) featured in 37 interventions; transfer practice featured in 21 interventions; and 10 interventions included practice of other basic ADLs, such as washing, dressing, eating, or grooming.

 
Recreation and leisure-like activities

Other recreation or leisure-like physical activities included kicking or throwing and catching balls, balloons or bean bags (10 interventions), rhythmic movement to music or dancing (5 interventions), Tai Chi (4 interventions), arts and crafts activities (1 intervention), meal preparation activities (2 interventions), and indoor gardening (1 intervention).

 
Combinations of physical components

Seventeen interventions only featured rote exercises; thirteen, basic ADL practice; and five, recreational activities. Eighteen combined basic ADL practice with rote exercises, seven combined recreational activities with rote exercises; and two combined basic ADL practice with recreational activities. In total, seven interventions included examples of all three of these types of component.

 
Components supplementary to physical activity

In addition to physical activity, 23 interventions contained other components. Among these were a social or communication element, for example, ‘walking and talking’ (Brittle 2009; Buettner 1997; Cott 2002; MacRitchie 2001; Tappen 2000). Twelve studies included music alongside the exercise (Chin A Paw 2004; Choi 2005; MacRitchie 2001; McMurdo 1993; McMurdo 1994; Pomeroy 1993; Rolland 2007; Sackley 2008; Santana-Sosa 2008; Stevens 2006; Sung 2009; Taboonpong 2008). Interventions to improve continence, for example, prompted voiding (Alessi 1999; Ouslander 2005; Sackley 2008; Schnelle 1995; Schnelle 2002), nutritional supplementation (Fiatarone 1994; Rosendahl 2006), and environmental adaptations designed to improve sleep (Alessi 1999). Sung 2009 included a health education programme, while Brown 2004 included a video on gardening.

 
Distinctive interventions

Four trials explored the potential of imagery or purposefulness for enhancing exercise participation (DeKuiper 1993; Lang 1992; Riccio 1990; Yoder 1989). Imagery (e.g. pretending to pick apples) or 'added purpose' exercise (e.g. rotary arm exercise in the form of making biscuits) were compared with rote exercise. Two studies explored 'Whole body vibration', where exercises are performed on an oscillating platform (Bautmans 2005; Bruyere 2005). One study (Sihvonen 2004) compared dynamic balance exercise visual feedback sessions on a 'Good Balance' force platform with an unspecified control activity. Przybylski 1996 did not specify particular physical components, but examined the effect of a four-fold increase in occupational therapy and physiotherapy staffing, comparing a 1:200 (standard) and 1:50 (enhanced) staff to participant ratio.

 
Format of intervention

Interventions were most often delivered as supervised 45-minute group sessions three times weekly. Forty-one interventions included a group component, two of which were provided in pairs and three of which also had an individually delivered component. Another 18 individual interventions were described, with 10 not specifying whether they were provided on a group or individual basis. Despite the predominance of group-based interventions, some degree of tailoring to the ability or needs of the participant was a feature of 43 interventions. In 11 trials, participants carried out the intervention seated (e.g. McMurdo 1993), and in five further studies, this was optional (e.g. Karl 1982). Sessions were time-limited in 47 interventions, ranging from nine minutes to two and a half hours, with a median and mode of 45 minutes (10 studies). In most cases, sessions occurred on a routine basis, varying from weekly to four times daily, but most often three times weekly (median and mode, N = 30). In other cases, the intervention was continuous in nature or only administered once where the exercise rate or duration, rather than the effect of exercise on health were being evaluated. In the 32 interventions for which a total time per week could be calculated, this varied widely from 20 to 750 minutes per week, with a median of 120 minutes per week.

Fifty-six interventions involved specific sessions primarily designed to deliver physical rehabilitation (Au-Yeung 2002; Baum 2003; Bautmans 2005; Brill 1998; Brittle 2009; Brown 2004; Bruunsgaard 2004; Bruyere 2005; Cheung 2008; Chin A Paw 2004; Choi 2005; Christofoletti 2008; Clark 1975; Cott 2002; Crilly 1989; de Bruin 2007; DeKuiper 1993; Donat 2007; Dorner 2007; Faber 2006 (both interventions); Fiatarone 1994; Gillies 1999; Hruda 2003; Karl 1982; Kinion 1993; Lang 1992; Lazowski 1999; Lee 2009; MacRitchie 2001; Makita 2006; McMurdo 1993; McMurdo 1994; Meuleman 2000; Mihalko 1996; Morris 1999 (fit for your life); Mulrow 1994; Naso 1990; Pomeroy 1993; Przybylski 1996; Riccio 1990; Rolland 2007; Sackley 2006; Sackley 2008; Santana-Sosa 2008; Sauvage 1992; Schnelle 1996; Schoenfelder 2000; Schoenfelder 2004; Sihvonen 2004; Stamford 1972; Stevens 2006; Sung 2009; Taboonpong 2008; Urbscheit 2001; Yoder 1989). Ten interventions involved rehabilitation that was embedded within, or incidental to, resident care (Alessi 1999; Buettner 1997; Kerse 2008; Morris 1999 (self care for seniors); Ouslander 2005; Peri 2008; Resnick 2009; Schnelle 1995; Schnelle 2002; Tappen 2000). Three interventions combined specific sessions and incidental rehabilitation (Rosendahl 2006; Sackley 2009; Tappen 1994). Examples of specific sessions include an interactive group exercise class with warm-up and cool-down periods, flexibility, balance, strengthening and endurance exercises (Brittle 2009) or client-centred occupational therapy (Sackley 2006). Examples of incidental rehabilitation include the Functional Incidental Training (FIT) and 'Promoting Independence' interventions described below.

Three studies evaluated FIT (Alessi 1999; Ouslander 2005; Schnelle 1995). Here, exercises targeting specific individual needs, such as standing up, were provided throughout the day, incidental to daily nursing care routines, such as toileting. The therapeutic recreation nursing team intervention (Buettner 1997) is comparable to these. Here, the nursing-home environment was enhanced, with every aspect of daily life regarded as part of the intervention. A range of activities were provided, including cardiovascular exercise, cooking, gardening, cognitive therapy, and sensory stimulation activities. Nursing staff were involved in provision, and ADLs such as dressing were targeted. Kerse 2008 and Peri 2008 evaluated variations of a 'Promoting Independence' plan, where a functional physical goal was set with the resident, an activity plan based on ADLs was devised, and a healthcare assistant encouraged the resident to perform these.

 
Delivery of intervention

It appeared that all interventions involved supervised delivery, as opposed to wholly self-directed interventions with a worksheet or video, for example. The majority were delivered by staff external to the home (54 interventions), using rehabilitation professionals (e.g. physiotherapists, occupational therapists, sports scientists, activities staff; 30 interventions), researchers (22 interventions), or a combination of these (2 interventions). Care facility staff delivered five interventions (Kinion 1993; Lazowski 1999; MacRitchie 2001; Morris 1999 (both interventions)). All of these included the healthcare staff, while two included activities staff, and two included other staff (e.g. domestic staff). In two of these studies, volunteers (e.g. family members) participated in the delivery. Ten interventions involved both internal and external staff (Baum 2003; Buettner 1997; Kerse 2008; Lee 2009; Makita 2006; Peri 2008; Przybylski 1996; Resnick 2009; Rosendahl 2006; Sackley 2009): In six, staff were external rehabilitation professionals and internal healthcare staff; in three, internal and external healthcare staff; and in one, internal and external rehabilitation professionals.

Among the 10 interventions that were incidental to the resident's care (see the above 'Format of intervention' section), research staff provided the care and rehabilitation in five interventions (Alessi 1999; Ouslander 2005; Schnelle 1995; Schnelle 2002; Tappen 2000); in four delivery was provided by a combination of internal and external staff (Buettner 1997; Kerse 2008; Peri 2008; Resnick 2009), and in one delivery was provided wholly by internal staff (Morris 1999 (self care for seniors)).

 
Duration of intervention

The interventions lasted between four weeks (Karl 1982; Sackley 2008; Sihvonen 2004) and a year (Naso 1990; Resnick 2009; Rolland 2007), with the exception of the four interventions that examined imagery or purposefulness and were only administered once (DeKuiper 1993; Lang 1992; Riccio 1990; Yoder 1989). Most typically, interventions were twelve weeks in duration (median and mode, N = 12), with 10 interventions lasting eight to nine weeks and 7 lasting six months. Total exposure to the intervention (total time per week multiplied by the duration of the intervention) ranged very widely from 240 minutes (four hours) (Karl 1982) to 15,653 minutes (approximately one and a half weeks delivered in two-hour sessions, five times per week for six months) (Christofoletti 2008), with a median of 1440 minutes (24 hours) in the 32 interventions where this could be calculated.

 

Comparison conditions

Most studies compared two groups: the intervention of interest and some sort of control. However, 10 studies compared three groups (Christofoletti 2008; Clark 1975; Cott 2002; Faber 2006; Gillies 1999; Lang 1992; Morris 1999; Schnelle 1995; Stevens 2006; Tappen 1994), and 4 studies compared four groups (Chin A Paw 2004; Faber 2006; Fiatarone 1994; Rosendahl 2006).

Thirty-five studies compared their intervention(s) to a 'usual care' control group, allowing examination of whether an intervention was better or worse than their usual situation. The remaining studies supplemented 'usual care' in some way, for example, with a social meeting or different exercise. A social or recreational activity control session, for example, talking, playing cards, or reminiscing, featured in 18 studies (e.g. Baum 2003; Brown 2004). Nineteen studies compared different exercise programmes, usually a novel approach with a traditional type (Au-Yeung 2002; Bautmans 2005; Brill 1998; Bruyere 2005; Cheung 2008; de Bruin 2007; Donat 2007; Dorner 2007; Gillies 1999; Lazowski 1999; Mihalko 1996; Riccio 1990; Urbscheit 2001; Yoder 1989). Two studies compared three exercise types (DeKuiper 1993; Lang 1992). Four studies compared four groups. Two studies crossed an exercise and a social activity control with a nutritional supplement and a placebo control to examine whether exercise alone was better than the social activity control, and whether benefit from exercise was enhanced by nutritional supplementation (Fiatarone 1994; Rosendahl 2006). For the purposes of this review, we ignored the impact of supplementation, and where possible, we combined nutrition and placebo variants of exercise and control groups for meta-analyses. One study compared two different exercise programmes, each with their own control group (Faber 2006: controls were located in the same facilities as the relevant exercise programme). Finally, one study compared the effects of strength training and functional skills training, with the effect of both interventions combined and with an educational control group (Chin A Paw 2004).

 

Outcome measures

As a consequence of the considerable variation in the purpose and content of the interventions outlined above, the studies used many outcome measures (327 in total). Frequently, these were study-specific, with 59 studies including a unique measure and 258 of the 327 measures used being unique. The studies reported only 13 measures five or more times (Timed Up and Go (TUG) test, six-metre walk time, BI, Berg Balance Scale, Tinetti Mobility Scale, 'sit-and-reach' test, average number of sit-to-stands in 30 seconds, hand grip strength, Geriatric Depression Scale, MMSE, falls (number of falls and any per participant), and attendance). In total, 51 trials reported an outcome measure related to ADL, our primary outcome. Other common outcomes addressed by the studies included balance (29 studies), muscle power (25 studies), flexibility (16 studies), exercise tolerance (7 studies), physical activity (7 studies), mood (15 studies), cognitive performance (11 studies), quality of life (7 studies), fear of falling (6 studies), and perceived health status (6 studies). The studies also recorded morbidity, mortality, adverse events, and attendance. We report details of the methods used by individual studies to assess these outcomes in the 'Characteristics of included studies' tables.

 

Follow up

All studies except Brittle 2009 assessed participants immediately after intervention completion; follow up of participants after this was rare, undertaken by just 14 studies. In these, follow-up was most frequently at three months after the end of the intervention (Au-Yeung 2002; Rosendahl 2006; Sackley 2006; Sackley 2009; Schoenfelder 2000; Schoenfelder 2004). The other follow-up periods were two weeks (Sackley 2008), one month (Clark 1975; Sihvonen 2004), two and five months (Brittle 2009), six months (Kerse 2008), and one year (Faber 2006; Meuleman 2000; Urbscheit 2001).

 

Excluded studies

We excluded 52 studies that may, on the surface, appear to meet the inclusion criteria, but do not: individual reasons are provided in the 'Characteristics of excluded studies' tables. We excluded these studies because the purpose was not to improve residents' physical condition (N = 14); assignment to groups was not random (N = 12); participants included those who were not residents of long-term care, and they did not report the results separately (N = 10); they evaluated a multi-faceted falls prevention intervention (N = 7); the aspect of the intervention that varied between groups was not physical rehabilitation (N = 4); they targeted contractures (N = 3); or there was insufficient information to include them (N = 2).

 

New studies found at this update

We included an additional 18 studies in this update. Half of the new studies have used a cluster-randomised design, previously only used by 20% of the included studies. Similarly, eight new studies had over 100 participants compared to 10 of the 49 studies in the previous version of the review. In total, the number of participants has almost doubled from 3611 to 6300. It was notable that only one new study came from North America, which had previously supplied 35 studies (71%) and that nine additional countries are represented in this review, including the first South American country (Brazil).

 

Risk of bias in included studies

We present our 'Risk of bias' judgements, made according to The Cochrane Collaboration's tool, in the 'Characteristics of included studies' tables and summarise them here in the text, in Figure 2, and in Appendix 7. We did not judge any studies to have low risk of bias across all categories, with no studies judged to have a low risk of performance bias or reporting bias. To enable an analysis of the best available evidence, we selected the seven studies judged to have low risk of bias in all other categories (selection, detection, attrition, and other sources of bias) as a subgroup named 'lower risk of bias' for meta-analysis (Brittle 2009; Chin A Paw 2004; Kerse 2008; McMurdo 1994; Sackley 2006; Sackley 2008; Sackley 2009) to be contrasted with all other studies (higher risk of bias).

 FigureFigure 2. 'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies

Several studies caused particular concern. Karl 1982 did not report baseline or follow-up data or randomisation procedure. Brill 1998 had only one room and time slot to conduct their weight-training intervention, which meant both groups received their intervention at the same time. It is unclear how far this deviates from the intended design. In Sauvage 1992, the study began with 12 individuals, and following the loss of two of the six intervention participants, crossed over four participants from the control group, whose results were reported in each group. They did not account for this in their statistical analysis (samples were treated as independent), nor did they discuss temporal differences or report results separately. The design used in one study (Przybylski 1996) also raised potential problems. Their intervention was implemented over two years, with 29 new participants recruited throughout to replace those who died or were discharged. The researchers had no control over who entered and left the groups and made the assumption that this was a random process.

 

Allocation

We judged the risk of selection bias to be unclear in the majority of studies because they reported insufficient information. We judged the risk in both categories to be low for 13 studies and high for 2 studies, where after the initial randomisation, these studies allocated further participants without stating that this was performed randomly. We judged risk of bias due to random sequence generation to be low for 32 studies, unclear for 33 studies, and high for 2 studies. We judged concealment of the allocation sequence to pose low risk of bias for 16 studies and high risk of bias for 4 studies; it was unclear for 47 studies.

 

Blinding

We did not judge blinding to pose low risk of bias in any of the studies, because none of them were able to achieve low risk with respect to blinding of participants and personnel (performance bias). We judged 47 studies to be at high risk of performance bias, usually because the control would have been obvious, while for 20 studies the risk of performance bias was judged unclear, typically where such blinding was feasible, using strategies including cluster randomisation and alternative interventions for the control groups, but not specifically reported. By contrast, blinding of outcomes assessors was often sufficient to judge a low risk of detection bias for the outcome measures entered into meta-analyses (for observed outcomes, 20 studies were at low risk, 16 studies were at unclear risk, and four studies were at high risk; for reported outcomes, 16 studies were at low risk, 9 studies were at unclear risk, and 3 studies were at high risk). Thirty-five of the 67 studies attempted blinding of some of their outcome assessments.

 

Incomplete outcome data

We judged incomplete outcome data to pose low risk of bias in 26 studies, high risk of bias in 21 studies, and it was unclear in 20 studies. Typically, high risk of bias related to differential attrition rates between study groups, but also high overall attrition, inability to get measurements for a significant proportion of participants, or post-randomisation exclusions. Overall attrition rates were reported by 59 of the 67 studies, among which the grand mean rate was 21.4% (N = 1300 of 6083). Five studies had no attrition, three of which were studies of single-session interventions (DeKuiper 1993; Lang 1992; Yoder 1989), the other two (Cheung 2008; Kinion 1993) lasting for 12 and 8 weeks, respectively. Attrition in 29 other studies was less than 20%, between 20% and 30% in 18 studies (Buettner 1997 (21%); Chin A Paw 2004 (28%); Christofoletti 2008; de Bruin 2007 (22%); Donat 2007 (24%); Dorner 2007 (29%); Gillies 1999 (25%); Lazowski 1999 (29%); Lee 2009 (21%); Meuleman 2000 (26%); Naso 1990 (27%); Ouslander 2005 (27%); Sackley 2006 (25%); Sackley 2009 (25%); Schnelle 1996 (26%); Schnelle 2002 (22%); Schoenfelder 2004 (28%); Taboonpong 2008 (29%)), between 30% and 40% in four studies (Kerse 2008 (31%); Pomeroy 1993 (33%); Resnick 2009 (33%); Stevens 2006 (38%)), and over 40% in three studies (Au-Yeung 2002 (42%); Bruunsgaard 2004 (46%); Przybylski 1996 (45%)). The eight studies that did not provide data on overall attrition were Brill 1998; Brown 2004; Karl 1982; Mihalko 1996; Santana-Sosa 2008; Sauvage 1992; Stamford 1972, and Urbscheit 2001, only two of which had more than 20 participants.

 

Selective reporting

We did not judge selective reporting to pose low risk of bias in any studies, often because a pre-study protocol was not available, and because of the wide range of outcomes measured across studies, a complete range could not be considered to have been assessed. We judged 53 studies to have an unclear risk of reporting bias, while we judged 14 studies to have a high risk of reporting bias, usually because they did not report (or did so insufficiently) outcomes specified in the methods section. It should be noted that many of the studies judged to have unclear risk of reporting bias reported a number of outcomes that did not reach (or even come close to) statistical significance, suggesting that these studies may have reported all outcomes.

 

Other potential sources of bias

In three studies, we identified a potential risk of bias due to contamination (control participants receiving the intervention). We judged this to pose an unclear risk of bias in Buettner 1997, where the review authors suspected contamination, and a high risk of bias in Peri 2008 and Baum 2003, where the study authors reported contamination.

 

Effects of interventions

 

Primary outcomes: function in activities of daily living

In total, 51 studies conducted a measure of our primary outcome, function in activities of daily living (ADL). However, only 33 studies measured an outcome that was included in one of our meta-analyses, nine of which were excluded from the analysis, either because they provided insufficient information to be included (N = 8) or had a substantial baseline imbalance in the specific measure (N = 1, sensitivity analysis presented). Therefore, we included the results of 24 studies in the meta-analyses (Au-Yeung 2002; Baum 2003; Bautmans 2005; Brill 1998; Brittle 2009; Bruyere 2005; Cheung 2008; Chin A Paw 2004; Dorner 2007; Hruda 2003; Kerse 2008; Lazowski 1999; MacRitchie 2001; Makita 2006; McMurdo 1993; Peri 2008; Przybylski 1996; Resnick 2009; Rolland 2007; Rosendahl 2006; Sackley 2006; Sackley 2009; Santana-Sosa 2008; Schoenfelder 2004). These studies initially randomised a total of 3139 participants into them. The other studies used ADL measures that they reported too infrequently for inclusion in meta-analyses. We provide details in the 'Characteristics of included studies' tables, but they are not synthesised here.

 

Independence in activities of daily living

 
Barthel Index

The Barthel Index (BI) assesses independence in physical ADL across 10 items, rated in increments of 5, e.g. scores of 0, 5, 10, with a maximum total score of 100 (best function). Some studies scaled this to increments of 1, e.g. scores of 0, 1, 2, with a maximum total score of 20. In this case, scores were multiplied by 5 to allow comparison with the original scaling.

Seven studies used the BI and contributed information to the meta-analysis (Dorner 2007; McMurdo 1993; Resnick 2009; Rosendahl 2006; Sackley 2006; Sackley 2009; Santana-Sosa 2008). Where the rules of the residential home restricted the total score, e.g. participants not being allowed to go to the toilet alone, reducing the maximum score to 95/100, we ignored this in pooling studies. In McMurdo 1993, it was unclear which scale had been used, so we assumed use of the 0 to 20 scale, because this is most common in the UK, and the standard errors would have been unfeasibly tight for such a small study if the alternative had been used. In Santana-Sosa 2008, the BI score was derived from the graphs presented in the publication. Five of these studies were cluster trials (McMurdo 1993; Resnick 2009; Rosendahl 2006; Sackley 2006; Sackley 2009), although two only reported unadjusted results (McMurdo 1993; Rosendahl 2006). We were able to adjust these results using an estimated intra-cluster correlation coefficient (ICC) of 0.38 based on Sackley 2006 and Sackley 2009.

The rehabilitation group had a BI on average six points higher than controls (95% CI 2 to 11, P = 0.008) when analysed with the random-effects method ( Analysis 1.1). We found similar results for the fixed-effect pooled estimate, with a BI five points higher (95% CI 2 to 7, P = 0.003) at follow-up than controls ( Analysis 1.43). There was substantial between-study heterogeneity (I² statistic = 48%, Q = 12 on 6 degrees of freedom (df), P = 0.07). Excluding cluster studies resulted in a much larger effect estimate of 18 points difference, with wide confidence intervals (95% CI 7 to 28, P = 0.001) ( Analysis 1.44), although this was based on two small studies.

The small number of studies limited the exploration of the potential sources of heterogeneity. There was no evidence that studies with a higher risk of bias had different measures of effect than those with a lower risk of bias ( Analysis 1.7) (P = 0.3). There was some evidence that studies with shorter interventions had larger effects than those with longer interventions ( Analysis 1.8) (P = 0.01). There was no evidence of differential effects on BI based on mode of delivery ( Analysis 1.9) (P = 0.3), baseline function ( Analysis 1.10) (P = 0.5), age ( Analysis 1.11) (P = 0.4), or gender ( Analysis 1.12) (P = 0.5).

There was some evidence of asymmetry in the contour-enhanced funnel plot (Figure 3) (Egger’s test P = 0.05), with larger studies indicating less benefit of rehabilitation. However, six of the seven studies were not statistically significant, suggesting that this asymmetry may not be due to publication bias. However, with only seven studies contributing, this should be interpreted with caution.

 FigureFigure 3. Funnel plot of comparison: 1 Rehabilitation versus control, outcome: 1.1 Barthel Index.

 
Functional Independence Measure

The Functional Independence Measure (FIM) assesses a participant’s degree of independence in self care, toileting, mobility, communication, and social cognition functions. It consists of 18 items rated on a 7-point scale, with higher scores indicating greater independence.

Four studies used the FIM and contributed information to the meta-analysis (Dorner 2007; Lazowski 1999; Makita 2006; Przybylski 1996). Przybylski 1996 did not present the numbers in each intervention group at follow-up, but did present total numbers, balanced numbers in each group at baseline, and report that attrition was similar. We therefore assumed an equal dropout rate in each group and similar numbers in each group at follow-up. All of these studies were randomised at the level of the individual.

The rehabilitation group had a FIM on average 5.0 points higher than controls (95% CI -1.6 to 11.5, P = 0.1) when analysed with the random-effects method ( Analysis 1.2). The fixed-effect pooled estimate was lower, but with narrower confidence intervals, with a FIM on average 1.5 points higher (95% CI -0.4 to 3.3, P = 0.1) at follow-up than controls ( Analysis 1.45). There was substantial between-study heterogeneity (I² statistic = 71%, Q = 10 on 3df, P = 0.02).

The small number of studies limited the exploration of the potential sources of heterogeneity. All studies were categorised as higher risk of bias, so it was not possible to assess this as a source of heterogeneity ( Analysis 1.13). There was no evidence of differential effects on FIM based on duration of intervention ( Analysis 1.14) (P = 0.6) or mode of delivery ( Analysis 1.15) (P = 0.3). Comparing studies with differing mean functional independence at baseline ( Analysis 1.16) suggested that participants with greater functional independence benefited more from intervention than those with less function at baseline (P = 0.03). There was evidence that younger participants (less than 85 years) benefited more from rehabilitation in terms of functional independence than older participants (85 years and older) ( Analysis 1.17) (P = 0.001). This also reduced the excess heterogeneity in both groups (from I² statistic = 71% to I² statistic = 0% in each group separately). There was no evidence of differential effects on FIM due to gender ( Analysis 1.18) (P = 0.8).

There were too few studies to explore asymmetry in the contour-enhanced funnel plot (Egger’s test P = 0.3).

 
Rivermead Mobility Index

The Rivermead Mobility Index (RMI) assesses mobility independence and performance across 15 items, with a score ranging from 0 to 15, with 15 being the best outcome.

Three studies contributed information to the meta-analysis (Brittle 2009; Sackley 2006; Sackley 2009); four studies used the RMI, but Sackley 2008 did not present results as it was a feasibility study. All of these studies were cluster trials, and all presented appropriately adjusted analyses.

Rehabilitation groups had a RMI on average 0.7 points higher at follow-up than controls (95% CI 0.04 to 1.3, P = 0.04) when analysed with the random-effects method ( Analysis 1.3). There was almost no excess between-study heterogeneity (I² statistic = 0%, Q = 0.02 on 2df, P = 0.99). Therefore, the fixed-effect pooled estimate ( Analysis 1.46) was identical to the random-effects model.

The small number of studies limited the exploration of the potential sources of heterogeneity. We had categorised all of these studies as lower risk of bias, so we were not able to assess risk of bias as a source of heterogeneity ( Analysis 1.19). There was no evidence of differential effects on RMI based on duration of intervention ( Analysis 1.20) (P = 0.9), mode of delivery ( Analysis 1.21) (P = 0.9), baseline function ( Analysis 1.22) (P = 0.9), age ( Analysis 1.23) (P = 0.9), or gender ( Analysis 1.24) (P = 0.9).

There were too few studies to explore asymmetry in the contour-enhanced funnel plot (Egger’s test P = 0.09).

 

Tests of ability in specific activities of daily living

 
Timed Up and Go test

The Timed Up and Go (TUG) test assesses participant mobility, measuring the time in seconds for a participant to rise from sitting in a standard armchair, then walk three metres, turn around, walk back to the chair, and sit down again. Therefore, a lower score indicates better performance. Two studies modified the distance for the TUG test (Hruda 2003; Santana-Sosa 2008), and one counted the number of steps taken in addition to the time taken (Christofoletti 2008). To reduce heterogeneity, the modified outcomes were not included in the meta-analyses.

Seven studies contributed to the rehabilitation versus control meta-analysis, and two studies contributed to the meta-analysis of rehabilitation (experimental) versus rehabilitation (control). Twelve studies used the standard TUG test (Au-Yeung 2002; Baum 2003; Bautmans 2005; Bruyere 2005; Cheung 2008; Christofoletti 2008; Donat 2007; Kerse 2008; Lazowski 1999; MacRitchie 2001; Peri 2008; Sackley 2009). However, we could not include Sackley 2009 in the meta-analyses because the authors did not present TUG test results on the grounds of extensive missing data and substantial variation in individual results. We could not include Donat 2007 in the meta-analyses because the study did not present a measure of variation in the outcome (e.g. standard error, standard deviation, or confidence interval). We excluded Christofoletti 2008 because of substantial baseline imbalance that persisted throughout the duration of the trial, with the control group taking more than twice as long to complete the TUG test before any intervention. We present below an analysis that re-includes these data. We analysed two studies in a separate meta-analysis because they compared exercise plus whole body vibration with exercise alone, so both groups contained a rehabilitative intervention (Bautmans 2005; Bruyere 2005). Kerse 2008 and Peri 2008 were cluster randomised trials and presented appropriately adjusted analyses.

The rehabilitation group was five seconds quicker on average at follow-up than controls (95% CI -9 to 0, P = 0.05) when analysed with the random-effects method ( Analysis 1.4). We observed substantial excess heterogeneity (I² statistic = 65%, Q = 17 on 6df, P = 0.009). The fixed-effect pooled estimate was similar: Rehabilitation groups had TUG test results four seconds quicker than controls (95% CI -6 to -1), and this was statistically significant (P = 0.001) ( Analysis 1.47). The sensitivity analysis excluding cluster trials ( Analysis 1.48) was significant (P = 0.02) and estimated a larger effect, with rehabilitation groups an average eight seconds faster, but with wide confidence intervals (95% CI -14 to -2). The sensitivity analysis including the study with substantial baseline imbalance (Christofoletti 2008) ( Analysis 1.49) was significant (P = 0.02) and estimated a larger effect, with rehabilitation groups an average eight seconds faster, but wide confidence intervals (95% CI -16 to -1) and further increased heterogeneity (I² statistic = 89%, Q = 65 on 7df, P < 0.00001).

Exploring the heterogeneity, we categorised only one study as lower risk of bias, and there was no evidence that this study had different measures of effect on TUG test scores than those with a higher risk of bias ( Analysis 1.25) (P = 0.1). There was some evidence that studies with shorter interventions had larger effects than those with longer interventions ( Analysis 1.26) (P = 0.06), though numbers of studies were small, and there was still substantial heterogeneity between studies with less than six months' intervention. There was no evidence that group interventions differed in effect from individual interventions ( Analysis 1.27) (P = 0.9). There was some evidence that participants with greater mobility benefited more from rehabilitation than those with less mobility at baseline ( Analysis 1.28) (P = 0.06). However, the numbers of studies in each subgroup were small, and substantial heterogeneity remained between studies with lower TUG test scores. A post-hoc analysis, moving the median study from the more mobile group to the less mobile group, found no evidence of this difference (P = 0.8). There was no evidence of difference in pooled estimates due to age ( Analysis 1.29) (P = 1.0). There was some evidence that participants in studies with a higher proportion of women (more than 80% compared with 80% or less) had lower (better) TUG test scores than those with a lower proportion of women ( Analysis 1.30) (P = 0.05).

There was no evidence of asymmetry in the contour-enhanced funnel plot (Figure 4) (Egger’s test P = 0.4).

 FigureFigure 4. Funnel plot of comparison: 1 Rehabilitation versus control, outcome: 1.4 TUG test

The whole body vibration plus exercise (experimental rehabilitation) group was eight seconds quicker on average at follow-up than exercise alone (control rehabilitation) (95% CI -19 to 3, P = 0.2) when analysed with the random-effects method ( Analysis 2.1). The fixed-effect pooled estimate was similar, with the experimental group seven seconds quicker ( Analysis 2.3) (95% CI -11 to -3, P = 0.0002). We observed substantial excess heterogeneity (I² statistic = 89%, Q = 9 on 1df, P = 0.003). However, because there were only two studies, we did not conduct subgroup analyses.

 
Walking time and speed over fixed distance

To investigate walking as a functional ability, we combined measures of time to walk a fixed distance with measures of speed over a fixed distance, converting these into speed in metres per second (m/s). We anticipated that varied distances may impact on speed to walk that distance. Therefore, to reduce heterogeneity, we decided a priori to only combine studies over a fixed distance (i.e. excluding studies of maximum distance walked in a fixed time) and for that fixed distance to be less than 10 metres. Where measures of 'fast' walking and 'normal' walking were available, we selected normal walking speed, again to reduce heterogeneity.

Fifteen studies met these criteria, but only nine studies contributed information to the meta-analysis (Au-Yeung 2002; Brill 1998; Chin A Paw 2004; Hruda 2003; Lazowski 1999; MacRitchie 2001; Rolland 2007; Rosendahl 2006; Schoenfelder 2004). One study did not report numeric results for the walking outcome (Schnelle 1996); two studies did not present any measure of variation in the outcome (Schnelle 1995; Schoenfelder 2000); and three studies only presented results as change in time, which we were unable to convert into change in speed (Choi 2005; Fiatarone 1994; Meuleman 2000). Rosendahl 2006 was a cluster randomised trial, but did not present correctly adjusted results, although they claimed results were similar. Because other trials were not cluster trials, we could not estimate an ICC from them. We were also unable to identify a suitable ICC estimate from external sources. Therefore, we presented the unadjusted results.

The rehabilitation group were on average 0.03 m/s (95% CI -0.01 to 0.07, P = 0.1) faster at walking a fixed distance less than 10 metres than controls when analysed with the random-effects method ( Analysis 1.5). There was very little between-study heterogeneity (I² statistic = 9%, Q = 9 on 8df, P = 0.4). Therefore, the fixed-effect pooled estimate was similar, also estimating that rehabilitation groups had a walking speed of on average 0.03 m/s faster over a fixed distance (95% CI 0.00 to 0.06, P = 0.02) at follow-up than controls ( Analysis 1.50). While statistically significant, this is a small effect and was not significant in the random-effects analysis. The sensitivity analysis excluding the one cluster trial ( Analysis 1.51) further reduced the estimated effect to an increase of 0.01 m/s (95% CI -0.05 to 0.08, P = 0.7) and slightly increased between-study heterogeneity (I² statistic = 16%, Q = 8 on 7df, P = 0.3).

We categorised only Chin A Paw 2004 as lower risk of bias, which appeared to be significantly different from the other studies, which were higher risk of bias ( Analysis 1.31) (P = 0.01), implying that studies with lower risk of bias recorded less impact of the rehabilitation. However, this was based on only one lower risk study, which differed in other ways, e.g. type of intervention, duration of intervention, and distance walked to measure speed. There was no evidence of differential effects due to duration of interventions ( Analysis 1.32) (P = 0.7), mode of delivery ( Analysis 1.33) (P = 0.6), or baseline walking speeds ( Analysis 1.34) (P = 0.6). All these studies had mean participant ages less than our predetermined threshold (less than 85 years), so we could not assess age as a potential source of heterogeneity in this outcome ( Analysis 1.35). There was no evidence of differential effects due to gender ( Analysis 1.36) (P = 0.2). There was no evidence that studies testing walking speeds over shorter distances measured different responses to rehabilitation than those testing over longer distances ( Analysis 1.37) (P = 0.5).

There was no evidence of any asymmetry in the contour-enhanced funnel plot (Figure 5) (Egger’s test P = 1.0).

 FigureFigure 5. Funnel plot of comparison: 1 Rehabilitation versus control, outcome: 1.5 Walking speed

 

Secondary outcomes

 

Strength

Twenty-five studies reported strength as an outcome, seven of which reported no significant effect at the end of the intervention. Five studies assessed upper body strength (excluding grip), three of which found significant differences between groups (Mihalko 1996; Ouslander 2005; Schnelle 2002), while two did not (Chin A Paw 2004; Lazowski 1999). However, in the case of Mihalko 1996, this was based on an unadjusted analysis of a cluster study. Seven studies assessed hand grip strength, four of which found significant differences (Brill 1998; Buettner 1997; McMurdo 1993; Schnelle 1996), although in two of these strength was assessed separately in each hand, and differences were only significant in one hand (Brill 1998; Schnelle 1996), while McMurdo 1993 presented an unadjusted analysis of a cluster study. Three studies found no significant difference in grip strength (Bautmans 2005; Lazowski 1999; Resnick 2009). Sixteen studies assessed lower body strength, with 11 finding significant differences favouring rehabilitation at the end of the intervention (Brill 1998; Bruunsgaard 2004; Choi 2005; de Bruin 2007; Donat 2007; Fiatarone 1994; Hruda 2003; Lazowski 1999; McMurdo 1994; Ouslander 2005; Sauvage 1992) and five finding no significant difference (Bautmans 2005; Chin A Paw 2004; Rosendahl 2006; Schoenfelder 2000; Schoenfelder 2004). However, among those finding in favour of rehabilitation, one study had a significant baseline imbalance (Choi 2005); this study and McMurdo 1994 were cluster trials that did not adjust their analysis for the design; one did not find significant differences in all types of strength measure (Hruda 2003); and three were limited to within-group improvements only (de Bruin 2007; Donat 2007; Sauvage 1992). Three studies assessed a global measure, combining measures of upper and lower body strength, with one finding significant difference in some measures (isometric and isokinetic concentric, not isokinetic eccentric) after training (Meuleman 2000), one finding significant difference in changes in strength, but with a large baseline imbalance likely to have produced a regression to the mean (Dorner 2007), and one finding no significant difference (Mulrow 1994).

Five studies addressed improvement sustainability (Buettner 1997; Meuleman 2000; Rosendahl 2006; Schoenfelder 2000; Schoenfelder 2004), although only two had found significant differences at the end of the intervention (Buettner 1997; Meuleman 2000). Buettner 1997 observed significant strength gains in very frail participants during the first 20 weeks of the intervention, while strength deteriorated among controls. However, during the final 10 weeks of the intervention, strength deteriorated among all participants, although the intervention group remained significantly stronger than at baseline and than the control group. The participants in Meuleman 2000 did not sustain the significant differences seen after four to eight weeks training at 6 or 12 months. Of the other studies, Schoenfelder 2000 and Schoenfelder 2004 still found no significant difference, while in Rosendahl 2006, improvement in the intervention group and deterioration in the control group led to a significant difference at six months not seen at the end of the intervention. This was in an unadjusted analysis of a cluster study.

 

Flexibility

Components targeting flexibility featured in 17 interventions, and 16 studies assessed it as an outcome measure (Bautmans 2005; Buettner 1997; Chin A Paw 2004; Choi 2005; Donat 2007; Kinion 1993; Lazowski 1999; Lee 2009; Makita 2006; McMurdo 1993; Mulrow 1994; Resnick 2009; Santana-Sosa 2008; Schnelle 1996; Sung 2009; Taboonpong 2008). Ten reported significant benefits to their participants at the end of the intervention (at P < 0.05) (Buettner 1997; Choi 2005; Donat 2007; Kinion 1993; Lazowski 1999; Makita 2006; McMurdo 1993; Santana-Sosa 2008; Schnelle 1996; Sung 2009), although three studies were cluster trials that did not adjust their analysis for the design (Choi 2005; McMurdo 1993; Sung 2009); in two studies, this was limited to within-group assessments (Donat 2007; Lazowski 1999); and in three studies, only some joints showed significant benefit (spine but not knees McMurdo 1993; shoulders and knees but not ankles Makita 2006; shoulders, hips, and elbows but not knees Kinion 1993). The within-group assessments of Donat 2007 found significant increases in flexibility in both the supervised and unsupervised exercise groups, but there was no usual care control group for comparison. Five other studies found no evidence of significant benefit to flexibility from their interventions (Bautmans 2005; Chin A Paw 2004; Mulrow 1994; Resnick 2009; Taboonpong 2008). Successful interventions included rowing by participants with advanced dementia and frailty (Schnelle 1996); a combination of walking, joint mobility, resistance and co-ordination exercises (Santana-Sosa 2008); Tai Chi (Choi 2005); a programme to increase the practice of sensorimotor activities (Buettner 1997); strengthening exercises with dancing to music and health education (Sung 2009); and exercise to music related to improvement in spinal flexion, which deteriorated in the control group (McMurdo 1993). Only Lazowski 1999 compared the effect of two types of physical rehabilitation on flexibility. They found their 'functional fitness' intervention significantly (P < 0.05) outperformed 'range of motion' exercises on several indices of flexibility. Studies rarely systematically assessed flexibility, and it was not clearly linked with overall activity restriction. Lee 2009 did not report results. None of the studies examined long-term effects.

 

Balance

Twenty-nine trials assessed balance as an outcome measure (Au-Yeung 2002; Baum 2003; Bautmans 2005; Brill 1998; Bruyere 2005; Cheung 2008; Choi 2005; Christofoletti 2008; Clark 1975; Crilly 1989; de Bruin 2007; Dorner 2007; Donat 2007; Kerse 2008; Lazowski 1999; Lee 2009; MacRitchie 2001; McMurdo 1993; Morris 1999; Mulrow 1994; Resnick 2009; Rolland 2007; Rosendahl 2006; Sauvage 1992; Schoenfelder 2000; Schoenfelder 2004; Sihvonen 2004; Sung 2009; Urbscheit 2001). Thirteen trials reported significantly benefiting their participants' balance at the end of the intervention (at P < 0.05) (Bautmans 2005; Bruyere 2005; Cheung 2008; Choi 2005; Christofoletti 2008; de Bruin 2007; Donat 2007; Lazowski 1999; MacRitchie 2001; Resnick 2009; Schoenfelder 2004; Sihvonen 2004; Sung 2009). However, Choi 2005 and Sung 2009 based this on an unadjusted analysis of a cluster study; Donat 2007 only reported within-group comparisons; in three studies, benefit was only significant for some of their measures of balance (Choi 2005; Schoenfelder 2004; Sihvonen 2004); and in one study (Resnick 2009), there was a significant baseline imbalance with possible regression to the mean. The within-group assessments of Donat 2007 found significant increases in balance in both the supervised and unsupervised exercise groups, but there was no usual care control group for comparison. Successful interventions included a combination of strength and balance exercises (Cheung 2008; Christofoletti 2008; de Bruin 2007; Lazowski 1999), strengthening exercises with dancing to music and health education (Sung 2009), and standing and walking activities performed to music (MacRitchie 2001). However, 14 studies were unable to demonstrate any effect of their programme on balance at the end of the intervention (Au-Yeung 2002; Baum 2003; Clark 1975; Crilly 1989; Dorner 2007; Kerse 2008; McMurdo 1993; Morris 1999; Mulrow 1994; Rolland 2007; Rosendahl 2006; Sauvage 1992; Schoenfelder 2000; Urbscheit 2001). Urbscheit 2001 suggested this was due to initial balance ability, with participants in poorer health unable to improve. Morris 1999 suggested some rehabilitation interventions may cause harm to the balance of elderly residents of long-term care: They found their nursing rehabilitation intervention group's balance deteriorated significantly compared to their control and 'fit for your life' groups. Two studies did not report the results of their balance assessments (Brill 1998; Lee 2009).

Eight studies conducted long-term follow up of balance (Au-Yeung 2002; Clark 1975; Kerse 2008; Rosendahl 2006; Schoenfelder 2000; Schoenfelder 2004; Sihvonen 2004; Urbscheit 2001). Results at follow-up were typically similar to those at the end of the intervention, with significant differences for some measures of balance found by Schoenfelder 2004 and Sihvonen 2004, and no evidence of effect in five studies (Au-Yeung 2002; Clark 1975; Kerse 2008; Schoenfelder 2000; Urbscheit 2001). Only Rosendahl 2006 found a different result at follow-up: While differences in balance were not significant at the end of the intervention, there was significant improvement in their experimental group's balance at follow-up. This was in an unadjusted analysis of a cluster study.

 

Mood

Fifteen studies assessed mood (Brill 1998; Brittle 2009; Brown 2004; Buettner 1997; Chin A Paw 2004; Dorner 2007; Kerse 2008; MacRitchie 2001; McMurdo 1993; Meuleman 2000; Mihalko 1996; Morris 1999; Mulrow 1994; Rolland 2007; Sung 2009). Five studies reported significant differences in mood at the end of the intervention, favouring the experimental group (P < 0.05), for depression (Brill 1998; Buettner 1997; McMurdo 1993), anxiety (Brill 1998), self-esteem (Sung 2009), and loneliness (Brown 2004), although two of these studies limited these conclusions to within-group comparisons (Brill 1998; Brown 2004), while two studies were cluster trials that did not adjust their analysis for the design (McMurdo 1993; Sung 2009). By contrast, Kerse 2008 found participants became significantly more depressed during the course of the intervention, while the control group did not: this increase was concentrated among cognitively-impaired participants. Ten studies found no significant difference in depression (Brittle 2009; Chin A Paw 2004; Dorner 2007; MacRitchie 2001; Meuleman 2000; Morris 1999; Mulrow 1994; Rolland 2007; Sung 2009) or positive and negative affect (Mihalko 1996).

Three studies conducted long-term follow up of mood (Brittle 2009; Kerse 2008; Meuleman 2000). Results were the same as at the end of the intervention, with no significant improvement in mood, while Kerse 2008 found intervention participants became significantly more depressed.

 

Cognitive status

Eleven studies assessed cognitive performance (Baum 2003; Buettner 1997; Christofoletti 2008; Dorner 2007; McMurdo 1993; McMurdo 1994; Mulrow 1994; Pomeroy 1993; Schoenfelder 2000; Schoenfelder 2004; Stevens 2006), nine of which used the Mini-Mental State Examination (MMSE). Three studies, at the end of the intervention, identified significant differences in cognitive performance (at P < 0.05) (Buettner 1997; Christofoletti 2008; Stevens 2006), although these results should be interpreted with caution. In Buettner 1997, the control group's cognition declined consistently, in contrast to the experimental group, but there was significant baseline imbalance, and at no point did the experimental group score higher than the control, suggesting regression to the mean. In Christofoletti 2008, the significant difference was only for two of the eight subscales of the Brief Cognitive Screening Battery, not its overall measure or for the MMSE, and it was described by the authors as probably fortuitous. In Stevens 2006, a comparison of their experimental group with their social-visit control group was significant, but comparison of the experimental group with the no-intervention control group was not. Within-group comparisons revealed statistically significant changes in the social-visit group only (significant decline). Five studies found no significant difference in cognition at the end of the intervention (Dorner 2007; McMurdo 1993; McMurdo 1994; Mulrow 1994; Schoenfelder 2004). Schoenfelder 2000 did not report results. Baum 2003 assessed cognition, but only tested significance in combination with three other outcomes to avoid multiple hypothesis testing. They reported an effect size of 0.54 (3.1 points better on the MMSE; 90% CI 0.15 to 0.92). Pomeroy 1993 did not analyse possible effect on cognition.

Two studies conducted long-term follow up of cognitive status (Schoenfelder 2000; Schoenfelder 2004), although only Schoenfelder 2004 reported results, finding no significant difference, as at the end of the intervention.

 

Exercise tolerance

Three studies examined the effect of interventions on exercise tolerance (Naso 1990; Sauvage 1992; Schnelle 1996); four other studies examined the effect of interventions on the quantity of exercise conducted (see the section below, 'Approaches to increase intervention compliance or quantity') (DeKuiper 1993; Lang 1992; Riccio 1990; Yoder 1989). The intervention condition had significantly greater exercise tolerance than the control group in one study (Schnelle 1996). In two studies, there was no significant difference between groups (Naso 1990; Sauvage 1992). None of the studies examined long-term effects.

 

Perceived health status

Six studies examined perceived health status (Bruyere 2005; Chin A Paw 2004; Kerse 2008; Lee 2009; Mulrow 1994; Peri 2008). The rehabilitation group had significantly greater perceived health (P < 0.05) than the control group at the end of the intervention in three studies (Bruyere 2005; Lee 2009; Peri 2008). However, in Bruyere 2005, there was significant difference for eight subscales of the Short Form-36 (SF-36), but not health change; while in Peri 2008, it was limited to the physical, but not mental, component; and in Lee 2009, it was only after adjustment for resident satisfaction, in a cluster trial that did not adjust the analysis to account for the design. Two studies showed no significant difference between groups (Kerse 2008; Mulrow 1994). In Chin A Paw 2004, there was a significant decline in perceived health among the intervention group, although this was not significant among regular attenders to the exercise sessions. Kerse 2008 and Peri 2008 examined long-term effects following the withdrawal of external nursing support; neither found a significant difference.

 

Fear of falling

Six studies measured fear of falling (Brill 1998; Choi 2005; Donat 2007; Kerse 2008; Schoenfelder 2000; Schoenfelder 2004). In Choi 2005, there was a significant difference between the groups in favour of the experimental group at the end of the intervention, but this was a cluster trial that did not adjust the analysis to account for the design. Three studies reported no significant difference (Donat 2007; Schoenfelder 2000; Schoenfelder 2004). Two studies did not report a statistical comparison (Brill 1998; Kerse 2008), which was explained by Kerse 2008 as being due to significant missing data because participants found it difficult to assign a number to their fear of falling. Three studies conducted long-term follow up (Kerse 2008; Schoenfelder 2000; Schoenfelder 2004), but as at the end of the intervention, it was not significant for two (Schoenfelder 2000; Schoenfelder 2004) and not analysed in Kerse 2008, as described above.

 

Economics

No study performed a full cost-benefit analysis, but three studies assessed costs (Mulrow 1994; Przybylski 1996; Schnelle 2002). Mulrow 1994 compared average costs of their one-to-one physical therapy intervention (USD 1220, 95% CI USD 412 to USD 1832) and their control, friendly visits, (USD 189, 95% CI USD 80 to USD 298) over four months. They also found that other healthcare charges did not differ significantly between the groups (average USD 11,398), the majority of which (81%) were nursing-home charges. Przybylski 1996 calculated the cost of providing their enhanced level physiotherapy and occupational therapy service as well as direct-care nursing costs from case-mix measures and found that reductions in nursing costs outweighed the cost of their service by USD 283 per bed per year. However, they did not test significance or perform sensitivity analyses. Schnelle 2002 compared the costs of evaluating and treating acute events between groups and found no significant difference as a result of their intervention. They also calculated that there would be insufficient staff resources to implement their FIT intervention at a ratio of 10 residents to one nursing aide.

 

Intervention compliance and feasibility

Many studies failed to report either intervention or control session attendance. Twenty-four studies reported experimental intervention session attendance, with a mean of 83% and only Cheung 2008 reporting 100%. Twelve studies reported control session attendance, with a mean of 82%; only Fiatarone 1994 reported 100% attendance. Varying attendance levels may enhance the apparent treatment effect in favour of the experimental intervention. Session attendance was irrelevant where interventions were not provided in discreet sessions, for example, the FIT studies, repeated measures designs, or for control groups that used 'usual care'. Resnick 2009 suggested additional measures of treatment fidelity for future studies and at each stage in the process, for example, training of providers and delivery as well as receipt.

Taboonpong 2008 reported that 4 of the 35 participants in the exercise group could not maintain the Tai Chi schedule. Similarly, Chin A Paw 2004 reported that 8 of 173 participants found the intervention "too intensive" and discontinued it. Brittle 2009 reported that cognitive impairment in 9 of 28 participants either rendered them unable to follow the instructions or disruptive. Peri 2008 reported that varying adherence across sites, in a programme implemented by care-home staff, appeared to be related to resource.

 

Approaches to increase intervention compliance or quantity

Four trials investigated different ways of maximising compliance, the amount of exercise a participant took, or both. Two studies (Riccio 1990; Yoder 1989) found verbally elicited imagery of purposeful activity resulted in more exercise than rote repetitions (P < 0.05). Two studies (DeKuiper 1993; Lang 1992) found that participants exercised more when engaged in activity with a real object compared to an imaginary one. This suggests that adding purpose and asking participants to work with an actual object is an effective way of increasing exercise quantity. Similarly, including conversation during walking exercises improved compliance (Tappen 1994; Tappen 2000), preventing the physical decline observed in the conversation-only and walk-only groups. Donat 2007 compared supervised and unsupervised exercise, with four unsupervised and two supervised participants giving up (21 in each group). Karl 1982 argued that perceived irrelevance of the intervention to participants' lives was the main cause of lack of success, and proposed that individualised interventions might have been more effective.

 

Adverse events

Few studies reported adverse events that were directly attributable to their intervention. Many reported morbidity and mortality for their participants during the trial period. However, morbidity and mortality should be expected among this population because of their age and often poor physical condition, making causality difficult to establish. The studies assessing whole body vibration reported some adverse events. Bautmans 2005 reports one participant developing a phobia of the treatment room. Other adverse events included the following: one case of groin pain (Bautmans 2005) and two cases of lower limb tingling (Bruyere 2005). Among other intervention types, few reported any problems. One of the only other studies to report adverse events was in the study by Rosendahl, et al (191 participants) of high intensity functional exercise and nutritional supplementation (Rosendahl 2006). They reported that adverse events occurred in 9% of 1906 sessions. Of these, they classified only two as major: one case of chest pain and another of loss of balance, neither of which led to manifest injury or disease. Mulrow 1994 found the intervention group suffered more, and more serious, falls, although this was not statistically significant. Rolland 2007 reported five falls occurring during the exercise sessions, one causing a head injury, although there was no significant difference in the number of falls between the groups over the 12-month programme. Six other studies found no significant difference in the number of falls between groups (Cheung 2008; Choi 2005; Faber 2006; Kerse 2008; MacRitchie 2001; Peri 2008).

 

Morbidity and mortality

Twenty-nine studies reported mortality within each group at the end of the intervention period, or we inferred it from reports of attrition. Fourteen of these studies were cluster trials, and we did not identify a suitable ICC by which to adjust the results; therefore, we presented unadjusted counts and events. Brittle 2009 reported mortality per group, but we did not include this in the meta-analysis because reports were at three and six months post-baseline, rather than at the end of the five-week intervention period. The meta-analysis for the 25 rehabilitation studies versus the control studies showed no evidence of an effect from a physical rehabilitation intervention ( Analysis 1.6) (P = 0.5), with the risk ratio slightly favouring the rehabilitation group (0.95, 95% CI 0.8 to 1.1). There was almost no excess between-study heterogeneity (I² = 0%, Q = 11 on 17df, P = 0.9). There is little evidence of asymmetry in the funnel plot (Figure 6). Prespecified sensitivity analyses also yielded no evidence of an effect with alternative methods (odds ratio (OR),  Analysis 1.52; risk difference,  Analysis 1.53; fixed-effect,  Analysis 1.54; and Peto odds ratio,  Analysis 1.55). Excluding cluster trials resulted in a similar risk ratio, but with wider confidence intervals (0.93, 95% CI 0.60 to 1.44, P = 0.8) ( Analysis 1.56). Results of a post-hoc sensitivity analysis including Brittle 2009 were very similar to the primary analysis ( Analysis 1.57) (P = 0.5). None of the prespecified subgroup analyses suggested differential mortality between studies based on risk of bias ( Analysis 1.38) (P = 0.4), duration of intervention ( Analysis 1.39) (P = 0.5), mode of delivery ( Analysis 1.40) (P = 0.6), age ( Analysis 1.41) (P = 0.4), or gender ( Analysis 1.42) (P = 0.9). Four studies contributed to the meta-analysis of rehabilitation (experimental) versus rehabilitation (control), but only one death was reported across these studies, leading to no evidence of an effect ( Analysis 2.2) (risk ratio = 2.7, 95% CI 0.1 to 61, P = 0.5).

 FigureFigure 6. Funnel plot of comparison: 1 Rehabilitation versus control, outcome: 1.6 Death

Several studies reported hospitalisations. Rolland 2007 reported a significantly increased number of hospitalisations per participant within the exercise group (at 12 months, 0.6 (1.3) versus 0.2 (0.6), P = 0.04). Meuleman 2000 found significantly fewer hospitalisations and significantly fewer days admitted to hospital among the intervention group compared to the control group (at 12 months, 0.2 versus 0.7, P = 0.005; and 2.3 versus 7.6, P = 0.005, respectively). Kerse 2008 and Schnelle 2002 found no significant difference.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Summary of main results

The present studies provide preliminary evidence that physical rehabilitation interventions may be associated with significant improvements across various measures of physical and mental functioning, without increasing the mortality risk in elderly care-home residents. This is traditionally regarded as a group that is hard to research, but this review has found a substantial body of evidence. Many studies concluded that their intervention was both successful and safe, achieving their study goals. However, these are mostly explanatory trials that require replication in routine care and direct comparison between different interventions. At present, there is no clear indication of the optimum type of intervention.

 

Activities of daily living

There is some evidence that activities of daily living (ADL) independence and performance in this population are enhanced, or decline less, through physical rehabilitation interventions when compared with usual care. All of the point estimates for measures of ADL for which we performed meta-analyses favour rehabilitation, and two have statistically significant random-effects estimates (Barthel Index (BI), Rivermead Mobility Index (RMI)). The fixed-effect models are significant for all measures except the Functional Independence Measure (FIM), although the heterogeneity expected and observed in many of the analyses suggest we should consider fixed-effect estimates with caution. The RMI estimate, which is significant in both models, is of note for only pooling studies of lower risk of bias. In each of the analyses of independence scales, the point estimates of the effect were approximately 5% of the scale total. For the Timed Up and Go (TUG) test, the point estimate was approximately 15% of the mean baseline time, while for walking speed, the point estimate was approximately 5% of the mean baseline speed. While these are not large effects, they at least imply a stabilisation of function. It should be remembered that these are estimates of the average intervention effect, which may vary widely with some interventions resulting in smaller or larger effects. Of interest is the large difference between TUG test estimate and walking speed estimate, which could conceivably suggest a greater effect of rehabilitation on standing up, sitting down, or turning around than walking speed. Alternatively, it may relate to differences in the participants, interventions, or other study features.

The subgroup analyses did not provide clear evidence across measures of sources of heterogeneity in effects, although the small number of studies in each subgroup hampered this. For all but one of the measures, there were greater estimates of effect in studies with participants with better baseline function, but this was only significant in one analysis (FIM). There was some evidence that shorter interventions had larger effects than longer interventions based on the BI and TUG test, but not other outcome measures. We did not perform subgroup analyses of interventions, which varied widely. It is plausible that some of the heterogeneity observed is related to differences in effect between interventions.

 

Secondary outcomes

Many of the studies measuring strength, flexibility, and balance found significant differences favouring the intervention. There was little evidence about the effect on exercise tolerance and perceived health status. There was some evidence of effect on mood and little evidence of effect on cognition and fear of falling. However, it should be noted that we excluded interventions primarily targeting improvements in cognitive, psychological, or psychosocial outcomes and multi-faceted falls interventions from this review. Therefore, it is possible that physical interventions other than those in the included studies would show greater evidence of effect on these outcomes or outcomes such as quality of life. There was very limited economic evidence and no cost-benefit analyses among the trials. Evidence from several trials suggests that ensuring an intervention is perceived as relevant and important by participants may be crucial to its success.

 

Adverse outcomes

The meta-analysis of mortality provides good evidence that rehabilitation does not increase mortality risk. Subgroup analyses also suggested there were not different effects among different types of participant (age or gender). There was relatively little evidence about other adverse outcomes. Most trials included very frail elderly individuals, among whom relatively high rates of morbidity and mortality would be expected, and high morbidity was often reported at baseline.

 

Overall completeness and applicability of evidence

 

Dominance of North American research

Of the 67 included studies, 36 took place in North America. This may be problematic if there are large differences in the nature of long-term care in North America or in the characteristics, such as age and physical condition, of the people who receive the intervention, when compared with Europe or the rest of the world. As a consequence, the present findings may be difficult to apply to long-term care settings elsewhere. However, the increase in nationalities represented in this update is welcome. We have described the characteristics of the participants and the interventions. The interventions may be effective in this frail elderly client group regardless of location of care, but this hypothesis remains to be tested.

 

Participant representativeness

The extent to which participants in the included studies are representative of the wider population residing in long-term care is unclear. This may present more of a problem where sample sizes were small, participant attrition was high, or both. It is notable that where studies did report the number of eligible individuals within the facility, on average they excluded more than half of its residents and less than one quarter of residents ultimately participated. This might suggest that the participant sample is not representative of the wider long-term care population. However, some studies included participants with multiple comorbidities and severe physical and cognitive disabilities.

 

Participant variation

There is substantial variation in the physical condition and mental health of people aged over 65 years in long-term care. It is improbable that the same intervention will be appropriate for all people. However, the subgroup analyses failed to identify clear differences in effect between different studies based on participant characteristics.

 

Economics

A convincing economic case for rehabilitation has yet to be made. Conceptually, it seems reasonable: improving physical condition should reduce ill health, reducing the burden of the individual on health care, the need for hospital treatment, and intensive personal care. Evidence for this would have to demonstrate that the absolute cost of the intervention is less than the amount the individual would cost if they remained in the same condition or deteriorated. A further effect to consider in an economic analysis is the additional cost of increased length of stay in long-term care that may result from a rehabilitative intervention increasing life expectancy. Consideration would also have to be given to the variety of funding models. Because of the variation between individuals in resource use, we will require large trials to evaluate economic arguments. Widespread provision of interventions, however effective they are in practical terms, are only likely to occur once a viable financial case has been demonstrated. However, benefits may go beyond reductions in healthcare costs to improvements in quality of life; these should be quantified and accounted for in future economic analysis.

Research conducted among the long-term care population may also be informative and applicable to similarly frail elderly people residing in the community. While none of the present trials investigated this adequately, it is reasonable to include it in future research.

 

Quality of the evidence

Overall, we included 67 studies, featuring 6300 participants, in this review. Within the analyses of specific outcomes, these numbers were reduced as each study only contributed data to some comparisons. Between three and nine studies contributed to each meta-analysis of ADL outcome measures. The direction of the effect estimates in these meta-analyses was consistently in favour of rehabilitation, though not always statistically significant. Twenty-five studies contributed to the meta-analysis of mortality where rehabilitation was compared with control.

 

Risk of bias

It is possible that biases have resulted in overestimation of the effects. Most of the included studies had unclear or high risk of bias across most categories. Blinding of participants and personnel was particularly problematic, a common limitation of trials of rehabilitative interventions. The risk of selective reporting was also often unclear, in part due to the range of different outcomes measured. A large number of studies also had substantially incomplete outcome data, often due to high and differential rates of attrition. However, there was evidence of an effect on the RMI among studies with the lowest risk of bias in this review. Yet, for the three measures where lower and higher risk of bias studies could be compared (BI, TUG test, and walking speed), lower estimates of effect were found in studies with lower risk of bias. However, this was only significant for one analysis (walking speed), and each comparison included only one or two lower risk studies. Based on funnel plots and Egger's test, there was little evidence of small studies effects.

 

Trial diversity

It was disappointing that the huge variety of outcome measures used precluded a comprehensive meta-analysis. While creative variation in interventions is desirable for promoting innovation, the extent of the diversity among these trials, in both interventions and in the extensive number of outcome measures used, is highly problematic. A particular obstacle was the small number of trials replicating previous work. Where replications occurred, most often the same research group within the same location undertook them.

 

Intervention fidelity

High levels of participant attrition and poor compliance with the intervention's demands were a fairly frequent problem among these trials. This is understandable; many participants would have been unused to activity and physically frail, making them vulnerable to illness and limiting their life expectancy. Many researchers reported reluctance to comply with intervention demands and felt this apathy adversely affected the trial. While it is impossible to prevent attrition through illness and death, it should be possible to improve motivation and compliance with interventions; enjoyment of, and satisfaction with, the intervention among participants should be a priority, especially if long-term and widespread provision is ultimately intended. Ways of achieving this might include ensuring that participants perceive the intervention to be both relevant and beneficial to their lives. Many trials included social elements in both the intervention and the control group; the relationship between use of such methods and compliance requires further exploration. Incorporating the therapy into daily activities as opposed to discreet sessions also warrants closer attention.

 

Long-term follow up

The lack of postintervention follow up is problematic. Among the trials that did follow participants after the intervention (for a maximum of one year, most often three months), there was frequently no finding of intervention benefits. However, this was also often the case in these studies at the end of the intervention. It is hard to justify provision of any short-term rehabilitation intervention if any benefits the individual gains dissipate as soon as it ends. However, if benefits are sustained while the intervention remains in place, the economic and practical viability of long-term or indefinite provision need to be assessed. Moreover, some studies addressed interventions that were designed to become self-sustaining, delivered by care-home staff after an initial training and support period. Future research should follow participants for a reasonable period postintervention to clarify the durability of improvements and whether some participants require some type of long-term maintenance. If this is the case, interventions should be designed with long-term provision as a clear consideration and sustainability of the programmes evaluated.

 

Cluster trials

While 19 of the studies used cluster randomisation, only six of the studies adjusted for this in their analysis. Where we have been unable to adjust these estimates (walking speed and mortality outcomes), the cluster studies are likely to have overly narrow confidence intervals and receive excess weight in the meta-analyses. Excluding cluster trials from the meta-analyses typically resulted in an increase in effect size, although for walking speed the estimated difference decreased. The use of cluster randomisation for this type of intervention and setting will often be appropriate, as the approach can help researchers to guard against contamination and identification of the experimental intervention by staff and residents. It is also possible that some interventions may have an effect at the group level, perhaps acting through culture or opportunities to socialise, although there was no evidence of this in the sensitivity analyses conducted.

 

Potential biases in the review process

We identified a considerable amount of literature for this systematic review, providing confidence in our search strategy and indicating the wealth of innovative research. The 67 included studies included 6300 participants. We have not included possible evidence from two studies in this review because they are awaiting translation (de Greef 2006; Sung 2007). A further 29 studies are awaiting assessment, and the additional information contained could have an important impact on the conclusions of the review. Identification of this volume of literature created its own problems. The included studies present an almost overwhelming number of different interventions, ranging from traditional exercise programmes to those requiring access to machinery, and the huge variety of outcome measures used hampered our ability to synthesise the evidence and compare the effectiveness of different interventions in different types of participant and in different circumstances. Two authors extracted all data, and this was combined automatically for numerical data where there was consensus and manually for qualitative data and conflicting results, giving confidence in its quality. We performed a variety of sensitivity analyses to evaluate the robustness of the outcomes of meta-analyses. A relatively low number of studies contributed to our analysis of ADL outcomes because many studies reported a measure that could not be quantitatively combined with others. However, we do not believe this has biased results. We included five of the seven lower risk of bias studies. The 24 studies represented almost half of the participants from the 67 included studies (3139/6300). The new analyses provided an estimate of the effect size, reducing our optimism about the effectiveness of physical rehabilitation in this population expressed in the original version of this review.

 

Agreements and disagreements with other studies or reviews

Two other systematic reviews (Rydwik 2004a; Weening-Dijksterhuis 2011) evaluated the effects of physical rehabilitation on elderly residents in long-term care. Both suggest there is moderate to good evidence of effects on strength, mobility, and flexibility. Weening-Dijksterhuis 2011 also concluded there were significant positive effects on balance and ADL, while Rydwik 2004a found contradictory evidence for these outcomes. The current review, including more studies overall and excluding multi-faceted falls interventions, finds significant positive effects on all of these outcomes, although the effect size appears small. The current review also synthesises data on adverse outcomes and reports the results of meta-analyses, which were not included in those reviews.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

 

Implications for practice

The included studies provide evidence that physical rehabilitation interventions for elderly people residing in long-term care may be both safe and effective, improving physical and possibly mental state. However, the size and duration of the effects of physical rehabilitation interventions are unclear. Although physical rehabilitation may be beneficial for care-home residents, the specific type(s) with most benefit, and how these relate to resident characteristics, is unclear.

 
Implications for research

Current research suggests rehabilitation improves short-term function in ADL and is safe among elderly residents of long-term care, but the evidence for this is limited by plausible risk of bias, inconsistency, and incompleteness in the outcomes reported. Further research is needed to establish the sustainability of any improvements, to demonstrate the effect of interventions on quality of life and caregiver satisfaction, to optimise interventions, to establish how individual differences (for example, age, gender, frailty, mental state) may affect treatment outcomes, and whether different interventions should be applied to disability-based subgroups. The provision of rehabilitation services to this client group requires robust health economic evaluation. Of the ongoing studies and those awaiting assessment, a variety of measures of well-being, life satisfaction, and perceived health status are in use and one is conducting a cost-effectiveness evaluation (Gerritsen 2011). We described the characteristics of the participants and the interventions. The interventions may be applicable to this frail elderly client group regardless of location of care, but this hypothesis requires testing in future research. Future research should utilise mechanisms such as cluster randomisation and placebo interventions as part of an explicit strategy to blind participants and personnel to the experimental intervention. Publication of pre-study protocols for analysis and reporting of all outcome measures is particularly important given the wide variety of outcome measures used in these studies. Outcome measures should be chosen with care, for their relevance, sensitivity, feasibility, validity, and reliability and to allow comparison between studies. Future research should report outcomes per group for mortality, fall incidence, number of participants who fell at least once, hospitalisation incidence, number of participants hospitalised at least once, and incidence of minor injuries.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

The review authors would like to thank the Physiotherapy Research Foundation for providing the funding for this review. Particular thanks must go to Ruth Lambley who, as an author on the original review, screened search results, managed and assimilated data, and assisted with the co-ordination of the review and its writing. Thanks to authors of the papers involved in these studies for their prompt responses to queries. Thanks to Brenda Thomas and Hazel Fraser from the Cochrane Stroke Group, Michelle Fiander from EPOC, and Rob de Bie from the Rehabilitation and Related Therapies Field. Thanks to Deirdre Andre, Pat Spoor, and Rosemary Campbell-Blair, University of Leeds, for assistance with developing the search strategy and undertaking searches. Thanks to Gillian Procter and Sarah Smith for assistance with screening search results, Will Green for assistance with data extraction, Ian Sleigh for assistance with database development, and Chung Fu for retrieving articles for the review.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
Download statistical data

 
Comparison 1. Rehabilitation versus control

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Barthel Index7857Mean Difference (Random, 95% CI)6.38 [1.63, 11.12]

 2 Functional Independence Measure (FIM)4303Mean Difference (Random, 95% CI)4.98 [-1.55, 11.51]

 3 Rivermead Mobility Index (RMI)3323Mean Difference (Random, 95% CI)0.69 [0.04, 1.33]

 4 Timed Up and Go (TUG) Test7885Mean Difference (Random, 95% CI)-4.59 [-9.19, 0.01]

 5 Walking speed9590Mean Difference (Random, 95% CI)0.03 [-0.01, 0.07]

 6 Death253721Risk Ratio (M-H, Random, 95% CI)0.95 [0.80, 1.13]

 7 Barthel Index (by risk of bias)7Mean Difference (Random, 95% CI)Subtotals only

    7.1 lower risk of bias
2275Mean Difference (Random, 95% CI)3.38 [-2.10, 8.86]

    7.2 higher risk of bias
5582Mean Difference (Random, 95% CI)8.25 [1.15, 15.34]

 8 Barthel Index (by duration of intervention)7Mean Difference (Random, 95% CI)Subtotals only

    8.1 shorter (< 3 months intervention)
246Mean Difference (Random, 95% CI)17.55 [6.97, 28.13]

    8.2 longer (3+ months intervention)
5811Mean Difference (Random, 95% CI)3.08 [-0.03, 6.19]

 9 Barthel Index (by mode of delivery)7Mean Difference (Random, 95% CI)Subtotals only

    9.1 group
4256Mean Difference (Random, 95% CI)10.99 [1.51, 20.48]

    9.2 individual
2275Mean Difference (Random, 95% CI)3.38 [-2.10, 8.86]

    9.3 not reported
1326Mean Difference (Random, 95% CI)2.19 [-4.35, 8.73]

 10 Barthel Index (by baseline Barthel Index score)6Mean Difference (Random, 95% CI)Subtotals only

    10.1 better (baseline Barthel Index score > median)
3511Mean Difference (Random, 95% CI)7.94 [-1.77, 17.64]

    10.2 worse (baseline Barthel Index score < median)
3305Mean Difference (Random, 95% CI)3.97 [-0.83, 8.78]

 11 Barthel Index (by age)7Mean Difference (Random, 95% CI)Subtotals only

    11.1 younger (mean age < 85 years)
4552Mean Difference (Random, 95% CI)8.02 [-0.25, 16.30]

    11.2 older (mean age 85+ years)
3305Mean Difference (Random, 95% CI)3.97 [-0.83, 8.78]

 12 Barthel Index (by gender)7Mean Difference (Random, 95% CI)Subtotals only

    12.1 < 80% female
4402Mean Difference (Random, 95% CI)7.93 [0.18, 15.69]

    12.2 80%+ female
3455Mean Difference (Random, 95% CI)4.29 [-1.25, 9.83]

 13 Functional Independence Measure (by risk of bias)4Mean Difference (Random, 95% CI)Subtotals only

   13.1 lower risk of bias
00Mean Difference (Random, 95% CI)0.0 [0.0, 0.0]

    13.2 higher risk of bias
4303Mean Difference (Random, 95% CI)4.98 [-1.55, 11.51]

 14 Functional Independence Measure (by duration of intervention)4Mean Difference (Random, 95% CI)Subtotals only

    14.1 shorter (< 3 months intervention)
130Mean Difference (Random, 95% CI)2.0 [-10.26, 14.26]

    14.2 longer (3+ months intervention)
3273Mean Difference (Random, 95% CI)5.85 [-2.22, 13.93]

 15 Functional Independence Measure (by mode of delivery)4Mean Difference (Random, 95% CI)Subtotals only

    15.1 group
3240Mean Difference (Random, 95% CI)3.90 [-3.08, 10.88]

    15.2 individual
163Mean Difference (Random, 95% CI)11.76 [-2.66, 26.18]

 16 Functional Independence Measure (by baseline FIM score)3Mean Difference (Random, 95% CI)Subtotals only

    16.1 better (baseline FIM score > median)
295Mean Difference (Random, 95% CI)7.77 [1.39, 14.14]

    16.2 worse (baseline FIM score < median)
1145Mean Difference (Random, 95% CI)0.3 [-1.73, 2.33]

 17 Functional Independence Measure (by age)4Mean Difference (Random, 95% CI)Subtotals only

    17.1 younger (mean age < 85 years)
2128Mean Difference (Random, 95% CI)9.91 [4.41, 15.42]

    17.2 older (mean age 85+ years)
2175Mean Difference (Random, 95% CI)0.35 [-1.65, 2.34]

 18 Functional Independence Measure (by gender)4Mean Difference (Random, 95% CI)Subtotals only

    18.1 < 80% female
293Mean Difference (Random, 95% CI)6.11 [-3.33, 15.55]

    18.2 80%+ female
2210Mean Difference (Random, 95% CI)4.51 [-4.56, 13.58]

 19 Rivermead Mobility Index (by risk of bias)3Mean Difference (Random, 95% CI)Subtotals only

    19.1 lower risk of bias
3323Mean Difference (Random, 95% CI)0.69 [0.04, 1.33]

   19.2 higher risk of bias
00Mean Difference (Random, 95% CI)0.0 [0.0, 0.0]

 20 Rivermead Mobility Index (by duration of intervention)3Mean Difference (Random, 95% CI)Subtotals only

    20.1 shorter (< 3 months intervention)
149Mean Difference (Random, 95% CI)0.6 [-1.48, 2.68]

    20.2 longer (3+ months intervention)
2274Mean Difference (Random, 95% CI)0.69 [0.02, 1.37]

 21 Rivermead Mobility Index (by mode of delivery)3Mean Difference (Random, 95% CI)Subtotals only

    21.1 group
149Mean Difference (Random, 95% CI)0.6 [-1.48, 2.68]

    21.2 individual
2274Mean Difference (Random, 95% CI)0.69 [0.02, 1.37]

 22 Rivermead Mobility Index (by baseline RMI score)3Mean Difference (Random, 95% CI)Subtotals only

    22.1 better (baseline RMI score > median)
2235Mean Difference (Random, 95% CI)0.70 [0.01, 1.39]

    22.2 worse (baseline RMI score < median)
188Mean Difference (Random, 95% CI)0.6 [-1.17, 2.37]

 23 Rivermead Mobility Index (by age)3Mean Difference (Random, 95% CI)Subtotals only

    23.1 younger (mean age < 85 years)
149Mean Difference (Random, 95% CI)0.6 [-1.48, 2.68]

    23.2 older (mean age 85+ years)
2274Mean Difference (Random, 95% CI)0.69 [0.02, 1.37]

 24 Rivermead Mobility Index (by gender)3Mean Difference (Random, 95% CI)Subtotals only

    24.1 < 80% female
2235Mean Difference (Random, 95% CI)0.70 [0.01, 1.39]

    24.2 80%+ female
188Mean Difference (Random, 95% CI)0.6 [-1.17, 2.37]

 25 TUG Test (by risk of bias)7Mean Difference (Random, 95% CI)Subtotals only

    25.1 lower risk of bias
1556Mean Difference (Random, 95% CI)0.6 [-5.36, 6.56]

    25.2 higher risk of bias
6329Mean Difference (Random, 95% CI)-5.92 [-11.29, -0.54]

 26 TUG Test (by duration of intervention)7Mean Difference (Random, 95% CI)Subtotals only

    26.1 shorter (< 6 months intervention)
4185Mean Difference (Random, 95% CI)-7.34 [-13.93, -0.75]

    26.2 longer (6+ months intervention)
3700Mean Difference (Random, 95% CI)0.13 [-4.28, 4.53]

 27 TUG Test (by mode of delivery)7Mean Difference (Random, 95% CI)Subtotals only

    27.1 group
4154Mean Difference (Random, 95% CI)-4.98 [-10.74, 0.77]

    27.2 individual
3731Mean Difference (Random, 95% CI)-4.56 [-14.02, 4.90]

 28 TUG Test (by baseline TUG score)7Mean Difference (Random, 95% CI)Subtotals only

    28.1 better (baseline TUG score < median)
4185Mean Difference (Random, 95% CI)-7.34 [-13.93, -0.75]

    28.2 worse (baseline TUG score > median)
3700Mean Difference (Random, 95% CI)0.13 [-4.28, 4.53]

 29 TUG Test (by age)7Mean Difference (Random, 95% CI)Subtotals only

    29.1 younger (mean age < 85 years)
5741Mean Difference (Random, 95% CI)-5.39 [-10.77, -2.05]

    29.2 older (mean age 85+ years)
2144Mean Difference (Random, 95% CI)-5.40 [-25.75, 14.96]

 30 TUG Test (by gender)7Mean Difference (Random, 95% CI)Subtotals only

    30.1 < 80% female
3594Mean Difference (Random, 95% CI)0.17 [-3.90, 4.24]

    30.2 80%+ female
4291Mean Difference (Random, 95% CI)-7.55 [-14.28, -0.82]

 31 Walking speed (by risk of bias)9Mean Difference (Random, 95% CI)Subtotals only

    31.1 lower risk of bias
175Mean Difference (Random, 95% CI)-0.10 [-0.21, 0.01]

    31.2 higher risk of bias
8515Mean Difference (Random, 95% CI)0.04 [0.01, 0.07]

 32 Walking speed (by duration of intervention)9Mean Difference (Random, 95% CI)Subtotals only

    32.1 shorter (< 3 months intervention)
359Mean Difference (Random, 95% CI)0.24 [-0.74, 1.22]

    32.2 longer (3+ months intervention)
6531Mean Difference (Random, 95% CI)0.02 [-0.03, 0.08]

 33 Walking speed (by mode of delivery)9Mean Difference (Random, 95% CI)Subtotals only

    33.1 group
7475Mean Difference (Random, 95% CI)0.03 [-0.02, 0.07]

    33.2 individual
148Mean Difference (Random, 95% CI)0.26 [-0.32, 0.83]

    33.3 not reported
167Mean Difference (Random, 95% CI)-0.03 [-0.19, 0.13]

 34 Walking speed (by baseline walking speed)9Mean Difference (Random, 95% CI)Subtotals only

    34.1 better (baseline walking speed > median)
5198Mean Difference (Random, 95% CI)-0.00 [-0.15, 0.14]

    34.2 worse (baseline walking speed < median)
4392Mean Difference (Random, 95% CI)0.04 [0.01, 0.07]

 35 Walking speed (by age)9Mean Difference (Random, 95% CI)Subtotals only

    35.1 younger (mean age < 85 years)
9590Mean Difference (Random, 95% CI)0.03 [-0.01, 0.07]

   35.2 older (mean age 85+ years)
00Mean Difference (Random, 95% CI)0.0 [0.0, 0.0]

 36 Walking speed (by gender)9Mean Difference (Random, 95% CI)Subtotals only

    36.1 < 80% female
5437Mean Difference (Random, 95% CI)0.01 [-0.04, 0.07]

    36.2 80%+ female
4153Mean Difference (Random, 95% CI)0.13 [-0.02, 0.28]

 37 Walking speed (by distance walked)9Mean Difference (Random, 95% CI)Subtotals only

    37.1 less far (< 6 metres)
2185Mean Difference (Random, 95% CI)0.04 [0.01, 0.07]

    37.2 further (6+ metres)
7405Mean Difference (Random, 95% CI)0.01 [-0.06, 0.09]

 38 Death (by risk of bias)25Risk Ratio (M-H, Random, 95% CI)Subtotals only

    38.1 lower risk of bias
61366Risk Ratio (M-H, Random, 95% CI)1.05 [0.76, 1.46]

    38.2 higher risk of bias
192355Risk Ratio (M-H, Random, 95% CI)0.88 [0.71, 1.10]

 39 Death (by duration of intervention)25Risk Ratio (M-H, Random, 95% CI)Subtotals only

    39.1 shorter intervention (< 3 months)
10663Risk Ratio (M-H, Random, 95% CI)0.64 [0.18, 2.29]

    39.2 longer intervention (3+ months)
153058Risk Ratio (M-H, Random, 95% CI)0.95 [0.80, 1.14]

 40 Death (by mode of delivery)25Risk Ratio (M-H, Random, 95% CI)Subtotals only

    40.1 group
121007Risk Ratio (M-H, Random, 95% CI)0.82 [0.46, 1.49]

    40.2 individual
92172Risk Ratio (M-H, Random, 95% CI)0.91 [0.70, 1.19]

    40.3 group and individual
124Risk Ratio (M-H, Random, 95% CI)5.0 [0.27, 94.34]

    40.4 not reported
3518Risk Ratio (M-H, Random, 95% CI)1.00 [0.73, 1.36]

 41 Death (by age)25Risk Ratio (M-H, Random, 95% CI)Subtotals only

    41.1 younger (mean age < 85 years)
163001Risk Ratio (M-H, Random, 95% CI)0.97 [0.81, 1.17]

    41.2 older (mean age 85+ years)
9720Risk Ratio (M-H, Random, 95% CI)0.79 [0.49, 1.27]

 42 Death (by gender)25Risk Ratio (M-H, Random, 95% CI)Subtotals only

    42.1 < 80% female
122366Risk Ratio (M-H, Random, 95% CI)0.98 [0.77, 1.25]

    42.2 80%+ female
121340Risk Ratio (M-H, Random, 95% CI)0.91 [0.71, 1.18]

    42.3 not reported
115Risk Ratio (M-H, Random, 95% CI)0.88 [0.16, 4.68]

 43 Sensitivity analysis: Barthel Index (fixed-effect)7857Mean Difference (Fixed, 95% CI)4.54 [1.59, 7.49]

 44 Sensitivity analysis: Barthel Index (cluster trials)7Mean Difference (Random, 95% CI)Subtotals only

    44.1 cluster (adjusted)
5811Mean Difference (Random, 95% CI)3.08 [-0.03, 6.19]

    44.2 individual
246Mean Difference (Random, 95% CI)17.55 [6.97, 28.13]

 45 Sensitivity analysis: Functional Independence Measure (fixed-effect)4303Mean Difference (Fixed, 95% CI)1.46 [-0.42, 3.34]

 46 Sensitivity analysis: Rivermead Mobility Index (fixed-effect)3323Mean Difference (Fixed, 95% CI)0.69 [0.04, 1.33]

 47 Sensitivity analysis: TUG Test (fixed-effect)7885Mean Difference (Fixed, 95% CI)-3.66 [-5.86, -1.45]

 48 Sensitivity anlaysis: TUG Test (cluster trials)7Mean Difference (Random, 95% CI)Subtotals only

    48.1 cluster (adjusted)
2Mean Difference (Random, 95% CI)0.51 [-3.93, 4.95]

    48.2 individual
5Mean Difference (Random, 95% CI)-7.85 [-14.34, -1.37]

 49 Sensitivity analysis: TUG Test (re-including Christofoletti 2008)8914Mean Difference (Random, 95% CI)-8.41 [-15.53, -1.29]

 50 Sensitivity analysis: Walking speed (fixed-effect)9590Mean Difference (Fixed, 95% CI)0.03 [0.00, 0.06]

 51 Sensitivity analysis: Walking speed (cluster trials)9Mean Difference (Random, 95% CI)Subtotals only

    51.1 cluster (unadjusted)
1Mean Difference (Random, 95% CI)0.04 [0.01, 0.07]

    51.2 individual
8Mean Difference (Random, 95% CI)0.01 [-0.05, 0.08]

 52 Sensitivity analysis: Death (random-effects: odds ratio)253721Odds Ratio (M-H, Random, 95% CI)0.93 [0.75, 1.15]

 53 Sensitivity analysis: Death (random-effects: risk difference)253721Risk Difference (M-H, Random, 95% CI)-0.01 [-0.02, 0.01]

 54 Sensitivity analysis: Death (fixed-effect)253721Risk Ratio (M-H, Random, 95% CI)0.95 [0.80, 1.13]

 55 Sensitivity analysis: Death (fixed-effect: Peto odds ratio)253721Peto Odds Ratio (Peto, Fixed, 95% CI)0.93 [0.75, 1.14]

 56 Sensitivity analysis: Death (cluster trials)25Risk Ratio (M-H, Random, 95% CI)Subtotals only

    56.1 cluster (unadjusted)
132644Risk Ratio (M-H, Random, 95% CI)0.95 [0.79, 1.15]

    56.2 individual
121077Risk Ratio (M-H, Random, 95% CI)0.93 [0.60, 1.44]

 57 Sensitivity analysis: Death (including Brittle 2009)263777Risk Ratio (M-H, Random, 95% CI)0.94 [0.79, 1.11]

 
Comparison 2. Rehabilitation (experimental) versus rehabilitation (control)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 TUG Test257Mean Difference (Random, 95% CI)-7.95 [-19.22, 3.31]

 2 Death4118Risk Ratio (M-H, Random, 95% CI)2.67 [0.12, 60.93]

 3 Sensitivity analysis: TUG Test (fixed-effect)257Mean Difference (Fixed, 95% CI)-7.19 [-10.92, -3.46]

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Appendix 1. CENTRAL search strategy

We used the following search strategy for CENTRAL

1 MeSH descriptor Homes for the Aged, this term only
2 MeSH descriptor Nursing Homes, this term only
3 "home* for the aged":ti,ab,kw or (aged NEAR/2 (care or nursing or healthcare or residential) NEAR/2 (facility or facilities or home*)):ti,ab,kw or (geriatric or elderly) NEAR/2 (facility or facilities or care home*):ti,ab,kw
4 (nursing home*):ti,ab,kw
5 MeSH descriptor Hospitals, Veterans, this term only
6 (#1 OR #2 OR #3 OR #4 OR #5)
7 MeSH descriptor Aged explode all trees
8 MeSH descriptor Geriatrics explode all trees
9 (gerontol* or ageing or aging or elder* or geriatric* or seniors or old age or older or late* life):ti,ab,kw
10 (older NEXT (person* or people or adult* or patient* or inpatient* or outpatient*)):ti,ab,kw
11 MeSH descriptor Veterans, this term only
12 (veteran*):ti,ab,kw
13 (#7 OR #8 OR #9 OR #10 OR #11 OR #12)
14 MeSH descriptor Nursing Care, this term only
15 MeSH descriptor Rehabilitation Nursing, this term only
16 MeSH descriptor Community Health Nursing, this term only
17 MeSH descriptor Hospitals, Convalescent, this term only
18 MeSH descriptor Rehabilitation Centers, this term only
19 MeSH descriptor Institutionalization, this term only
20 (#14 OR #15 OR #16 OR #17 OR #18 OR #19)
21 (#13 AND #20)
22 MeSH descriptor Group Homes, this term only
23 MeSH descriptor Assisted Living Facilities, this term only
24 MeSH descriptor Residential Facilities, this term only
25 MeSH descriptor Long-Term Care, this term only
26 MeSH descriptor Halfway Houses, this term only
27 (group or residential) NEXT (home or homes):ti,ab,kw
28 (hous* or residental or residence* or institution* or facility or facilities) NEAR/5 (elder* or geriatric* or seniors or older or aged):ti,ab,kw
29 ((residential or long-term or longterm) NEAR/5 (care or facility or facilities)):ti,ab,kw
30 (sheltered or retirement or residential or halfway or half-way) NEAR/5 (hous* or home* or accommodation):ti,ab,kw
31 (life care cent* or continuing care cent* or extended care facility or extended care facilities):ti,ab,kw
32 (care or convalescent) NEXT (home* or cent* or facility or facilities):ti,ab,kw
33 (skilled or intermediate) NEAR/2 (nursing facility or nursing facilities):ti,ab,kw
34 (healthcare NEAR/2 (facility or facilities)):ti,ab,kw
35 (#32 OR #33 OR #34)
36 (#35 AND #13)
37 (assisted living):ti,ab,kw
38 (#22 OR #23 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29 OR #30 OR #31 OR #36 OR #37)
39 (#6 OR #21 OR #38)
40 MeSH descriptor Rehabilitation, this term only
41 MeSH descriptor Activities of Daily Living, this term only
42 MeSH descriptor Dance Therapy, this term only
43 MeSH descriptor Early Ambulation, this term only
44 MeSH descriptor Exercise Therapy, this term only
45 MeSH descriptor Muscle Stretching Exercises, this term only
46 MeSH descriptor Resistance Training, this term only
47 MeSH descriptor Occupational Therapy, this term only
48 MeSH descriptor Physical Therapy Modalities, this term only
49 MeSH descriptor Hydrotherapy, this term only
50 MeSH descriptor Musculoskeletal Manipulations, this term only
51 MeSH descriptor Physical Therapy (Specialty), this term only
52 MeSH descriptor Exercise Movement Techniques, this term only
53 MeSH descriptor Exercise, this term only
54 MeSH descriptor Tai Ji, this term only
55 MeSH descriptor Walking, this term only
56 MeSH descriptor Yoga, this term only
57 MeSH descriptor Physical Education and Training, this term only
58 MeSH descriptor Physical Fitness, this term only
59 MeSH descriptor Recovery of Function, this term only
60 MeSH descriptor Residential Treatment, this term only
61 MeSH descriptor Physical Stimulation, this term only
62 MeSH descriptor Health Promotion, this term only
63 MeSH descriptor Leisure Activities, this term only
64 MeSH descriptor Recreation, this term only
65 MeSH descriptor Dancing, this term only
66 MeSH descriptor Health Facility Environment, this term only
67 (rehabilitat* or exercise* or physiotherap* or "keep fit"):ti,ab,kw
68 (physical near/3 (therap* or education or train* or stimulat* or fitness or activit* or function)):ti,ab,kw
69 (exercise or movement or occupational or residential) near/5 (therap* or train* or treatment or program*):ti,ab,kw
70 (strength* or aerobic or resistance) near/3 activit*:ti,ab,kw
71 (improve* near/3 (function or mobil* or recover*)):ti,ab,kw
72 (fitness or health) near/3 promotion:ti,ab,kw
73 (danc* or walk* or yoga or "tai chi" or "tai ji" or "tai chi" or "ji quan" or taiji or taijiquan or "leisure activit*" or recreation* or bicycl* or cycl* or bike* or biking):ti,ab,kw
74 (endurance or balance or strength or flexibility or resistance) near/3 training:ti,ab,kw
75 (#40 OR #41 OR #42 OR #43 OR #44 OR #45 OR #46 OR #47 OR #48 OR #49 OR #50 OR #51 OR #52 OR #53 OR #54 OR #55 OR #56 OR #57 OR #58 OR #59 OR #60 OR #61 OR #62 OR #63 OR #64 OR #65 OR #66 OR #67 OR #68 OR #69 OR #70 OR #71 OR #72 OR #73 OR #74)
76 (#39 AND #75), from 2009 to 2011

 

Appendix 2. MEDLINE search strategy

We used the following search strategy for MEDLINE (Ovid) and adapted it for the other databases

1. Homes for the Aged/ or "homes for the aged".tw.
2. exp Nursing Homes/ or nursing home?.tw.
3. (aged adj2 (care or nursing or healthcare or residential) adj2 (facility or facilites or home?)).ti,ab.
4. ((geriatric or elderly) adj2 (facility or facilities or care home?)).ti,ab.
5. Hospitals, Veterans/
6. Housing for the Elderly/
7. Geriatric Nursing/
8. or/1-7 [care facilities/nursing - aged terms]
9. exp aged/
10. (gerontol* or ageing or aging or elder* or geriatric* or seniors or old age or older or late* life).ti,ab.
11. (older adj (person* or people or adult* or patient* or inpatient* or outpatient*)).ti,ab.
12. veterans/
13. veteran.ti,ab.
14. or/9-13 [elderly terms]
15. Nursing Care/
16. Rehabilitation Nursing/
17. Community Health Nursing/
18. Hospitals, Convalescent/
19. Rehabilitation Centers/
20. Institutionalization/
21. or/15-20 [institutional care terms]
22. 14 and 21 [institutional care terms and elderly terms]
23. Group Homes/
24. Assisted Living Facilities/
25. Residential Facilities/
26. Long-Term Care/
27. Halfway Houses/
28. ((group or residential) adj home?).ti,ab.
29. ((hous$ or residental or residence? or institution$ or facility or facilities) adj5 (elder* or geriatric* or seniors or older or aged)).ti,ab.
30. ((residential or long-term or longterm) adj5 (care or facility or facilities)).ti,ab.
31. ((sheltered or retirement or residential or halfway or half-way) adj5 (hous$ or home? or accommodation)).ti,ab.
32. (life care cent$ or continuing care cent$ or extended care facility or extended care facilities).ti,ab.
33. ((care or convalescent) adj (home? or cent$ or facility or facilities)).ti,ab. and 14
34. ((skilled or intermediate) adj2 (nursing facility or nursing facilities)).ti,ab. and 14
35. (healthcare adj2 (facility or facilities)).ti,ab. and 14
36. assisted living.ti,ab.
37. or/23-35 [other residential are terms]
38. 8 or 22 or 37 [care facilities/nursing -aged or institutional care terms and elder or other residential care terms]
39. rehabilitation/ or "activities of daily living"/
40. dance therapy/ or early ambulation/ or exercise therapy/ or muscle stretching exercises/ or resistance training/ or occupational therapy/
41. physical therapy modalities/ or hydrotherapy/ or musculoskeletal manipulations/
42. "Physical Therapy (Specialty)"/
43. Exercise Movement Techniques/
44. Exercise/
45. Tai Ji/
46. aqua.mp.
47. walking/ or yoga/
48. "Physical Education and Training"/
49. Physical Fitness/
50. "Recovery of Function"/
51. Residential Treatment/
52. Physical Stimulation/
53. Health Promotion/
54. leisure activities/ or recreation/ or dancing/
55. Health Facility Environment/
56. (rehabilitat$ or exercise$ or physiotherap$ or keep fit).tw.
57. (physical adj3 (therap$ or education or train$ or stimulat$ or fitness or activit$ or function)).tw.
58. ((exercise or movement or occupational or residential) adj5 (therap$ or train$ or treatment or program$)).tw.
59. ((strength$ or aerobic or resistance) adj3 activit$).tw.
60. (improve$ adj3 (function or mobil$ or recover$)).tw.
61. ((fitness or health) adj3 promotion).tw.
62. (danc$ or walk$ or yoga or tai chi or tai ji or ji quan or taiji or taijiquan or leisure activit$ or recreation$ or bicycl$ or cycl$ or bike$ or biking).tw.
63. ((endurance or balance or strength or flexibility or resistance) adj3 training).tw.
64. or/39-63 [rehabilitation terms]
65. randomized controlled trials as topic/
66. random allocation/
67. controlled clinical trials as topic/
68. control groups/
69. clinical trials as topic/ or clinical trials, phase i as topic/ or clinical trials, phase ii as topic/ or clinical trials, phase iii as topic/ or clinical trials, phase iv as topic/
70. clinical trials data monitoring committees/
71. double-blind method/
72. single-blind method/
73. placebos/
74. placebo effect/
75. cross-over studies/
76. multicenter studies as topic/
77. therapies, investigational/
78. drug evaluation/
79. research design/
80. program evaluation/
81. evaluation studies as topic/
82. randomized controlled trial.pt.
83. controlled clinical trial.pt.
84. (clinical trial or clinical trial phase i or clinical trial phase ii or clinical trial phase iii or clinical trial phase iv).pt.
85. multicenter study.pt.
86. (evaluation studies or comparative study).pt.
87. meta analysis.pt.
88. meta-analysis as topic/
89. random$.tw.
90. (controlled adj5 (trial$ or stud$)).tw.
91. (clinical$ adj5 trial$).tw.
92. ((control or treatment or experiment$ or intervention) adj5 (group$ or subject$ or patient$)).tw.
93. (surgical adj5 (group$ or subject$ or patient$)).tw.
94. (quasi-random$ or quasi random$ or pseudo-random$ or pseudo random$).tw.
95. ((multicenter or multicentre or therapeutic) adj5 (trial$ or stud$)).tw.
96. ((control or experiment$ or conservative) adj5 (treatment or therapy or procedure or manage$)).tw.
97. ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).tw.
98. (coin adj5 (flip or flipped or toss$)).tw.
99. latin square.tw.
100. versus.tw.
101. (cross-over or cross over or crossover).tw.
102. placebo$.tw.
103. sham.tw.
104. (assign$ or alternate or allocat$ or counterbalance$ or multiple baseline).tw.
105. controls.tw.
106. (treatment$ adj6 order).tw.
107. (meta-analy$ or metaanaly$ or meta analy$ or systematic review or systematic overview).tw.
108. or/65-107
109. exp animals/ not humans.sh.
110. 108 not 109 [RCT Filter - Cochrane Stroke Group]
111. 38 and 64 and 110 [care facilities/nursing -aged or institutional care terms and elder or other residential care and rehabilitation terms and RCT]

 

Appendix 3. EMBASE search strategy

We used the following search strategy for EMBASE

1. "homes for the aged".tw.
2. exp nursing home/ or nursing home?.tw.
3. (aged adj2 (care or nursing or healthcare or residential) adj2 (facility or facilites or home?)).ti,ab.
4. ((geriatric or elderly) adj2 (facility or facilities or care home?)).ti,ab.
5. exp elderly care/
6. geriatric hospital/
7. or/1-6 [care facilities - aged terms]
8. aging/
9. gerontology/
10. (gerontol* or ageing or aging or elder* or geriatric* or seniors or old age or older or late* life).ti,ab.
11. (older adj (person* or people or adult* or patient* or inpatient* or outpatient*)).ti,ab.
12. veteran.ti,ab.
13. or/8-12 [elderly terms]
14. nursing care/ or patient care/
15. Rehabilitation Nursing/ or Rehabilitation Center/
16. exp convalescence/
17. exp community health nursing/
18. residential care/
19. or/14-18 [institutional care terms]
20. 19 and 13 [instutional care homes and elderly terms]
21. residential home/
22. assisted living facility/
23. residential home/
24. long term care/
25. Halfway House/
26. ((group or residential) adj home?).ti,ab.
27. ((hous$ or residental or residence? or institution$ or facility or facilities) adj5 (elder* or geriatric* or seniors or older or aged)).ti,ab.
28. ((residential or long-term or longterm) adj5 (care or facility or facilities)).ti,ab.
29. ((sheltered or retirement or residential or halfway or half-way) adj5 (hous$ or home? or accommodation)).ti,ab.
30. (life care cent$ or continuing care cent$ or extended care facility or extended care facilities).ti,ab.
31. ((care or convalescent) adj (home? or cent$ or facility or facilities)).ti,ab. and 13
32. ((skilled or intermediate) adj2 (nursing facility or nursing facilities)).ti,ab. and 13
33. (healthcare adj2 (facility or facilities)).ti,ab. and 13
34. assisted living.ti,ab.
35. or/21-34 [other residential are terms]
36. 7 or 20 or 35 [care facilities/nursing -aged or institutional care terms and elder or other residential care terms]
37. exp rehabilitation/
38. daily life activity/
39. exp Physiotherapy/ or physical activity/ or physical education/
40. exp KINESIOTHERAPY/
41. fitness/ or training/ or sport/
42. hydrotherapy/
43. mobilization/ or stimulation/
44. dancing/
45. health promotion/ or health education/ or health program/
46. recreation/ or leisure/
47. (rehabilitat$ or exercise$ or physiotherap$ or kinesiotherap$ or keep fit).tw.
48. (physical adj3 (therap$ or education or train$ or stimulat$ or fitness or activit$ or function)).tw.
49. ((exercise or movement or occupational or residential) adj5 (therap$ or train$ or treatment or program$)).tw.
50. ((strength$ or aerobic or resistance) adj3 activit$).tw.
51. (improve$ adj3 (function or mobil$ or recover$)).tw.
52. recovery of function/
53. ((fitness or health) adj3 promotion).tw.
54. (danc$ or walk$ or yoga or tai chi or tai ji or ji quan or taiji or taijiquan or leisure activit$ or recreation$ or bicycl$ or cycl$ or bike$ or biking).tw.
55. ((endurance or balance or strength or flexibility or resistance) adj3 training).tw.
56. or/37-55 [rehab terms]
57. randomized controlled trial/
58. randomization/
59. controlled study/
60. control group/
61. clinical trial/ or phase 1 clinical trial/ or phase 2 clinical trial/ or phase 3 clinical trial/ or phase 4 clinical trial/ or controlled clinical trial/
62. crossover procedure/
63. double blind procedure/
64. single blind procedure/ or triple blind procedure/
65. latin square design/
66. parallel design/
67. placebo/
68. multicenter study/
69. experimental design/ or experimental study/ or quasi experimental study/
70. experimental therapy/
71. drug comparison/ or drug dose comparison/
72. drug screening/
73. evaluation/ or "evaluation and follow up"/ or evaluation research/ or clinical evaluation/
74. methodology/
75. "types of study"/
76. research subject/
77. comparative study/
78. "systematic review"/
79. meta analysis/
80. random$.tw.
81. (controlled adj5 (trial$ or stud$)).tw.
82. (clinical$ adj5 trial$).tw.
83. ((control or treatment or experiment$ or intervention) adj5 (group$ or subject$ or patients$)).tw.
84. (surgical adj5 (group$ or subject$ or patient$)).tw.
85. (quasi-random$ or quasirandom$ or pseudo-random$ or pseudorandom$).tw.
86. ((multicenter or multi center or multicentre or multi centre or therapeutic) adj5 (trial$ or stud$)).tw.
87. ((control or experiment$ or conservative) adj5 (treatment or therapy or procedure or manage$)).tw.
88. ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).tw.
89. (coin adj5 (flip or flipped or toss$)).tw.
90. latin square.tw.
91. versus.tw.
92. (cross-over or crossover).tw.
93. placebo$.tw.
94. sham.tw.
95. (assign$ or alternate or allocat$ or counterbalance$ or multiple baseline).tw.
96. controls.tw.
97. (treatment$ adj6 order).tw.
98. (meta-analy$ or metaanaly$ or metanaly$ or systematic review or systematic overview).tw.
99. or/57-98
100. human/
101. nonhuman/
102. 100 and 101
103. 101 not 102
104. 99 not 103 [RCT Filter]
105. 36 and 56 and 104 [care facilities/nursing -aged or institutional care terms and elder or other residential care and rehabilitation terms and RCT]

 

Appendix 4. CINAHL search strategy

We used the following search strategy for CINAHL


S1 "homes for the aged"

S2 MH Nursing Homes+ or MW Nursing Home OR "nursing home" OR "nursing homes"

S3 TI aged N2 care facilit* or AB aged N2 care facilit* or TI aged N2 care home* or AB aged care home* or TI aged N2 nursing facilit* or AB aged N2 nursing facilit* or TI aged nursing home* or AB aged nursing home* or TI aged N1 healthcare facilit* or AB aged N1 healthcare facilit* or TI resident* N2 care or AB resident* N2 care or TI resident* N2 facilit* or AB resident* N2 facilit*

S4 TI geriatric N2 facility OR AB geriatric N2 facility OR TI elderly N2 facility OR AB elderly N2 facility OR TI geriatric N2 facilities OR AB elderly N2 facilities OR TI geriatric N2 "care home" OR AB elderly N2 "care home" OR TI geriatric N2 "care homes" OR AB elderly N2 "care homes"

S5 MH hospitals, veterans

S6 MH housing for the elderly

S7 MH gerontologic nursing

S8 MH gerontologic care or MH rehabilitation, geriatric

S9 (S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8)

S10 (MH "Aged+")

S11 TI ( (gerontol* or ageing or aging or elder* or geriatric* or seniors or old age or older or late* life) ) OR AB ( (gerontol* or ageing or aging or elder* or geriatric* or seniors or old age or older or late* life) )

S12 TI ( (older N1 person* older N1 people or older N1 adult* or older N1 patient* or older N1 inpatient* or older N1 outpatient*) ) OR AB ( (older N1 person* older N1 people or older N1 adult* or older N1 patient* or older N1 inpatient* or older N1 outpatient*) )

S13 (MH "Veterans")

S14 TI veteran* OR AB veteran*

S15 (S10 or S11 or S12 or S13 or S14)

S16 MH nursing care

S17 MH rehabilitation nursing

S18 MH rehabilitation patients

S19 MH community health nursing

S20 MH rehabilitation centers

S21 MH institutionalization

S22 (S16 or S17 or S18 or S19 or S20 or S21)

S23 S15 and S22

S24 MH Assisted Living

S25 TI ( longterm N5 care or longterm N5 facilit* ) or AB ( longterm N5 care or longterm N5 facilit* ) or TI ( long-term N5 care or long-term N5 facilit* ) or AB ( long-term N5 care or long-term N5 facilit* )

S26 (MH "Halfway Houses")

S27 TI ( group N1 home* or residential N1 home* ) or AB ( group N1 home* or residential N1 home* )

S28 TI ( hous* N5 elder* or residential N5 elder* or residence N5 elder* or residences N5 elder*or institution* N5 elder* or facility N5 elder* or facilities N5 elder*or hous* N5 geriatric* or residential N5 geriatric* or residence N5 geriatric* or residences N5 elder*or institution* N5 geriatric* or facility N5 geriatric* or facilities N5 geriatric*or hous* N5 seniors or residential N5 seniors or residence N5 seniors or residences N5 elder*or institution* N5 seniors or facility N5 seniors or facilities N5 seniors or hous* N5 older or residential N5 older or residence N5 older or residences N5 elder*or institution* N5 older or facility N5 older or facilities N5 older or hous* N5 aged or residential N5 aged or residence N5 aged or residences N5 elder*or institution* N5 aged or facility N5 aged or facilities N5 aged ) OR AB ( hous* N5 elder* or residential N5 elder* or residence N5 elder* or residences N5 elder*or institution* N5 elder* or facility N5 elder* or facilities N5 elder*or hous* N5 geriatric* or residential N5 geriatric* or residence N5 geriatric* or residences N5 elder*or institution* N5 geriatric* or facility N5 geriatric* or facilities N5 geriatric*or hous* N5 seniors or residential N5 seniors or residence N5 seniors or residences N5 elder*or institution* N5 seniors or facility N5 seniors or facilities N5 seniors or hous* N5 older or residential N5 older or residence N5 older or residences N5 elder*or institution* N5 older or facility N5 older or facilities N5 older or hous* N5 aged or residential N5 aged or residence N5 aged or residences N5 elder*or institution* N5 aged or facility N5 aged or facilities N5 aged )

S29 ( TI resident* N2 care or AB resident* N2 care or TI resident* N2 facilit* or AB resident* N2 facilit* ) OR ( TI ( longterm N3 care or longterm N3 facilit* ) or AB ( longterm N3 care or longterm N3 facilit* ) or TI ( long-term N3 care or long-term N3 facilit* ) or AB ( long-term N3 care or long-term N3 facilit* ) )

S30 TI ( sheltered hous* or sheltered home or sheltered homes or sheltered accommodation or retirement hous* or retirement home or retirement homes or retirement accommodation or residential hous* or residential home or residential homes or residential accommodation or Halfway hous* or halfway home or halfway homes or halfway accommodation or Half-way hous* or half-way home or half-way homes or half-way accommodation ) OR AB ( sheltered hous* or sheltered home or sheltered homes or sheltered accommodation or retirement hous* or retirement home or retirement homes or retirement accommodation or residential hous* or residential home or residential homes or residential accommodation or Halfway hous* or halfway home or halfway homes or halfway accommodation or Half-way hous* or half-way home or half-way homes or half-way accommodation )

S31 TI ( life care cent* or continued care cent* or extended care facilit* ) or AB ( life care cent* or continued care cent* or extended care facilit* )

S32 TI (care W1 home*) or AB (care W1 home*) or TI (care W1 center*) or AB (care W1 center*) or TI (care W1 centre*) or AB (care W1 centre*) or TI ( care W1 facilit*) or AB ( care W1 facilit* ) or TI (convalescent W1 home*) or AB (convalescent W1 home*) or TI (convalescent W1 center*) or AB (convalescent W1 center*) or TI (convalescent W1 centre*) or AB (convalescent W1 centre*) or TI ( convalescent W1 facilit*) or AB ( convalescent W1 facilit* )

S33 TI skilled W2 nursing facilit* or AB skilled W2 nursing facilit* or TI intermediate W2 nursing facilit* or AB intermediate W2 nursing facilit*

S34 TI ( healthcare N2 facilitiy or healthcare N2 facilities ) OR AB ( healthcare N2 facilitiy or healthcare N2 facilities )

S35 (S32 or S33 or S34)

S36 S15 and S35

S37 TI Assisted Living or AB Assisted Living

S38 (S24 or S25 or S26 or S27 or S28 or S29 or S30 or S31 or S36 or S37)

S39 MH rehabilitation

S40 MH occupational therapy

S41 MH physical therapy

S42 MH therapeutic exercise

S43 MH exercise

S44 MH dance therapy

S45 MH early ambulation

S46 MH tai chi

S47 MH walking

S48 MH yoga

S49 MH "physical education and training"

S50 MH physical fitness

S51 MH physical stimulation

S52 MH health promotion

S53 MH leisure activities or MH recreation or MH dancing

S54 MH health facility environment

S55 "activities of daily living"

S56 aqua

S57 rehabilitat* or exercise* or physiotherap* or keep fit

S58 hydrotherap* or musculoskeletal manipulations

S59 physical N3 therap* or physical N3 education or physical N3 train$ or physical N3 stimulat* or fitness or physical N3 activit* or physical N3 function*

S60 movement N5 therap* or movement N5 train* or movement N5 treatment* or movement N5 program*

S61 occupational N5 therap* or occupational N5 train* or occupational N5 treatment* or occupational N5 program*

S62 residential N5 therap* or residential N5 train* or residential N5 treatment* or residential N5 program*

S63 dance therapy or early ambulation or exercise* or muscle stretching

S64 strength* N3 activit* or aerobic N3 activit* or resistance N3 activit*

S65 improv* N3 function or improv* N3 mobil* or improv* N3 recover*

S66 fitness promotion or health promotion

S67 danc* or walk* or yoga or tai chi or tai ji or tai chi or ji quan or taiji or taijiquan or leisure activit* or recreation* or bicycl* or cycl* or bike* or biking

S68 endurance N3 training or balance N3 training or strength N3 training or flexibility N3 training or resistance N3 training

S69 recover* N3 function*

S70 health N3 facilit*

S71 (MH "Activities of Daily Living+") or (MH "Activities of Daily Living (Saba CCC)") or (MH "Activities of Daily Living Alteration (Saba CCC)") or (MH "Instrumental Activities of Daily Living (Saba CCC)") or (MH "Instrumental Activities of Daily Living Alteration (Saba CCC)") or (MH "Altered Activities of Daily Living (NANDA) (Non-Cinahl)+") or (MH "Self Care: Activities of Daily Living (Iowa NOC)") or (MH "Self-Care: Instrumental Activities of Daily Living (Iowa NOC)")

S72 MH random assignment

S73 MH random sample+

S74 MH crossover design

S75 MH clinical trials+

S76 MH comparative studies

S77 MH "control (research)"

S78 MH control group

S79 MH factorial design

S80 MH quasi-experimental studies

S81 MH nonrandomized trials

S82 MH placebos

S83 MH meta analysis

S84 MH clinical nursing research or MH clinical research

S85 MH community trials or MH experimental studies or MH one-shot case study or MH pre-test-post-test design or MH solomon four-group design or MH static group comparison or MH study design

S86 PT clinical trial or systematic review

S87 random*

S88 singl* N25 blind* or singl* N25 mask*

S89 doubl* N25 blind* or doubl* N25 mask*

S90 tripl* N25 blind* or tripl* N25 mask*

S91 trebl* N25 blind* or trebl* N25 mask*

S92 crossover or cross over or placebo* or control* or factorial

S93 crossover or cross over or placebo* or control* or factorial or sham*

S94 clin* N10 trial* or intervention* N10 trial* or compar* N10 trial* or experiment* N10 trial* or preventive N10 trial* or therapeutic N10 trial*

S95 counterbalance* or multiple baseline* or abab design*

S96 metaanalys* or meta analys* or metanalys* or systematic review*

S97 S72 or S73 or S74 or S75 or S76 or S77 or S78 or S79 or S80 or S81 or S82 or S83 or S84 or S85 or S86 or S87 or S88 or S89 or S90 or S91 or S92 or S93 or S94 or S95 or S96

S98 S39 or S40 or S41 or S42 or S43 or S44 or S45 or S46 or S47 or S48 or S49 or S50 or S51 or S52 or S53 or S54 or S55 or S56 or S57 or S58 or S59 or S60 or S61 or S62 or S63 or S64 or S65 or S66 or S67 or S68 or S69 or S70 or S71

S99 S38 and S97 and S98



 

Appendix 5. AMED search strategy

We used the following search strategy for AMED

1. "homes for the aged".tw.
2. nursing home?.tw.
3. (aged adj2 (care or nursing or healthcare or residential) adj2 (facility or facilites or home?)).ti,ab.
4. ((geriatric or elderly) adj2 (facility or facilities or care home?)).ti,ab.
5. exp Geriatric nursing/
6. geriatric assessment/
7. exp health services for the aged/
8. or/1-7 [caring - elderly terms]
9. aged/ or aging/
10. (gerontol* or ageing or aging or elder* or geriatric* or seniors or old age or older or late* life).ti,ab.
11. (older adj (person* or people or adult* or patient* or inpatient* or outpatient*)).ti,ab.
12. veteran.ti,ab.
13. or/9-12 [elderly terms]
14. nursing care/
15. rehabilitation nursing.ti,ab.
16. (rehabilitation center$ or rehabilitation centre$).ti,ab.
17. rehabilitation speciality/
18. exp Institutionalization/
19. exp Community health nursing/
20. or/14-19 [institutional care terms]
21. 13 and 20 [institutional care terms and elderly]
22. residential facilities/
23. exp Long term care/
24. ((group or residential) adj home?).ti,ab.
25. ((hous$ or residental or residence? or institution$ or facility or facilities) adj5 (elder* or geriatric* or seniors or older or aged)).ti,ab.
26. ((residential or long-term or longterm) adj5 (care or facility or facilities)).ti,ab.
27. ((sheltered or retirement or residential or halfway or half-way) adj5 (hous$ or home? or accommodation)).ti,ab.
28. (life care cent$ or continuing care cent$ or extended care facility or extended care facilities).ti,ab.
29. ((care or convalescent) adj (home? or cent$ or facility or facilities)).ti,ab. and 14
30. ((skilled or intermediate) adj2 (nursing facility or nursing facilities)).ti,ab. and 14
31. (healthcare adj2 (facility or facilities)).ti,ab. and 14
32. assisted living.ti,ab.
33. or/22-32 [other residential terms]
34. 8 or 21 or 33 [care facilities/nursing -aged or institutional care terms and elder or other residential care terms]
35. rehabilitation/
36. occupational therapy/
37. physical therapy modalities/
38. exp exercise therapy/
39. exp Hydrotherapy/
40. exp mobilisation/ or exp movement/
41. aqua.mp.
42. muscle strength/ or muscle weakness/ or pliability/
43. exp physical education/
44. exp Physical fitness/
45. recovery of function.ti,ab.
46. exp rehabilitation techniques/
47. exp Residential treatment/
48. "delivery of health care"/
49. (rehabilitat$ or exercise$ or physiotherap$ or keep fit).ti,ab.
50. (physical and (therap$ or education or train$ or stimulat$ or fitness or activit$ or function$)).ti,ab.
51. ((exercise or occupational or residential) and (therap$ or train$ or treatment or program$)).ti,ab.
52. ((strength$ or aerobic or resistance) and activit$).ti,ab.
53. (improve$ and (function or mobil$ or recover$)).ti,ab.
54. ((fitness or health) and promotion).ti,ab.
55. (danc$ or walk$ or yoga or tai chi or tai ji or tai chi or ji quan or taiji or taijiquan or leisure activit$ or recreation$ or bicycl$ or cycl$ or bike$ or biking).ti,ab.
56. ((endurance or balance or strength or flexibility or resistance) and train$).ti,ab.
57. or/35-56 [rehab terms]
58. research design/
59. clinical trials/
60. randomized controlled trials/
61. comparative study/
62. double blind method/
63. meta analysis/
64. random allocation/
65. program evaluation/
66. placebos/
67. (evaluation studies or brief research report or clinical trial or clinical trial phase iii or meta analysis or clinical trialb or clinical trials or multicenter study or multicentre study or comparative studies or comparative study or randomised controlled trial or randomized controlled trial or "review academic" or controlled clinical trial or "review literature" or controlled trial).pt.
68. random$.tw.
69. (controlled adj5 (trial$ or stud$)).tw.
70. (clinical$ adj5 trial$).tw.
71. ((control or treatment or experiment$ or intervention) adj5 (group$ or subject$ or patient$)).tw.
72. (surgical adj5 group$).tw.
73. (quasi-random$ or quasirandom$ or pseudo-random$ or pseudorandom$).tw.
74. ((multicenter or multi center or multicentre or multi centre or therapeutic) adj5 (trial$ or stud$)).tw.
75. ((control or experiment$ or conservative) adj5 (treatment or therapy or procedure or manage$)).tw.
76. ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or mask$)).tw.
77. (coin adj5 (flip or flipped or toss$)).tw.
78. latin square.tw.
79. versus.tw.
80. (cross-over or crossover).tw.
81. placebo$.tw.
82. sham.tw.
83. (assign$ or alternate or allocat$ or counterbalance$ or multiple baseline).tw.
84. control$.tw.
85. (treatment$ adj6 order).tw.
86. (meta-analy$ or metaanaly$ or metanaly$ or systematic review or systematic overview).tw.
87. or/58-86 [RCT]
88. 35 and 57 and 87 [care facilities/nursing -aged or institutional care terms and elder or other residential care and rehabilitation terms and RCT]

 

Appendix 6. PsycINFO search strategy

We used the following search strategy for PsycINFO

1. "homes for the aged".tw.
2. nursing home?.tw.
3. (aged adj2 (care or nursing or healthcare or residential) adj2 (facility or facilites or home?)).ti,ab.
4. ((geriatric or elderly) adj2 (facility or facilities or care home?)).ti,ab.
5. exp elder care/
6. or/1-5 [care facilities/nursing - aged terms]
7. exp Geriatric Patients/
8. exp Geriatrics/
9. exp Gerontology/
10. exp Aging/
11. (gerontol* or ageing or aging or elder* or geriatric* or seniors or old age or older or late* life).ti,ab.
12. (older adj (person* or people or adult* or patient* or inpatient* or outpatient*)).ti,ab.
13. veteran.ti,ab.
14. or/7-13 [elderly terms]
15. exp Nursing/
16. exp Rehabilitation Centers/
17. rehabilitation/
18. exp Institutionalization/
19. or/15-18 [institutional care terms]
20. 14 and 19 [elderly and institutional care terms]
21. exp Residential Care Institutions/
22. exp Treatment Facilities/
23. exp Assisted Living/
24. exp Group Homes/
25. exp Long Term Care/
26. ((group or residential) adj home?).tw.
27. ((hous$ or residental or residence? or institution$ or facility or facilities) adj5 (elder* or geriatric* or seniors or older or aged)).ti,ab.
28. ((residential or long-term or longterm) adj5 (care or facility or facilities)).ti,ab.
29. ((sheltered or retirement or residential or halfway or half-way) adj5 (hous$ or home? or accommodation)).ti,ab.
30. (life care cent$ or continuing care cent$ or extended care facility or extended care facilities).ti,ab.
31. ((care or convalescent) adj (home? or cent$ or facility or facilities)).ti,ab. and 14
32. ((skilled or intermediate) adj2 (nursing facility or nursing facilities)).ti,ab. and 14
33. (healthcare adj2 (facility or facilities)).ti,ab. and 14
34. assisted living.ti,ab.
35. or/21-34 [other residential care terms]
36. 6 or 20 or 35 [care facilities/nursing -aged or institutional care terms and elder or other residential care terms]
37. exp REHABILITATION/
38. exp Motor Processes/
39. exp Movement Therapy/
40. exp Physical Fitness/
41. physical strength/
42. exp Therapeutic Environment/
43. exp Physical Endurance/
44. (rehabilitat$ or exercise$ or physiotherap$ or keep fit).tw.
45. (physical adj3 (therap$ or education or train$ or fitness or activit$ or function)).tw.
46. ((exercise or movement or occupational or residential) adj5 (therap$ or train$ or treatment or program$)).tw.
47. ((strength$ or aerobic or resistance) adj3 activit$).tw.
48. (improve$ adj3 (function or mobil$ or recover$)).tw.
49. ((fitness or health) adj3 promotion).tw.
50. (danc$ or walk$ or yoga or tai chi or tai ji or tai chi or ji quan or taiji or taijiquan or leisure activit$ or recreation$ or bicycl$ or cycl$ or bike$ or biking).tw.
51. ((endurance or balance or strength or flexibility or resistance) adj3 training).tw.
52. or/37-51
53. 36 and 52 [care facilities/nursing -aged or institutional care terms and elder or other residential care and rehabilitation terms]

 

Appendix 7. 'Risk of bias' summary

Figure 7

 FigureFigure 7. 'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study

 

Feedback

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Feedback, 13 November 2009

 

Summary

During a recent course we gave on Cochrane Reviews, we discussed the topic of how to best make comparisons when a review includes many different kinds of interventions. We used your review as an example of a review that can include many studies but where the authors are then faced with the task of somehow grouping the interventions to produce useful comparisons. In your review you concluded that it was impossible to make comparisons because of the heterogeneity of the included studies. However, we felt that there would be several possibilities of making comparisons that would lead to more informative recommendations for the reader. We also found it difficult to follow how you came to your conclusion that provision of physical rehabilitation interventions to long-term care residents is worthwhile and safe, reducing disability with few adverse events.

We came to the conclusion that it is important to first separate studies that report primary outcomes from those that report secondary outcomes only. In your review, it would mean that you would first report about the studies that used a measure of ADL such as the Barthel Index or the FIM and then you would report on the studies that reported a secondary outcome only. We think that this information is lacking now. In addition, we concluded that it would be helpful to make a classification of the interventions based on their most important features. For your review, we assumed that exercise would be the most important feature of the biggest part of the interventions. Next we would subclassify exercise interventions according to their most important features. You already did this in your review with exercises that use imagery to enhance participation. All four studies that used imagery report endurance or the number of exercises that participants were able to perform and they use the same control group with rote exercise, which all in all makes for a perfectly homogenous comparison. Moreover, we thought that even when studies are heterogeneous, it is worthwhile to extract data about the outcomes and report them. In your review, you report outcomes only as the conclusions of the authors of the primary studies. This makes it, in our view, impossible to draw conclusions about the results. For example, four imagery studies with a non-significant outcome could well add up to a significant result in a meta-analysis. In our view, a meta-analysis of the four imagery studies would be well warranted by the homogeneity of the studies. This in turn could lead to a very relevant practical recommendation to use imagery to improve the results of exercise.

We hope that, with an update, better data extraction and better construction of comparisons will lead to better underpinned conclusions from this important review.

 

Reply

Many thanks for your comments on our review. The review was complex so we much appreciate any comments which will help us enhance the quality.

We are uncertain of the meaning of your first comment. We state in the review the number of trials reported an outcome measure related to ADL, our primary outcome measure.

We are currently updating the review and will consider classifying the interventions based on the most important features as you suggest.

We considered presentation of results in the review extremely carefully, and the current format seemed the best option at the time. However we are updating our review and during this process we will consider other ways of presenting the data.

We agree that it may be appropriate to undertake meta-analysis on the imagery studies.

Thank you for your comments, and the time you and your colleagues have taken to consider and feedback on our review. We will re-consider all your comments as we are up-dating.

 

Contributors

Feedback submitted by: Jos Verbeek
Reply provided by: Anne Forster

 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Last assessed as up-to-date: 28 September 2012.


DateEventDescription

2 October 2012New search has been performedEighteen new studies have been incorporated. Meta-analyses of activities of daily living outcomes and death from all causes have been included for the first time. The Background, Methods, Results and Discussion have been substantially rewritten.

2 October 2012New citation required and conclusions have changedConclusions have become more cautious on the basis of evidence from meta-analyses about effect size. New authors have been included. The title has been modified to clarify the content of the review.



 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Protocol first published: Issue 3, 2003
Review first published: Issue 1, 2009


DateEventDescription

3 March 2011Feedback has been incorporatedFeedback and the authors' response has been added to the review.

1 February 2010AmendedMinor amendments.

17 March 2008AmendedConverted to new review format.



 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

Anne Forster conceived and designed the review and wrote the funding application, with the assistance of John Young, Jane Smith, and John Green. Jo Hardy and Anne Forster took a lead role in writing the protocol, with advice from John Young, Jane Smith, and John Green. Anne Forster co-ordinated the review, with assistance from Jo Hardy and Tom Crocker. Jo Hardy and Anne Forster developed the search strategy and organised the retrieval of papers. Anne Forster, Jo Hardy, and Tom Crocker screened search results. Jo Hardy, Tom Crocker, Lesley Brown, and Seline Ozer wrote to authors of papers for additional information. All co-authors assisted in the identification of papers for inclusion into the review, appraised quality of papers, assisted in the design of the data extraction protocol, and extracted data from papers. For this updated review, Tom Crocker developed the database and managed the data. Lesley Brown, Tom Crocker, and Seline Ozer combined the independent data extractions. Darren Greenwood led and conducted the meta-analyses, which were reproduced in Review Manager by Tom Crocker. Tom Crocker assimilated the information and led the writing of this update, with support from Anne Forster.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms

John Young was a co-applicant for a research grant from BUPA to investigate delirium prevention in care homes. Anne Forster, John Young, and Ruth Lambley were developing a research project to investigate exercise programmes in care homes. This work started after the results of the original Cochrane review had been submitted.

Anne Forster and John Young have conducted a NIHR (National Institute for Health Research) development programme to investigate activity in care homes (barriers, enablers, and its measurement). They are applying for a NIHR programme grant to develop and test the feasibility of an intervention to increase activity in care homes.

Darren Greenwood has received grant funding for statistical analysis from Bradford Teaching Hospitals NHS Foundation Trust, and he has received funding from the Department of Health for a systematic review of diet and stroke.

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Internal sources

  • NHS R&D Levy Funding, UK.

 

External sources

  • Physiotherapy Research Foundation, UK.

 

Differences between protocol and review

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Differences between protocol and review
  18. Index terms
 

Title

The title has been amended to clarify that the review focuses on the physical aspects of rehabilitation.

 

Study criteria

The original intention was to limit inclusion to studies that undertook follow up at a minimum of one month. However, because of a lack of such studies, this criterion was not applied.

 

Outcome measures

We clarified our meaning of function in activities of daily living to include specific measures of performance in physical ADL function, e.g. mobility.

We specified economic outcomes and additional adverse outcomes.

The original intention was to assess outcomes at the scheduled end of each trial (after follow up). However, as many studies lacked follow up, we assessed outcomes at the end of the intervention for consistency. In the narrative synthesis, we also reported follow-up data.

We had planned, in the face of varied assessment tools, to dichotomise outcomes into deteriorated versus maintained or improved prior to meta-analysis. For the same purpose, we specified a global poor outcome (death or deterioration). However, we have not included such varied measures in meta-analysis because we lack the individual level data required to do this.

 

Search methods for identification of studies

We originally planned to search SIGLE (System for Information on Grey Literature in Europe), but we did not do so because it is no longer accessible. Furthermore, we planned to handsearch relevant journals, but because of their inclusion in electronic databases and the extensive results returned through electronic searches, we considered this unnecessary. In addition to the planned searches, we searched Google Scholar.

 

Data collection and analysis

We replaced the assessment of methodological quality described in the protocol and undertaken in the original review with The Cochrane Collaboration’s new 'Risk of bias' assessment tool (Higgins 2011). We reassessed all studies in the original review in line with these criteria. We performed data collection on a standardised electronic database, rather than a paper form. We clarified our approach to analysing data from cluster trials. We originally intended to combine results in a fixed-effect meta-analysis where sufficient homogeneity existed. However, because of the extensive heterogeneity in interventions (contents, intensity, and duration), we used a random-effects meta-analysis as our primary approach, but we still report the results of fixed-effect models as sensitivity analyses. We did not perform all the subgroup analyses originally proposed in the protocol because there are too few pathology-specific interventions for any one pathology, and studies often include both nursing and residential care homes. However, both of these groupings were partly intended to split participants by functional ability. Therefore, we instead grouped studies by baseline function in the measure being analysed. In addition to the subgroups suggested in the protocol, we added gender, duration of intervention, and risk of bias. We specified all of these subgroups before analysis commenced and presented and reported all of them for each measure.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. References to ongoing studies
  24. Additional references
Alessi 1999 {published data only}
  • Alessi CA, Yoon EJ, Schnelle JF, Al-Samarrai NR, Cruise PA. A randomized trial of a combined physical activity and environmental intervention in nursing home residents: do sleep and agitation improve?. Journal of the American Geriatrics Society 1999;47:784-91.
Au-Yeung 2002 {published data only}
  • Au-Yeung SS, Ho HP, Lai JW, Lau RW, Wong AY, Lau SK. Did mobility and balance of residents living in private old age homes improve after a mobility exercise programme? A pilot study. Hong Kong Physiotherapy Journal 2002;20:16-21.
Baum 2003 {published data only}
  • Baum EE, Jarjoura D, Polen AE, Faur D, Rutecki G. Effectiveness of a group exercise program in a long-term care facility: a randomized pilot trial. Journal of the American Medical Directors Association 2003;4:74-80.
Bautmans 2005 {published data only}
  • Bautmans I, Van Hees E, Lemper JC, Mets T. The feasibility of whole body vibration in institutionalised elderly persons and its influence on muscle performance, balance and mobility: a randomised controlled trial. BMC Geriatrics 2005;5:17.
Brill 1998 {published data only}
  • Brill P, Jensen R, Koltyn K, Morgan LA, Morrow JR, Keller MJ, et al. The feasibility of conducting a group-based progressive strength training program in residents of a multi-level care facility. Activities, Adaptation & Aging 1998;22(4):53-63.
Brittle 2009 {published data only}
  • Brittle N, Patel S, Wright C, Baral S, Versfeld P, Sackley C. An exploratory cluster randomized controlled trial of group exercise on mobility and depression in care home residents. Clinical Rehabilitation 2009;23(2):146-54.
Brown 2004 {published data only}
  • Brown VM, Allen AC, Dwozan M, Mercer I, Warren K. Indoor gardening and older adults: effects on socialization, activities of daily living, and loneliness. Journal of Gerontological Nursing 2004;30:34-42.
Bruunsgaard 2004 {published data only}
Bruyere 2005 {published data only}
  • Bruyere O, Wuidart MA, Di Palma E, Gourlay M, Ethgen O, Richy F, et al. Controlled whole body vibration to decrease fall risk and improve health-related quality of life of nursing home residents. Archives of Physical Medicine & Rehabilitation 2005;86(2):303-7.
Buettner 1997 {published data only}
  • Buettner LL, Ferrario J. Therapeutic recreation-nursing team: a therapeutic intervention for nursing home residents with dementia. Annual in Therapeutic Recreation 1997-1998;7:21-8.
Cheung 2008 {published data only}
  • Cheung KKW, Au KY, Lam WWS, Jones AYM. Effects of a structured exercise programme on functional balance in visually impaired elderly living in a residential setting. Hong Kong Physiotherapy Journal 2008;26:45-50.
Chin A Paw 2004 {published data only}
  • Chin A Paw MJ, van Poppel MNM, Twisk JWR, van Mechelen W. Effects of resistance and all-round, functional training on quality of life, vitality and depression of older adults living in long-term care facilities: a 'randomized' controlled trial. BMC Geriatrics 2004;4:5.
  • Chin A Paw MJ, van Poppel MNM, Twisk JWR, van Mechelen W. Once a week not enough, twice a week not feasible? A randomised controlled exercise trial in long-term care facilities. Patient Education & Counseling 2006;63(1-2):205-14.
  • Chin A Paw MJ, van Poppel MNM, van Mechelan W. Effects of resistance and functional-skills training on habitual activity and constipation among older adults living in long-term care facilities: a randomized controlled trial. BMC Geriatrics 2006;6:9.
Choi 2005 {published data only}
Christofoletti 2008 {published data only}
  • Christofoletti G, Oliani MM, Gobbi S, Stella F, Gobbi LTB, Canineu PR. A controlled clinical trial on the effects of motor intervention on balance and cognition in institutionalized elderly patients with dementia. Clinical Rehabilitation 2008;22:618-26.
Clark 1975 {published data only}
  • Clark BA, Wade MG, Massey BH, Van Dyke R. Response of institutionalized geriatric mental patients to a twelve week program of regular physical activity. Journal of Gerontology 1975;30(5):565-73.
Cott 2002 {published data only}
  • Cott CA, Dawson P, Sidani S, Wells D. The effects of a walking/talking program on communication, ambulation, and functional status in residents with Alzheimer Disease. Alzheimer Disease and Associated Disorders 2002;16(2):81-7.
Crilly 1989 {published data only}
  • Crilly RG, Willems DA, Trenholm KJ, Hayes KC, Delaquerrière-Richardson LFO. Effect of exercise on postural sway in the elderly. Gerontology 1989;35:137-43.
de Bruin 2007 {published data only}
DeKuiper 1993 {published data only}
  • DeKuiper WP, Nelson DL, White BE. Materials-based occupation versus imagery-based occupation versus rote exercise: a replication and extension. Occupational Therapy Journal of Research 1993;13(3):183-97.
Donat 2007 {published data only}
  • Donat H, Ozcan A. Comparison of the effectiveness of two programmes on older adults at risk of falling: unsupervised home exercise and supervised group exercise. Clinical Rehabilitation 2007;21(3):273-83.
Dorner 2007 {published data only}
  • Dorner T, Kranz A, Zettl-Wiedner K, Ludwig C, Rieder A, Gisinger C. The effect of structured strength and balance training on cognitive function in frail, cognitive impaired elderly long-term care residents. Aging Clinical and Experimental Research 2007;19(5):400-5.
Faber 2006 {published data only}
  • Faber MJ, Bosscher RJ, Chin A Paw MJ, van Wieringen PC. Effects of exercise programs on falls and mobility in frail and pre-frail older adults: a multicenter randomized controlled trial. Archives of Physical Medicine and Rehabilitation 2006;87:885-95.
Fiatarone 1994 {published data only}
  • Fiatarone MA, O'Neill EF, Ryan ND, Clements KM, Solares GR, Nelson ME, et al. Exercise training and nutritional supplementation for physical frailty in very elderly people. The New England Journal of Medicine 1994;330(25):1769-75.
Gillies 1999 {published data only}
  • Gillies E, Aitchision T, MacDonald J, Grant S. Outcomes of a 12-week functional exercise programme for institutionalised elderly people. Physiotherapy 1999;85(7):349-57.
Hruda 2003 {published data only}
  • Hruda KV, Hicks AL, McCartney N. Training for muscle power in older adults: effects on functional abilities. Canadian Journal of Applied Physiology. 2003;28:178-89.
Karl 1982 {published data only}
  • Karl CA. The effect of an exercise program on self-care activities for the institutionalized elderly. Journal of Gerontological Nursing. 1982;8:282-5.
Kerse 2008 {published data only}
  • Kerse N, Peri K, Robinson E, Wilkinson T, von Randow M, Kiata L, et al. Does a functional activity programme improve function, quality of life, and falls for residents in long term care? Cluster randomised controlled trial. BMJ 2008;337:a1445.
Kinion 1993 {published data only}
  • Kinion ES, Christie N, Villella AM. Promoting activity in the elderly through interdisciplinary linkages. Nursing Connections 1993;6(3):19-26.
Lang 1992 {published data only}
  • Lang EM, Nelson DL, Bush MA. Comparison of performance in materials-based occupation, imagery-based occupation, and rote exercise in nursing home residents. American Journal of Occupational Therapy 1992;46(7):607-11.
Lazowski 1999 {published data only}
  • Lazowski DA, Ecclestone NA, Myers AM, Paterson DH, Tudor-Locke C, Fitzgerald C, et al. A randomized outcome evaluation of group exercise programs in long-term care institutions. Journal of Gerontology 1999;54(12):M621-8.
Lee 2009 {published data only}
MacRitchie 2001 {unpublished data only}
  • MacRitchie RF. Reducing the incidence of falls among nursing home residents: an evaluation of an ameliorative program. MSc Thesis 2001.
Makita 2006 {published data only}
  • Makita M, Nakadaira H, Yamamoto M. Randomized controlled trial to evaluate effectiveness of exercise therapy (Takizawa Program) for frail elderly. Environmental Health and Preventive Medicine 2006;11:221-7.
McMurdo 1993 {published data only}
McMurdo 1994 {published data only}
  • McMurdo MET, Rennie LM. Improvements in quadriceps strength with regular seated exercise in the institutionalized elderly. Archives of Physical Medicine and Rehabilitation 1994;75:600-3.
Meuleman 2000 {published data only}
  • Meuleman JR, Brechue WF, Kubilis PS, Lowenthal DT. Exercise training in the debilitated aged: strength and functional outcomes. Archives of Physical Medicine and Rehabilitation 2000;81:312-8.
Mihalko 1996 {published data only}
  • Mihalko SL, McAuley E. Strength training effects on subjective well-being and physical function in the elderly. Journal of Aging and Physical Activity 1996;4:56-68.
Morris 1999 {published data only}
  • Morris JN, Fiatarone M, Kiely DK, Belleville-Taylor P, Murphy K, Littlehale S, et al. Nursing rehabilitation and exercise strategies in the nursing home. Journal of Gerontology 1999;54(10):M494-500.
Mulrow 1994 {published data only}
  • Mulrow CD, Gerety MB, Kanten D, Cornell JE, DeNino LA, Chiodo L, et al. A randomized trial of physical rehabilitation for very frail nursing home residents. JAMA 1994;271(7):519-24.
Naso 1990 {published data only}
  • Naso F, Carner E, Blankfort-Doyle W, Coughey K. Endurance training in the elderly nursing home patient. Archives of Physical Medicine and Rehabilitation 1990;71:241-3.
Ouslander 2005 {published data only}
  • Ouslander JG, Griffiths P, McConnell E, Riolo L, Schnelle JF. Functional incidental training: applicability and feasibility in the Veterans Affairs nursing home patient population. Journal of the American Medical Directors Association. 2005;6(2):121-7.
Peri 2008 {published data only}
  • Peri K, Kerse N, Robinson E, Parsons M, Parsons J, Latham N. Does functionally based activity make a difference to health status and mobility? A randomised controlled trial in residential care facilities (The Promoting Independent Living Study; PILS). Age and Ageing 2008;37(1):57-63.
Pomeroy 1993 {published data only}
  • Pomeroy VM. The effect of physiotherapy input on mobility skills of elderly people with severe dementing illness. Clinical Rehabilitation 1993;7:163-70.
Przybylski 1996 {published data only}
  • Przybylski BR, Dumont ED, Watkins ME, Warren SA, Beaulne AP, Lier DA. Outcomes of enhanced physical and occupational therapy service in a nursing home setting. Archives of Physical Medicine and Rehabilitation 1996;77:554-61.
Resnick 2009 {published data only}
  • Resnick B, Galik E, Pretzer-Aboff I, Gruber-Baldini AL, Russ K, Cayo J, et al. Treatment fidelity in nursing home research: the Res-Care intervention study. Research in Gerontological Nursing 2009;2(1):30-8.
  • Resnick B, Gruber-Baldini AL, Zimmerman S, Galik E, Pretzer-Aboff I, Russ K, et al. Nursing home resident outcomes from the Res-Care intervention. Journal of the American Geriatrics Society 2009;57(7):1156-65.
Riccio 1990 {published data only}
  • Riccio CM, Nelson DL, Bush MA. Adding purpose to the repetitive exercise of elderly women through imagery. The American Journal of Occupational Therapy 1990;44(8):714-9.
Rolland 2007 {published data only}
Rosendahl 2006 {published data only}
  • Littbrand H, Lundin-Olsson L, Gustafson Y, Rosendahl E. The effect of a high-intensity functional exercise program on activities of daily living: a randomized controlled trial in residential care facilities. Journal of the American Geriatrics Society 2009;57(10):1741-9.
  • Littbrand H, Rosendahl E, Lindelöf N, Lundin-Olsson L, Gustafson Y, Nyberg L. A high-intensity functional weight-bearing exercise program for older people dependent in activities of daily living and living in residential care facilities: evaluation of the applicability with focus on cognitive function. Physical Therapy 2006;86(4):489-98.
  • Rosendahl E, Gustafson Y, Nordin, E, Lundin-Olsson L, Nyberg L. A randomized controlled trial of fall prevention by a high-intensity functional exercise program for older people living in residential care facilities. Aging Clinical and Experimental Research 2008;20(1):67-75.
  • Rosendahl E, Lindelöf N, Littbrand H, Yifter-Lindgren E, Lundin-Olsson L, Håglin L, et al. High-intensity functional exercise program and protein-enriched energy supplement for older persons dependent in activities of daily living: a randomised controlled trial. The Australian Journal of Physiotherapy 2006;52(2):105-13.
Sackley 2006 {published data only}
  • Sackley CM, Wade DT, Mant D, Atkinson JC, Yudkin P, Cardoso K, et al. Cluster randomized pilot controlled trial of an occupational therapy intervention for residents with stroke in UK care homes. Stroke 2006;37(9):2336-41.
Sackley 2008 {published data only}
  • Sackley CM, Rodriguez NA, van den Berg M, Badger F, Wright C, Besemer J, et al. A phase II exploratory cluster randomized controlled trial of a group mobility training and staff education intervention to promote urinary continence in UK care homes. Clinical Rehabilitation 2008;22(8):714-21.
Sackley 2009 {published data only}
  • Sackley CM, Patel S, Wright C. Rehabilitation in care homes (RICH-T): a cluster-randomized controlled trial. Physiotherapy Research International 2007;12(4):205.
    Direct Link:
  • Sackley CM, van den Berg ME, Lett K, Patel S, Hollands K, Wright CC, et al. Effects of a physiotherapy and occupational therapy intervention on mobility and activity in care home residents: a cluster randomised controlled trial. BMJ (Clinical research ed.) 2009;339:b3123.
Santana-Sosa 2008 {published data only}
Sauvage 1992 {published data only}
  • Sauvage LR, Myklebust MB, Crow-Pan J, Novak S, Millington P, Hoffman MD, et al. A clinical trial of strengthening and aerobic exercise to improve gait and balance in elderly male nursing home residents. American Journal of Physical Medicine and Rehabilitation 1992;71:333-42.
Schnelle 1995 {published data only}
  • Schnelle JF, MacRae PG, Ouslander JG, Simmons SF, Nitta M. Functional incidental training, mobility performance, and incontinence care with nursing home residents. Journal of the American Geriatrics Society 1995;43:1356-62.
Schnelle 1996 {published data only}
  • Schnelle JF, MacRae PG, Giacobassi K, MacRae HSH, Simmons SF, Ouslander JG. Exercise with physically restrained nursing home residents: maximizing benefits of restraint reduction. Journal of the American Geriatrics Society 1996;44(5):507-12.
Schnelle 2002 {published data only}
  • Schnelle JF, Alessi CA, Simmons SF, Al-Samarrai NR, Beck JC, Ouslander JG. Translating clinical research into practice: a randomized controlled trial of exercise and incontinence care with nursing home residents. Journal of the American Geriatrics Society 2002;50:1476-83.
  • Schnelle JF, Kapur K, Alessi C, Osterweil D, Beck JG, Al-Samarrai NR, et al. Does an exercise and incontinence intervention save healthcare costs in a nursing home population?. Journal of the American Geriatrics Society 2003;51(2):161-8.
  • Simmons SF, Ferrell BA, Schnelle JF. Effects of a controlled exercise trial on pain in nursing home residents. Clinical Journal of Pain 2002;18(6):380-5.
  • Simmons SF, Schnelle JF. Effects of an exercise and scheduled-toileting intervention on appetite and constipation in nursing home residents. The Journal of Nutrition, Health & Aging 2004;8(2):116-21.
Schoenfelder 2000 {published data only}
  • Schoenfelder DP. A fall prevention program for elderly individuals. Journal of Gerontological Nursing 2000;26:43-51.
Schoenfelder 2004 {published data only}
Sihvonen 2004 {published data only}
  • Sihoven SE, Sipilä S, Era P. Changes in postural balance in frail elderly women during a 4-week visual feedback training: a randomized controlled trial. Gerontology 2004;50:87-95.
Stamford 1972 {published data only}
  • Stamford BA. Physiological effects of training upon institutionalized geriatric men. Journal of Gerontology 1972;27(4):451-5.
Stevens 2006 {published data only}
  • Stevens J, Kileen M. A randomised controlled trial testing the impact of exercise on cognitive symptoms and disability of residents with dementia. Contemporary Nurse 2006;21:32-40.
Sung 2009 {published data only}
  • Sung K. The effects of 16-week group exercise program on physical function and mental health of elderly Korean women in long-term assisted living facility. The Journal of Cardiovascular Nursing 2009;24(5):344-51.
Taboonpong 2008 {published data only}
  • Taboonpong S, Puthsri N, Kong-In W, Saejew A. The effects of Tai Chi on sleep quality, well-being and physical performances among older adults. Thai Journal of Nursing Research 2008;12(1):1-13.
Tappen 1994 {published data only}
Tappen 2000 {published data only}
  • Tappen RM, Roach KE, Applegate EB, Stowell P. Effect of a combined walking and conversation intervention on functional mobility of nursing home residents with Alzheimer Disease. Alzheimer Disease and Associated Disorders 2000;14(4):196-201.
Urbscheit 2001 {published data only}
  • Urbscheit NL, Wiegand MR. Effect of two exercise programs on balance scores in elderly ambulatory people. Physical and Occupational Therapy in Geriatrics 2001;19(4):49-58.
Yoder 1989 {published data only}
  • Yoder RM, Nelson DL, Smith DA. Added-purpose versus rote exercise in female nursing home residents. The American Journal of Occupational Therapy 1989;43(9):581-6.

References to studies excluded from this review

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. References to ongoing studies
  24. Additional references
Alessi 1995b {published data only}
  • Alessi CA, Schnelle JF, MacRae PG, Ouslander JG, Al-Samarrai N, Simmons SF, et al. Does physical activity improve sleep in impaired nursing home residents?. Journal of the American Geriatrics Society 1995;43:1098-102.
Alexander 2001 {published data only}
  • Alexander NB, Galecki AT, Genier ML, Nyquist LV, Hofmeyer MR, Grunawalt JC, et al. Task-specific resistance training to improve the ability of activities of daily living-impaired older adults to rise from a bed and from a chair. Journal of the American Geriatrics Society 2001;49:1418-27.
  • Alexander NB, Grunawalt JC, Carlos S, Augustine J. Bed mobility task performance in older adults. Journal of Rehabilitation Research and Development 2000;37:633-8.
Backman 1986 {published data only}
  • Backman SJ, Mannell RC. Removing attitudinal barriers to leisure behavior and satisfaction: a field experiment among the institutionalized elderly. Therapeutic Recreation Journal 1986;20:46-53.
Beck 2009 {published data only}
  • Beck AM, Damkjaer K, Tetens I. Lack of compliance of staff in an intervention study with focus on nutrition, exercise and oral care among old (65+ yrs) Danish nursing home residents. Aging Clinical and Experimental Research 2009;21(2):143-9.
Becker 2003 {published data only}
Binder 1995 {published data only}
  • Binder EF. Implementing a structured exercise program for frail nursing home residents with dementia: issues and challenges. Journal of Aging and Physical Activity 1995;3:383-95.
Blair 1996 {published data only}
Brill 1999b {published data only}
  • Brill PA, Cornman CB, Davis DR, Lane MJ, Mustafa T, Sanderson M, et al. The value of strength for older adults. Home Care Provider 1999;4(2):62-6.
  • Brill PA, Matthews M, Mason J, Davis D, Mustafa T, Macera C. Improving functional performance through a group-based free weight strength training program in residents of two assisted living communities. Physical and Occupational Therapy in Geriatrics 1998;15(3):57-69.
Carmeli 2000 {published data only}
  • Carmeli E, Reznick AZ, Coleman R, Carmeli V. Muscle strength and mass of lower extremities in relation to functional abilities in elderly adults. Gerontology 2000;46:249-57.
Collier 2007 {published data only}
  • Collier L. The use of multi-sensory stimulation to improve functional performance in older people with dementia: a randomised single blind trial. England, University of Southampton (United Kingdom) 2007:219.
de Carvalho Bastone 2004 {published data only}
  • de Carvalho Bastone A, Wilson JF. Effect of an exercise program on functional performance of institutionalized elderly. Journal of Rehabilitation Research & Development 2004;41(5):659-68.
Dyer 2004 {published data only}
Eggermont 2009 {published data only}
  • Eggermont LH, Swaab DF, Hol EM, Scherder EJ. Walking the line: a randomised trial on the effects of a short term walking programme on cognition in dementia. Journal of Neurology, Neurosurgery, and Psychiatry 2009;7:802-4.
Evans 1995 {published data only}
  • Evans WJ. Effects of exercise on body composition and functional capacity of the elderly. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences 1995;50A(Special Issue):147-50. [DOI: 10.1093/gerona/50A.Special_Issue.147]
Fisher 1991 {published data only}
  • Fisher NM, Pendergast DR, Calkins E. Muscle rehabilitation in impaired elderly nursing home residents. Archives of Physical Medicine and Rehabilitation 1991;72:181-5.
Fitzimmons 2001 {published data only}
  • Fitzsimmons S, Buettner LL. Easy rider wheelchair biking: a nursing-recreation therapy clinical trial for the treatment of depression. Journal of Gerontological Nursing 2001;27(5):14-23.
Fox 2000 {published data only}
  • Fox P, Richardson J, McInnes B, Tait D, Bedard M. Effectiveness of a bed positioning program for treating older adults with knee contractures who are institutionalized. Physical Therapy 2000;80(4):363-72.
Friedman 1991 {published data only}
Goldberg 1980 {published data only}
  • Goldberg WG, Fitzpatrick JJ. Movement therapy with the aged. Nursing Research 1980;29(6):339-46.
Hagen 2003 {published data only}
  • Hagen B, Armstrong-Esther C, Sandilands M. On a happier note: validation of musical exercise for older persons in long-term care settings. International Journal of Nursing Studies 2003;40:347-57.
Hara 2007 {published data only}
  • Hara T, Shimada T. Effects of exercise on the improvement of the physical functions of the elderly. Journal of Physical Therapy Science 2007;19(1):15-26.
Hopman-Rock 1999 {published data only}
Ikezoe 2005 {published data only}
  • Ikezoe T, Tsutou A, Asakawa Y, Tsuboyama T. Low intensity training for frail elderly women: long-term effects on motor function and mobility. Journal of Physical Therapy Science 2005;17(1):43-9.
Jensen 2002 {published data only}
  • Jensen J, Lundin-Olsson L, Nyberg L, Gustafson Y. Fall and injury prevention in older people living in residential care facilities: a cluster randomized trial. Annals of Internal Medicine 2002;136(10):733-41.
Jensen 2004 {published data only}
  • Jensen J, Nyberg L, Rosendahl E, Gustafson Y, Lundin-Olsson L. Effects of a fall prevention program including exercise on mobility and falls in frail older people living in residential care facilities. Aging Clinical and Experimental Research 2004;16(4):283-92.
Judge 1993 {published data only}
Kapasi 2007 {published data only}
  • Kapasi Z, Ignatius J, Kuhn B, Master P, Schnelle J, Fahey J. Effects of an exercise intervention on the relationship between muscle strength and immune cells in frail elderly nursing home residents. Journal of Geriatric Physical Therapy 2007;30(3):142-3.
Kelly 1983 {published data only}
  • Kelly GR, McNally E, Chambliss L. Therapeutic recreation for long-term care patients. Therapeutic Recreation Journal 1983;1:33-41.
Kerse 2004 {published data only}
Koc 2008 {published data only}
  • Koc A, Turgut G, Kilic M, Karabulut N, Tufekci FG, Kockar C. Exercise therapy for vital symptoms and daily functioning. International Journal of Stroke 2008;3 Suppl 1:297 (Abst. PO02-135).
Krishnamurthy 2007 {published data only}
  • Krishnamurthy MN, Telles S. Assessing depression following two ancient Indian interventions: effects of yoga and ayurveda on older adults in a residential home. Journal of Gerontological Nursing 2007;33(2):17-23.
Light 1984 {published data only}
  • Light KE, Nuzik S, Personius W, Barstrom A. Low-load prolonged stretch vs. high-load brief stretch in treating knee contractures. Physical Therapy 1984;64(3):330-3.
MacRae 1996 {published data only}
  • MacRae PG, Asplund LA, Schnelle JF, Ouslander JG, Abrahamse A, Morris C. A walking program for nursing home residents: effects on walk endurance, physical activity, mobility, and quality of life. Journal of the American Geriatrics Society 1996;44:175-80.
McMurdo 2000 {published data only}
Moye 1996 {published data only}
  • Moye J, Hanlon S. Relaxation training for nursing home patients: suggestions for simplifying and individualizing treatment. Clinical Gerontologist 1996;16(3):37-48.
Mozley 2007 {published data only}
  • Mozley CG, Schneider J, Cordingley L, Molineux M, Duggan S, Hart C, et al. The care home activity project: does introducing an occupational therapy programme reduce depression in care homes?. Aging & Mental Health 2007;11(1):99-107.
Nowalk 2001 {published data only}
O'Hagan 1994 {published data only}
Ray 1997 {published data only}
  • Ray WA, Taylor JA, Meador KG, Thapa PB, Brown AK, Kajihara HK, et al. A randomized trial of a consultation service to reduce falls in nursing homes. JAMA: Journal of the American Medical Association 1997;278(7):557-62.
Remsburg 1999 {published data only}
  • Remsburg RE, Armacost KA, Radu C, Bennett RG. Two models of restorative nursing care in the nursing home: designated versus integrated restorative nursing assistants. Geriatric Nursing 1999;20(6):321-6.
Rydwik 2004 {published data only}
  • Rydwik E, Frändin K, Akner G. Physical training in institutionalized elderly people with multiple diagnoses - a controlled pilot study. Archives of Gerontology and Geriatrics 2005;40:29-44.
Sato 2007 {published data only}
  • Sato D, Kaneda K, Wakabayashi H, Nomura T. Some effect of water exercise frequency on functional mobility in nursing care elderly. Japanese Journal of Physical Fitness and Sports Medicine 2007;56(1):141-8.
Sherrington 1997 {published data only}
  • Sherrington C, Lord SR. Home exercise to improve strength and walking velocity after hip fracture: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation 1997;78:208-12.
Shimada 2003 {published data only}
Shumway-Cook 1997 {published data only}
  • Shumway-Cook A, Gruber W, Baldwin M, Liao S. The effect of multidimensional exercises on balance, mobility, and fall risk in the community-dwelling older adults. Physical Therapy 1997;77(1):46-57.
Stasi 2004 {published data only}
  • Stasi MF, Amati D, Costa C, Resta D, Senepa G, Scarafioiti C, et al. Pet-Therapy: a trial for institutionalized frail elderly patients. Archives of Gerontology and Geriatrics 2004;9:407-12.
Steffen 1995 {published data only}
  • Steffen TM, Mollinger LA. Low-load, prolonged stretch in the treatment of knee flexion contractures in nursing home residents. Physical Therapy 1995;75(10):886-97.
Stones 1993 {published data only}
Tan 2004 {published data only}
  • Tan YSC, Alina I, Chua SH, Lee SL, Kumari PM, Vasanthi V. The effects of exercise on the functional status of the elderly persons living in the long-term care setting of a psychiatric hospital. Annals Academy of Medicine 2004;33(5):S22-4.
Tseng 2006 {published data only}
van Heugten 2000 {published data only}
  • van Heugten CM, Dekker J, Deelman BG, Stehmann-Saris JC, Kinebanian A. Rehabilitation of stroke patients with apraxia: the role of additional cognitive and motor impairments. Disability and Rehabilitation 2000;22(12):547-54.
Wolf 2001 {published data only}
  • Wolf B, Feys H, De Weerdt W, van der Meer J, Noom M, Aufdemkampe G. Effect of a physical therapeutic intervention for balance problems in the elderly: a single-blind, randomized, controlled multicentre trial. Clinical Rehabilitation 2001;15:624-36.
Yip 2004 {published data only}
  • Yip YB, Sit JWH, Wong DYS. A quasi-experimental study on improving arthritis self-management for residents of an aged people's home in Hong Kong. Psychology Health and Medicine 2004;9(2):235-46.

References to studies awaiting assessment

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. References to ongoing studies
  24. Additional references
Cakar 2010 {published data only}
  • Cakar E, Dincer U, Kiralp MZ, Cakar DB, Durmus O, Kilac H, et al. Jumping combined exercise programs reduce fall risk and improve balance and life quality of elderly people who live in a long-term care facility. European Journal of Physical and Rehabilitation Medicine 2010;46(1):59-67.
Chang 2010 {published data only}
Chen 2010a {published data only}
  • Chen KM, Fan JT, Wang HH, Wu SJ, Li CH, Lin HS. Silver yoga exercises improved physical fitness of transitional frail elders. Nursing Research 2010;59(5):364-70.
Ciairano 2010 {published data only}
  • Ciairano S, Liubicich ME, Rabaglietti E. The effects of a physical activity programme on the psychological wellbeing of older people in a residential care facility: an experimental study. Ageing & Society 2010;30(4):609-26.
Dechamps 2010 {published data only}
Dechamps 2010a {published data only}
  • Dechamps A, Diolez P, Thiaudière E, Tulon A, Onifade C, Vuong T, et al. Effects of exercise programs to prevent decline in health-related quality of life in highly deconditioned institutionalized elderly persons: a randomized controlled trial. Archives of Internal Medicine 2010;170(2):162-9.
de Greef 2006 {published data only}
  • de Greef MH, Weening-Dijksterhuis B, van Buren M, Hardeman F, Slutter K. The effect of a physiotherapeutic exercise programme on disability in older adults. Nederlands tijdschrift voor Fysiotherapie 2006;5:106-10. [: ISSN 0377 208X]
Deschamps 2009 {published data only}
  • Deschamps A, Onifade C, Decamps A, Bourdel-Marchasson I. Health-related quality of life in frail institutionalized elderly: effects of a cognition-action intervention and Tai Chi. Journal of Aging and Physical Activity 2009;17(2):236-48.
Fonseca 2010 {published data only}
  • Fonseca MD, Cader SA, Dantas EHM, Bacelar SC, Silva EB, Leal SM. Respiratory muscle training programs: impact on the functional autonomy of the elderly. Revista da Associação Médica Brasileira 2010;56(6):642-8.
Frändin 2009 {published data only}
  • Andresen M, Runge U, Hoff M, Puggaard L. Perceived autonomy and activity choices among physically disabled older people in nursing home settings: a randomized trial. Journal of Aging and Health 2009;21(8):1133-58.
  • Bergland A, Narum I, Grönstedt H, Hellström K, Helbostad JL, Puggaard L, et al. Evaluating the feasibility and intercorrelation of measurements on the functioning of residents living in Scandinavian nursing homes. Physical & Occupational Therapy in Geriatrics 2010;28(2):154-69.
  • Frändin K, Borell L, Grönstedt H, Bergland A, Helbostad J L, Puggaard L, et al. A Nordic multi-center study on physical and daily activities for residents in nursing home settings: design of a randomized, controlled trial. Aging Clinical and Experimental Research 2009;21(4-5):314-22.
  • Vinsnes AG, Helbostad JL, Nyronning S, Granbo R, Seim A. A general physical training programme for residents in nursing homes and the effect on urinary incontinence: a randomized controlled trial. Neurourology and Urodynamics 2010;29(6):852-3.
Gallon 2011 {published data only}
  • Gallon D, Rodacki ALF, Hernandez SG, Drabovski B, Outi T, Bittencourt LR, et al. The effects of stretching on the flexibility, muscle performance and functionality of institutionalized older women. Brazilian Journal of Medical and Biological Research 2011;44(3):229-35.
Gerritsen 2011 {published data only}
  • Gerritsen DL, Smalbrugge M, Teerenstra S, Leontjevas R, Adang EM, Vernooij-Dassen MJFJ, et al. Act In case of Depression: the evaluation of a care program to improve the detection and treatment of depression in nursing homes. Study Protocol. BMC Psychiatry 2011;11(91):1-7. [: Netherlands Trial Register (NTR): NTR1477]
Holmerová 2010 {published data only}
  • Holmerová I, Machácovv K, Vanková H, Veleta P, Jurasková B, Hrnciariková D, et al. Effect of the Exercise Dance for Seniors (EXDASE) program on lower-body functioning among institutionalized older adults. Journal of Aging and Health 2010;22(1):106-19.
Hsu 2011 {published data only}
  • Hsu JK, Thibodeau R, Wong SJ, Zukiwsky D, Cecile S, Walton DM. A "Wii" bit of fun: the effects of adding Nintendo Wii® Bowling to a standard exercise regimen for residents of long-term care with upper extremity dysfunction. Physiotherapy Theory and Practice 2011;27(3):185-93.
Jeon 2009 {published data only}
  • Jeon EY, Kim SY, Yoo HS. Effects of music therapy and rhythmic exercise on quality of life, blood pressure and upper extremity muscle strength in institution-dwelling elderly women. Journal of Korean Academy of Nursing 2009;39(6):829-39.
Kemoun 2010 {published data only}
  • Kemoun G, Thibaud M, Roumagne N, Carette P, Albinet C, Toussaint L, et al. Effects of a physical training programme on cognitive function and walking efficiency in elderly persons with dementia. Dementia and Geriatric Cognitive Disorders 2010;29(2):109-14.
Lee 2007 {published data only}
  • Lee YK. Promoting psychosocial health of elderly residential care home residents: implementation of a Tai Chi program. Chinese University of Hong Kong (People's Republic Of China) 2007.
Lee 2010 {published data only}
Montgomery 2010 {published data only}
  • Montgomery CA. Effects of quantitative progressive exercise rehabilitation on muscle function, functional performance, and quality of life of assisted living residents. Dissertation Abstracts International: Section B: The Sciences and Engineering, 2010.
Nalbant 2009 {published data only}
  • Nalbant O, Toktaş N, Toraman NF, Ogüş C, Aydin H, Kaçar C, et al. Vitamin E and aerobic exercise: effects on physical performance in older adults. Aging Clinical and Experimental Research 2009;21(2):111-21.
Pan 2011 {published data only}
  • Pan T-L, Lin S-Y. Ameliorating elder frailty in nursing home residents: the efficacy of group play. Journal of Nursing & Healthcare Research 2011;7(1):54.
Piedras-Jorge 2010 {published data only}
  • Piedras-Jorge C, Meléndez-Moral JC, Tomás-Miguel JM. Benefits of physical activity in nursing home residents. Revista Española de Geriatría y Gerontología 2010;45(3):131-5.
Resnick 2009 awaiting {published data only}
  • Resnick B, Cayo J, Galik E, Pretzer-Aboff I. Implementation of the 6-week educational component in the Res-Care intervention: process and outcomes. Journal of Continuing Education in Nursing 2009, issue 8:353-60.
Rosendahl 2006 awaiting {published data only}
  • Carlsson M, Littbrand H, Gustafson Y, Lundin-Olsson L, Lindelöf N, Rosendahl E, et al. Effects of high-intensity exercise and protein supplement on muscle mass in ADL dependent older people with and without malnutrition: a randomized controlled trial. Journal of Nutrition, Health & Aging 2011;15(7):554-60.
  • Conradsson M, Littbrand H, Lindelof N, Gustafson Y, Rosendahl E. Effects of a high-intensity functional exercise programme on depressive symptoms and psychological well-being among older people living in residential care facilities: a cluster-randomized controlled trial. Aging & Mental Health 2010;14(5):565-76.
  • Littbrand H, Carlsson M, Lundin-Olsson L, Lindelöf N, Håglin L, Gustafson Y, et al. Effect of a high-intensity functional exercise program on functional balance: preplanned subgroup analyses of a randomized controlled trial in residential care facilities. Journal of the American Geriatrics Society 2011;59(7):1274-82.
  • Rosendahl E. Fall prediction and a high-intensity functional exercise programme to improve physical functions and to prevent falls among older people living in residential care facilities. Umeå University Medical Dissertations, 2006.
Sackley 2010 {published data only}
  • Health Technology Assessment. A cluster randomised controlled trial of an occupational therapy intervention for residents with stroke living in UK care-homes (Project record). Health Technology Assessment 2010.
Serra-Rexach 2011 {published data only}
  • Serra-Rexach JA, Bustamante-Ara N, Hierro Villarán M, González Gil P, Sanz Ibáñez MJ, Blanco Sanz N, et al. Short-term, light- to moderate-intensity exercise training improves leg muscle strength in the oldest old: a randomized controlled trial. Journal of the American Geriatrics Society 2011;59(4):594-602.
Sung 2007 {published data only}
  • Sung KW. The effect of a health maintenance program on physical function and mental health of the elderly in nursing homes. Daehan Ganho Haghoeji 2007;37(4):478-89.
Swiniarek 2009 {published data only}
  • Swiniarek D, Elchner G, Kleist B, Beyer WF. Effects of 3-month whole-body vibration training on hip density trunk muscle strength, and balance in elderly people. Manuelle Medizin 2009;47(2):117-22.
Takeuchi 2011 {published data only}
  • Takeuchi R, Hatano Y, Yamasaki M. The influence of different exercise intervention programs on changes in quality of life and activity of daily living levels among geriatric nursing home residents. Journal of Physical Therapy Science 2011;23(1):133-6.
Tse 2010 {published data only}
Żak 2006 {published data only}
  • Żak M. Physical rehabilitation regimens designed to aid the frail elderly in executing postural shifts safely and coping after incidental falls. Postępy Rehabilitacji [Advances in Rehabilitation] 2006;20(1):17-24.

References to ongoing studies

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. References to ongoing studies
  24. Additional references
ISRCTN43769277 {published data only}
  • ISRCTN43769277. Older people's exercise intervention in residential and nursing accommodation. http://www.controlled-trials.com/ISRCTN43769277 (accessed November 2007).
NCT00105807 {published data only}
  • NCT00105807. The effect of exercise on muscle, function and cost in VA nursing home residents. http://clinicaltrials.gov/show/NCT00105807 (accessed December 2007).
NCT00218842 {published data only}
  • NCT00218842. Physical and daily activity for residents in a nursing home setting - A Nordic multi-centre study. http://www.clinicaltrials.gov/ct2/show/NCT00218842 (accessed November 2007).
Serra-Rexach 2009 {published data only}
  • Serra-Rexach JA, Ruiz JR, Bustamante-Ara N, Villarán MH, Gil PG, Sanz Ibáñez MJ, et al. Health enhancing strength training in nonagenarians (STRONG): rationale, design and methods. BMC Public Health 2009;9:152.

Additional references

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Feedback
  13. What's new
  14. History
  15. Contributions of authors
  16. Declarations of interest
  17. Sources of support
  18. Differences between protocol and review
  19. Characteristics of studies
  20. References to studies included in this review
  21. References to studies excluded from this review
  22. References to studies awaiting assessment
  23. References to ongoing studies
  24. Additional references
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