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Körperliche Rehabilitation für ältere Menschen in der Langzeitpflege

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Referencias

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}

Bruunsgaard H, Bjerregaard E, Schroll M, Pedersen BK. Muscle strength after resistance training is inversely correlated with baseline levels of soluble tumor necrosis factor receptors in the oldest old. Journal of the American Geriatrics Society. 2004;52:237‐41.

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}

Choi JH, Moon JS, Song R. Effects of Sun‐style Tai Chi exercise on physical fitness and fall prevention in fall‐prone older adults. Journal of Advanced Nursing 2005;51:150‐7.

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}

de Bruin ED, Murer K. Effect of additional functional exercises on balance in elderly people. Clinical Rehabilitation 2007;21(2):112‐21.

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}

Lee LYK, Lee DTF, Woo J. Tai Chi and health‐related quality of life in nursing home residents. Journal of Nursing Scholarship 2009;41(1):35‐43.

MacRitchie 2001 {unpublished data only}

MacRitchie RF. Reducing the incidence of falls among nursing home residents: an evaluation of an ameliorative program. MSc Thesis2001.

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 MET, Rennie LM. A controlled trial of exercise by residents of old people's homes. Age and Ageing 1993;22:11‐5.

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}

Rolland Y, Pillard F, Klapouszczak A, Reynish E, Thomas D, Andrieu S, et al. Exercise program for nursing home residents with Alzheimer's disease: a 1 year randomized, controlled trial. Journal of the American Geriatric Society 2007;55:158‐65.

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.
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}

Santana‐Sosa E, Barriopedro MI, López‐Mojares LM, Pérez M, Lucia A. Exercise training is beneficial for Alzheimer's patients. International Journal of Sports Medicine 2008;29(10):845‐50.

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}

Schoenfelder DP, Rubenstein LM. An exercise program to improve fall‐related outcomes in elderly nursing home residents. Applied Nursing Research. 2004;17:21‐31.

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 RM. The effect of skill training on functional abilities of nursing home residents with dementia. Research in Nursing & Health 1994;17(4):159‐65.

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

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}

Becker C, Kron M, Lindemann U, Sturm E, Eichner B, Walter‐Jung B, et al. Effectiveness of a multifaceted intervention on falls in nursing home residents. American Geriatrics Society 2003;51(3):306‐13.

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}

Blair CE, Lewis R, Vieweg V, Tucker R. Group and single‐subject evaluation of a programme to promote self‐care in elderly nursing home residents. Journal of Advanced Nursing 1996;24:1207‐13.

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}

Dyer CAE, Taylor GJ, Reed M, Dyer CA, Robertson DR, Harrington R. Falls prevention in residential care homes: a randomised controlled trial. Age and Ageing 2004;33:596‐602.

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}

Friedman R, Tappen RM. The effect of planned walking on communication in Alzheimer's disease. Journal of the American Geriatrics Society 1991;39:650‐4.

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}

Hopman‐Rock M, Staats PGM, Tak EC, Dröes RM. The effects of a psychomotor activation programme for use in groups of cognitively impaired people in homes for the elderly. Journal of Geriatric Psychiatry 1999;14:633‐42.

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}

Judge JO, Underwood M, Gennosa T. Exercise to improve gait velocity in older persons. Archives of Physical Medicine and Rehabilitation 1993;74:400‐6.

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}

Kerse N, Butler M, Robinson E, Todd M. Fall prevention in residential care: a cluster, randomized, controlled trial. Journal of American Geriatrics Society 2004;52:524‐31.

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}

McMurdo ME, Millar AM, Daly F. A randomized controlled trial of fall prevention strategies in old peoples' homes. Gerontology 2000;46:83‐7.

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}

Nowalk MP, Prendergast JM, Bayles CM, D'Amico FJ, Colvin GC. A randomized trial of exercise programs among older individuals living in two long‐term care facilities: The FallsFREE Program. Journal of the American Geriatrics Society 2001;49:859‐65.

O'Hagan 1994 {published data only}

O'Hagan CM, Smith DM, Pileggi KL. Exercise classes in rest homes: effect on physical function. The New Zealand Medical Journal 1994;107:39‐40.

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}

Shimada H, Obuchi S, Furuna T, Suzuki T. New intervention program for preventing falls among frail elderly people. American Journal of Physical Medicine and Rehabilitation 2004;83(7):493‐9.
Shimada H, Uchiyama Y, Kakurai S. Specific effects of balance and gait exercises on physical function among the frail elderly. Clinical Rehabilitation 2003;17:472‐9.

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}

Stones MJ, Dawe D. Acute exercise facilitates semantically cued memory in nursing home residents. Journal of the American Geriatrics Society 1993;41:531‐4.

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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.

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Tseng CN, Chen CC, Wu SC, Lin LC. Effects of a range‐of‐motion exercise programme. Journal of Advanced Nursing 2006;57(2):181‐91.

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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.

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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.

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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.

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Chang SH, Fang MC, Chang HY. Enhancing three bliss concepts among nursing home elders in Taiwan. Journal of Clinical Nursing 2010;19(5‐6):682‐90.

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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.

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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.
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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.

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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 Nursing2009, issue 8:353‐60.

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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.
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Characteristics of studies

Characteristics of included studies [ordered by study ID]

Alessi 1999

Methods

Design: RCT
Duration: 14 weeks
Method of randomisation: not described
Concealment of allocation: unclear
Outcome assessor blinding: unclear
Group comparability at entry: yes, no significant differences, P > 0.05
Losses to follow up: none

Participants

Country: USA
Setting: community nursing home
Randomised: 29
% women = 90
Age: mean = 88.3 ± 5.7 years; range = not reported

Consent: assent accepted

Inclusion criteria: urinary incontinence

Exclusion criteria: cognitive = comatose, severe physical aggression; medical = life expectancy < 3 months, length of stay < 3 months

% Eligible within home: 49.6
% Eligible that participate: 45.3

Intervention: N = 15; % women = 92.9; age (mean) = 88.6 years ± 10.4
Control: N = 14; % women = 92.9; age (mean) = 88.3 years ± 5.7

Interventions

Study aim or objective: to test whether an intervention combining increased daytime physical activity with improvement in the night‐time environment improves sleep and decreases agitation in nursing‐home residents

Intervention group: FIT programme, individualised intervention, session duration = n/a, number of sessions per week = maximum of 20
Exercise features: upper limb and lower limb exercises, walking/wheelchair propulsion delivered by research personnel twice hourly up to a maximum of 4 sessions per day, 5 days a week for 14 weeks
Nonexercise features: night‐time program commenced in 14th week for 5 nights, reduction of noise, reducing sleep‐disruptive nursing care practices, night‐time incontinence care

Control group: usual care for 14 weeks, then 1 week of night‐time programme

Outcomes

Physical function in ADL: 10‐minute walk/wheel (time), 10‐minute walk/wheel (average distance)
Agitation: agitation (daytime behavioural observation)
Physical activity: in‐bed time (% of daytime behavioural observations)
Energy expenditure: physical activity (kCal/hr)
Sleeping: sleep episodes (maximum duration), sleep episodes (average duration), sleep (night‐time) %, sleeping (daytime behavioural observation, % of observations asleep)
Environment (physical): night‐time noise (> 60 dB in 2‐minute period), night‐time light

Notes

Funding: not reported

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Quote: "Randomization occurred after baseline assessment"
No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Quote: "Randomization occurred after baseline assessment"
Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Study was performed in a single home with an observable intervention

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Unclear risk

Quote: "...performed by independent evaluators..."
Details of blinding or likelihood of it being broken not reported

Incomplete outcome data (attrition bias)
All outcomes

High risk

25 participants lost prior to baseline assessment because of time taken for parent study. 4 further participants lost to follow up, but unclear if already randomised and if so from which group

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable. Some baseline assessments could have been outcome measures (e.g. OSAI)

Other bias

Low risk

No other apparent risks of bias

Au‐Yeung 2002

Methods

Design: randomised, assessor‐blind trial, matched pairs
Duration: 18 sessions over 2 months, 3‐month follow‐up
Method of randomisation: drawing lots ‐ matched according to age, sex, ambulatory status, medical history, length in home; each pair randomly allocated to control or intervention by physiotherapist not involved in the exercise programme by drawing lots
Concealment of allocation: assessors blinded to allocation of participants
Intra and interrater reliability established before study
Group comparability at entry: yes, no significant differences, P > 0.05
Losses to follow up: 31 consented; 13 dropped out because of lack of interest, medical problems, or personal reasons

Participants

Country: Hong Kong
Setting: 3 private old‐age homes
Randomised: 31
% women = 78
Age: mean = approximately 80 years; range = not reported
Consent: fully‐informed consent

Inclusion criteria: able to understand and follow verbal instructions, ambulate independently (with or without aids), tolerate standing, and walking for at least 5 minutes

Exclusion criteria: medical= acute musculoskeletal pain, neurological signs and symptoms not under medication control, unstable medical conditions, complaint of dizziness and blurred vision leading to difficulty walking, medical conditions contraindicative to physical activity

% Eligible within home: not reported
% Eligible that participate: not reported

Intervention: N = baseline not reported; % women = not reported; age (mean) = 79.1 years ± 8.41

Control: N = baseline not reported; % women = not reported; age (mean) = 81.0 years ± 7.45

Interventions

Study aim or objective: to examine the effects of a short‐term mobility programme on the balance and mobility of elderly residents in private old‐age homes in Hong Kong
Number of experimental groups: 2
Groups: 2 exercise programmes
Group intervention delivery
Session duration: 45 minutes
Number of sessions per week: 3 (18 sessions over 2 months conducted in the home by qualified physiotherapist or 2 students)

Intervention: M programme (N = 10) = lower limb strengthening and balance training based on the overloading principle for strengthening and specificity for challenging balance in the upright position

Control: C programme (N = 8) = general light exercises performed while sitting without progression

Training session adherence: 98%
Mobility: 17.2 ± 1.4
Control: 18 ± 1.07 of 18 sessions

Outcomes

Physical function in ADL: TUG test (seconds) (Podsiadlo 1991), 4 metre walk (time seconds)
Balance: BBS

Notes

Funding: not reported
Pilot study

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "Subjects of each matched pair were randomly allocated...by drawing of lots"

Allocation concealment (selection bias)

Unclear risk

Quote: "...by drawing of lots..."

Unclear if concealed

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Not mentioned. Both participant groups received exercise interventions

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Low risk

Quote: "They were blinded to the allocation of subjects to the exercise programmes"

Incomplete outcome data (attrition bias)
All outcomes

High risk

31 participants consented; 13 dropped out (unclear numbers per group). Analysed as treated

Selective reporting (reporting bias)

Unclear risk

The three measures were appropriate. However, may not have been exclusive. Protocol not available

Other bias

Low risk

No other apparent risks of bias

Baum 2003

Methods

Design: randomised controlled semi‐cross‐over trial
Duration: 12 months (control group joined exercise group at 6 months)
Method of randomisation: after baseline assessments, randomisation was determined by computer‐generated algorithm stratified by place of residence (nursing home or assisted‐living)
Concealment of allocation: unclear ‐ all participants had been promised they would receive the intervention eventually
Outcome assessor blinding: yes ‐ all performance tests carried out by occupational therapists and physiotherapists blinded to allocation
Group comparability at entry: yes, no significant differences, P > 0.05
Losses to follow up: 2 participants non‐compliant with their assignment ‐ 1 switched to exercise immediately and another assigned to exercise refused to attend ‐; some analyses included them; 13% missing measurements

Participants

Country: USA
Setting: 50‐bed long‐term care facility comprising 32 nursing‐home beds and 18 assisted‐living beds
Randomised: 21
21 met criteria, and 20 consented (5 from nursing home; 15 from assisted‐living)
% women = 75
Age: mean = 88 years; range = 75 to 99 years

Consent: not specified

Inclusion criteria: age > 65, residence at facility > 3 months, ability to ambulate alone (included with assistive devices or carer)

Exclusion criteria: cognitive = inability to follow 2‐step command; medical = acute unstable illness (e.g. pneumonia),chronic illness (e.g. uncompensated congestive heart failure); functional = assaultive behaviour pattern, unwillingness to discontinue current physical therapy

% Eligible within home: 42
% Eligible that participate: 95.2

Intervention: N = 11; % women = 82; age (mean) = 88 years, range = 75 to 96 years

Control: N = 9; % women = 67; age (mean) = 88 years, range = 78 to 99 years

Interventions

Study aim or objective: to determine whether a strength and flexibility programme in frail long‐term care facility residents would result in improved function

Number of experimental groups: 2
Group intervention delivery
Session duration: 60 minutes
Number of sessions per week: 3
Seated: yes
Attendance records kept

Intervention: conducted by exercise physiologist in the lounge, exercises done in seated position (frailty), warm‐up; upper body strengthening; lower‐body strengthening; cool down, soft ankle and wrist weights (2 to 4 lbs), Thera‐Bands® (resistance 2.5 to 9 lbs), weighted hand‐sized balls, beach balls for kicking and throwing, weekly evaluations of progress

Control: art therapist or social worker; sessions of drawing, painting, puzzles, or cards; encouraged to continue normal activities; discouraged from joining exercise regime during the intervention

Outcomes

Physical function in ADL: Physical Performance Test, TUG test (seconds) (Podsiadlo 1991)
Balance: BBS
Cognition: MMSE

Notes

Funding: not reported

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "Randomisation was determined by a computer‐generated algorithm (permuted blocks) stratified by place of residence within the LTC facility"

Allocation concealment (selection bias)

Low risk

Quote: "Assignment to the study group was done by opening sealed envelopes with the random numbers supplied in sequence by the study coordinator"

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Participants were not blinded

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Low risk

Quote: "All the performance tests were administered by physical and occupational therapists who were blinded to the group assignments. The MMSE was administered by two trained medical students and research nurses also blinded to group membership"
FIM not administered after baseline because could not be blinded

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

13% of total repeated measures after baseline missing because of death or acute illness, but not reported which groups. ITT analysis performed

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

High risk

Quote: "Two patients were non‐compliant with their assignment; one switched to exercise immediately...results...included these patients as they were assigned...When they were eliminated from analysis, the results were slightly more positive in favour of the exercise intervention"

Evidence of contamination reported

Bautmans 2005

Methods

Design: RCT
Duration: 6‐week intervention
Follow up: none
Method of randomisation: done by lottery at the same time; stratification was applied for gender, ADL dependence, and age
Concealment of allocation: yes ‐ participants in the control group thought they were also receiving the vibration treatment
Outcome assessor blinding: yes ‐ all functional assessments done by assessors blind to allocation
Group comparability at entry: yes, no significant differences, P > 0.05
Losses to follow up: 3 (13%)

Participants

Country: Belgium
Setting: nursing home with capacity for 102 beds
Randomised: 24
% women = 63
Age (mean) = 77.5 years ± 11.0; range = not given
Consent: informed consent

Inclusion criteria: dependent in no more than 2 of 6 ADL categories (Katz Scale)

Exclusion criteria: cognitive = cognitive dysfunction interfering with test and training procedures; medical = presence of infectious disease, insulin‐dependent diabetes mellitus, endogenous osteosynthetic material, knee or hip prosthesis, pacemaker, epilepsy, musculoskeletal disorders

% Eligible within home: 33.7
% Eligible that participate: 72.7

Intervention: N = 13; men:women ratio = 5:8; age (mean) = 76.6 years ± 11.8

Control: N = 11; men:women ratio = 4:7; age (mean) = 78.6 years ± 10.4

Interventions

Study aim or objective: to investigate the feasibility of whole body vibration in the institutionalised elderly and its impact on functional capacity and muscle performance
Number of experimental groups: 2
Individualised intervention delivery
Session duration: not reported
Number of sessions per week: 3
Seated: no
Both groups attended "two‐weekly seated gymnastic sessions together with other residents of the nursing home" organised by independent physical therapists unaware of the participant's group

Targeted social interaction

Intervention: used Power Plate vibration platform, sessions 3 times a week with at least 1 day of rest between; 6 static exercises targeting lower limb muscles, exercise volume, and intensity gradually increased

Control: the same exercise regimen on the same vibration platform but machine switched off and sound produced by tape recorder

Outcomes

Physical function in ADL: TUG test (seconds) (Podsiadlo 1991)
Physical function (other): Tinetti Mobility Scale (gait and balance) (Tinetti 1986), Tinetti Test (gait)
Muscle power (anaerobic): leg extension (60 cm/second) ‐ work, leg extension (40 cm/second) ‐ maximal explosivity, leg extension (40 cm/second) ‐ maximal force, leg extension (40 cm/second) ‐ work, leg extension (60 cm/second) ‐ maximal force, leg extension (60 cm/second) ‐ maximal explosivity, hand grip strength (maximal), leg extension (40 cm/second) ‐ maximal power, leg extension (60 cm/second) ‐ maximal power
Balance: Tinetti Test ‐ Body Balance
Flexibility: 'Sit‐and‐reach' test, Back Scratch test (Rikli 1999)
Adverse events (other): occurrence of complications
Feasibility and acceptability: attendance

Notes

Funding: not reported, were given the loan of the vibration platform by 'Power Plate Belgium'

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "Randomisation was done for all 24 participants together at the same moment by lottery"
Cards representing participants (stratified) assigned to intervention or control by means of lottery. Starting sequence determined by tossing a coin

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Blinding of participants attempted ‐ reproduced sound of vibration platform to convince control group that it was working, but participants may have felt that it was not working

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Low risk

Quote: "Functional performance assessment was done by a physical therapist who was unaware of group assignment of the participants"

Incomplete outcome data (attrition bias)
All outcomes

High risk

Three dropouts in whole body vibration group compared with no dropouts in control group ‐ two dropouts likely to be related to whole body vibration program

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Brill 1998

Methods

Design: RCT
Duration: 8 weeks
Follow up: none
Method of randomisation: random numbers table
Concealment of allocation: unclear
Outcome assessor blinding: unclear
Group comparability at entry: yes, no significant differences, P > 0.05
Losses to follow up: none

Participants

Country: USA
Setting: integrated health services of Dallas multi‐level assisted‐living facility
Randomised: 16
% women = 87
Age: 25% older than 90 years, mean = approximately 82 years; range = 69 to 96
Consent: fully‐informed consent

Inclusion criteria: residential status, > 65 years old, ambulatory (± assistive device)

Exclusion criteria: history of heart attack/stroke within previous 6 months, unstable angina, any condition that the physician felt might be worsened by exercise

% Eligible within home: not reported
% Eligible that participate: not reported

Training group 1: N = 8; mean age = 84 years ± 9.6; range = 71 to 96 years; 6 women, 2 men

Training group 2: N = 8; mean age = 80 years ± 6.6; range = 69 to 90 years; all women

Interventions

Study aim or objective: to evaluate the effect of a 8‐week progressive functional fitness strength programme using dumbbells and ankle weights on strength, functional capability, balance, and selected psychological variables in residents in an assisted‐living facility
Number of experimental groups: 2
Group intervention delivery
Session duration: 30 minutes
Number of sessions per week: 3
Seated: unclear

Intervention: both groups followed the same exercise routine, only the weights varied (see Notes), the exercise routine comprised 5 upper and 5 lower body strengthening exercises targeting the major muscle groups, using different weights of dumbbells as resistance, cadence exercises wearing ankle weights were also performed, a gerontologist specialising in exercise training for older adults led the exercise sessions, which included all of the participants in 1 large group (see Notes)

Training group 1: the dumbbell and ankle weights and number of exercise repetitions were gradually increased over the course of the study

(Control) Training group 2: Used 1 lb dumbbells throughout the study, and cadence exercises were performed wearing ankle straps without the addition of weights

Outcomes

Falls: number of falls
Fear of falling: fear of falling (single item 4‐point scale) (Tinetti 1990)
Physical function in ADL: steps required to walk 6 metres, Stair Climb test (1 flight of 7 steps), ADL score (Brill 1998), six‐metre walk (time)
Physical function (other): sit‐to‐stand (fastest time to stand up)
Muscle power (anaerobic): hand grip strength, upper body strength (chest press), lower body strength (leg extension)
Balance: balance (Brill 1998)
Mood related: trait anxiety (State‐Trait Anxiety Inventory), depression (Beck Depression Inventory)
Pain: ADL level of pain (Brill 1998)

Notes

Funding: University of North Texas Research and Professional Development Grant
An issue arose when the participants refused to serve as controls; all wanted to participate in the strength‐training programme. In addition to this, the facility would only permit use of 1 time period and 1 room. The investigators resolved these issues by combining the 2 treatment groups together. Cross‐over was prevented by the exercise leader handing out the appropriate weights to each participant

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "Subjects were entered into training group 1 or training group 2 through random assignment by a random number table"

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

The two treatment groups trained together ‐ participants may have noticed that different groups were receiving different weighted dumbbells and wearing different ankle weights

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Unclear risk

No report of blinding of assessors

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Unclear risk

Interviewer not described

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

No report of missing data. No reports of attrition and exclusions

Selective reporting (reporting bias)

High risk

Prespecified measures 'balance' and 'number of falls' not reported at 8 weeks

Other bias

Low risk

No other apparent risks of bias

Brittle 2009

Methods

Design: cluster RCT
Clustering accounted for
Details: exploratory cluster RCT
Duration: 5 weeks
Follow up: yes

Participants

Characterisation: residents with self‐care dependency needs
Country: UK
Setting: nursing and residential homes
Randomised: 56
% women = 71%
Age details: mean (SD) for control = 82 (9.98); mean (SD) for exercise = 87 (6.99)
Statistically significant difference between groups
Inclusion criteria:

Nursing and residential homes: +5 beds with residents > 65 years with self‐care dependency needs
Residents: expected to survive for more than 9 months, had reduced mobility indicated by a Barthel Activities of Daily Living Index score of 17, less than or equal to 16
Exclusion criteria: none stated
ADL status details: mean (SD) BI Score for control = 11.0 (4.19); mean (SD) BI Score for exercise = 11.1 (4.20)
Cognitive status details: MMSE, n (%): < 21: 39 (70%); 21 to 23: 9 (16%); > 24: 8 (14%)
Significant comorbidities: at least 1 confirmed stroke, n (%): 13 (23%)
Assessed: not reported
Excluded: not reported

Interventions

Study aim or objective: to investigate the feasibility, acceptability, and potential efficacy of group exercise for residents in care homes

2 groups:

Intervention: exercise group (N = 28)
Format: group, delivered by 2 physiotherapists in lounge area
Session length: 40 to 60 minutes, twice weekly
Interactive group exercise class including:
‐ warm‐up and cool‐down period
‐ flexibility: range of movement and stretching
‐ sitting balance: postures that progressively reduce the base of support and dynamic movements, such as reaching and throwing that perturb the body's centre of gravity
‐ Posture: education and practice of good posture during exercises
‐ Co‐ordination: reaching targets and dual tasking
‐ Strengthening of the clinically major muscle groups
‐ Cardiovascular, e.g. marching on the spot (in sitting or standing)
Feedback to participants: group cohesion, peer reinforcement, social support

Control: control group (N = 28)
Usual care (no provision of regular physiotherapy or exercise training)

Outcomes

Physical function in ADL: RMI (Collen 1991)
Mood related: depression subscore, (HADS‐D) (Zigmond 1983)

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "Randomization was performed...using computer‐generated random numbers"

Allocation concealment (selection bias)

Low risk

Quote: "Randomization was performed by an independent principal statistician from Birmingham Clinical Trials Unit"

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Personnel designed and delivered the intervention to exercise, but control received usual care, so personnel knew. No report of blinding of participants ‐ although, intervention and control groups were in separate homes, so may not have been aware of which group they were in

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Low risk

Quote: "Assessments were conducted...by one of two research staff... masked to group allocation"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Same number of losses to follow up in each group

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Brown 2004

Methods

Design: Cluster RCT
Duration: 9 weeks; 2‐week baseline, 5‐week intervention for experimental group 1 followed by 2‐week intervention for experimental group 2
Follow up: none
Method of randomisation: coin toss
Concealment of allocation: unclear
Outcome assessor blinding: unclear ‐ pre‐test and post‐test data collected by the same person for consistency
Group comparability at entry: yes, no significant differences, P > 0.05
Losses to follow up: none reported for phase 1; of group B, 21 did not enter the second phase

Participants

Country: USA
Setting: 2 rural public nursing homes; home A had 98 beds; home B had 100
Randomised: 66
% women = 82
Age: mean = approximately 82 years; range = 60 to 96 years
Consent: assent accepted

Inclusion criteria: their current health status did not preclude participation, aged = 60, could speak and understand English, cognitively comprehend and answer questions, communicate verbally or in writing, were willing to participate in indoor gardening activities for 6 weeks

Exclusion criteria: see inclusion criteria

% Eligible within home: not reported
% Eligible that participate: not reported

Experimental group 1: N = 33, men = 6
Experimental group 2: N = 33, men = 6
Experimental group 3: N = 12, men = 6

Interventions

Study aim or objective: the effects of indoor gardening on socialisation, activities of daily living, and perceptions of loneliness
Number of experimental groups: 3
Group intervention delivery
Session duration: 20 minutes
Number of sessions per week: 2
Seated: yes

Phase 1: residents in home A comprised experimental group 1 and participated in an indoor gardening project once a week for 5 weeks; home B, the control group, received 20‐minute visits over the same 5‐week period

Phase 2: residents of home B became experimental group 2 and participated in indoor gardening twice a week for 2 weeks

Intervention: decorating flowerpots and planting bulbs of their choice, choosing and transplanting colourful flowering plants, discussing proper care of plants, viewing video on gardening, arranging plants in a hanging basket, arranging fresh cut flowers and greenery

Control: 20‐minute visits during the 5‐week intervention period to control for social interaction and changes due to the presence of experimenters; control group then invited to participate in the gardening (phase 2)

Outcomes

Physical function in ADL: MDS: transfer item (Brown 2004), MDS: eating item (Brown 2004), MDS: locomotion item (Brown 2004), MDS: grooming item (Brown 2004), MDS: dressing item (Brown 2004), MDS: bathing item (Brown 2004), MDS: Physical Functioning scale (6 items, Brown 2004)
Mood related: UCLA Loneliness Scale (version 3)
Social support: Revised Social Provisions Scale

Notes

Funding: not reported

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "A coin toss was used to determine the assignment of each nursing home"

Allocation concealment (selection bias)

High risk

Coin toss ‐ allocation could have been foreseen by researchers

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Unblinded participants and personnel

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Unclear risk

Outcome assessor unreported

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

No report of loss to follow up or otherwise

Selective reporting (reporting bias)

High risk

Only some sub‐scales reported for some comparisons

Other bias

Low risk

No other apparent risks of bias

Bruunsgaard 2004

Methods

Design: RCT
Duration: 12 weeks
Follow up: none
Method of randomisation: not specified
Concealment of allocation: not specified
Outcome assessor blinding: not specified
Group comparability at entry: yes, no significant differences, P > 0.05
Losses to follow up: 18 (46%)

Participants

Country: Denmark
Setting: nursing homes
Randomised: 39
% women = 99
Age: mean = approximately 89 years; range = 85 to 95 years
Consent: not specified

Inclusion criteria: see exclusion criteria

Exclusion criteria: cognitive = moderate/severe cognitive impairment; medical = acute illness, hypertension, severe cardiovascular disease, severe impairment of motor function, neurological disorder

% Eligible within home: not reported
% Eligible that participate: 53.8

Intervention: N = 10; men:women ratio = 1:9; age = 88.6 years (86 to 95 years)

Control: N = 11; men:women ratio = 1:10; age = 90.6 years (86 to 95 years)

Interventions

Study aim or objective: to test the hypothesis that physical exercise induces an anti‐inflammatory response that is associated with reduced chronic activation of the tumour necrosis factor (TNF)‐alpha system in frail elders and that the increase in muscle strength after resistance training is limited by systemic low‐grade inflammation

Number of experimental groups: 2
Unclear whether intervention delivery was group or individual
Session duration: 45 minutes
Number of sessions per week: 3
Seated: yes

Exercise features: training protocol from Harridge 1999. 3 exercise sessions a week for 12 weeks, low repetitions with high weight resistance, seated upright in training chair. 3 sets of 8 knee extensions

Non‐exercise features: subgroup of participants gave blood samples for examining inflammatory marker

Control: occupational therapist supervised social activities twice a week for 12 weeks; no physical training

Outcomes

Muscle power (anaerobic): knee flexor muscle strength, knee extensor muscle strength
Physiology: plasma levels of cytokines

Notes

Funding: Danish Medical Research Council

NOVO Foundation

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Quote: "Participants were randomly assigned..."
No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No report of blinding of participants, but social control intervention with physical outcome measures, so intervention would have been obvious

Incomplete outcome data (attrition bias)
All outcomes

High risk

Excluded results of the two men from the analysis

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Bruyere 2005

Methods

Design: RCT
Duration: 6 weeks
Follow up: none
Method of randomisation: not specified
Concealment of allocation: unclear
Outcome assessor blinding: unclear
Group comparability at entry: no, significant group differences, P < 0.05

Treatment group significantly older than control group (P = 0.03)
Treatment group had significantly better TUG scores at baseline (P = 0.04)

Losses to follow up: 6 (14%)

Participants

Country: Belgium
Setting: nursing home in Liège, Belgium

Randomised: 42
% women = 73
Age: mean = 81.9 ± 6.9 years; range= 63 to 98 years

Consent: not specified

Inclusion criteria: ambulatory, no major cognitive disorders that would effect their ability to complete questionnaires

Exclusion criteria: medical = people with a high risk or thromboembolism, history of hip or knee replacement

% Eligible within home: not reported
% Eligible that participated: 87.5

Intervention (vibration therapy plus physiotherapy): N = 22; % women = 81; age: mean: 83.6 years ± 4.8 years

Control (physiotherapy alone): N = 20; % women = 65; age(mean) = 78.9 years ± 6.9 years

Interventions

Study aim or objective: to investigate the effects of whole body vibration in the elderly
Number of experimental groups: 2
Individual intervention delivery
Session duration: 10 minutes
Number of sessions per week: 3
Seated: no

Groups: randomised to receive vibration intervention plus a standard physical training regimen or physical training alone

Exercise features:

Intervention – controlled whole body vibration: at each session stood on vertical vibrating platform for 4 series of 1 minute of vibration alternating with 90 seconds of rest, vibration set at 10 Hz for the first and third series with peak to peak amplitude of 3 mm; for second and fourth series, vibration set at 26 Hz with peak to peak 7 mm, blood pressure and pulse were taken before the first series, immediately after the second and fourth series, and 2 minutes after the fourth series in each session

Physical therapy: standard exercise programme, gait and balance exercises, training in transfer skill, strengthening exercises with resistive mobilisation of lower limbs, 3 times weekly for 10 minutes during the 6‐week study, provided by only 1 physical therapist

Outcomes

Physical function in ADL: TUG test (seconds) (Podsiadlo 1991)
Physical function (other): Tinetti Mobility Scale (gait and balance) (Tinetti 1986), Tinetti Test (gait), SF‐36 physical function
Balance: Tinetti Test ‐ Body Balance
Perceived health status: SF‐36 vitality, SF‐36 social function, SF‐36 Role‐physical, SF‐36 Role‐emotional, SF‐36 mental health, SF‐36 health change, SF‐36 general health
Pain: SF‐36 pain

Notes

Funding: not reported; no commercial party had any financial interests

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No evidence of blinding. The potential influence of the additional treatment in the intervention group, and outcome expectations of the intervention provider could have influenced participant response

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Unclear risk

No information provided

Incomplete outcome data (attrition bias)
All outcomes

High risk

Lost to follow up from intervention (27%); none lost from control. ITT analysis undertaken utilising last available data

Selective reporting (reporting bias)

High risk

Some results were reported as ITT analysis, others as per‐protocol (possible selective reporting)

Other bias

Low risk

No other apparent risks of bias

Buettner 1997

Methods

Design: RCT
Duration: 30 weeks
Method of randomisation: name draw
Concealment of allocation: unclear
Outcome assessor blinding: yes ‐ evaluators blind to participant assignment
Group comparability at entry: yes, no significant differences, P > 0.05
Losses to follow up: N = 14 (21%); 12 deaths ‐ 2 became unstable on their medications, does not report which group(s) they were from

Participants

Country: USA
Setting: nursing home
Randomised: N = 66
% women = 88
Age: mean = 86.2 years; range = 54 to 100 years
MMSE score: range = 0 to 19; mean score = 7.5

Consent: assent accepted

Inclusion criteria: diagnosis of dementia, family consent, stable on medications, resident in the home for 3 months

Exclusion criteria: medical: use of tacrine, a drug used in the treatment of Alzheimer's disease (centrally acting anticholinesterase)

% Eligible within home: not reported
% Eligible that participate: not reported

Interventions

Study aim or objective: to assess the impact of a highly structured interdisciplinary programme of sensorimotor activities on the function and behaviour of nursing‐home residents with dementia

Number of experimental groups: 2
Both small groups and personalised interventions
Session duration: n/a
Number of sessions per week: n/a
Seated: unclear

Intervention: first 10‐week period: Intervention provided by certified therapeutic recreation specialists in collaboration with the unit managers; design based on level of functioning, personal care schedule, and interests; small group activities among people of similar functioning; co‐ordinated schedule of care established for the treatment group including all aspects of care and therapeutic programming; staff were encouraged to walk with residents, interact socially, and promote functional independence during activities; intervention participants received therapeutic programming and diversional stimulatory activities throughout the day and evening; every aspect of the day considered programming and outcome‐based – all sensory motor activities, no matter how mundane (e.g. hand washing, waking to meals); cooking, herb gardening, group cognitive therapy, fitness sessions, various sensory (water, relaxation activities); second 10‐week period: home staff took over 50% of the programming; third 10‐week period: nursing‐home staff took over all aspects of the programming

Control: usual care: same schedule of regular nursing‐home activities and standard nursing care

Outcomes

Physical function in ADL: timed walk over 50 feet
Physical function (other): Timed Manual Performance (TMP) test
Muscle power (anaerobic): grip strength (lbs)
Mood related: GDS
Agitation: Cohen‐Mansfield Agitation Inventory
Cognition: MMSE
Flexibility: 'Sit‐and‐Reach' test (Modified Wells)
Psychosocial and physical functioning: Multidimensional Observation Scale for Elderly Subjects (MOSES)

Notes

Funding: National Alzheimer's Association
Evaluators were unit managers; participants came from the same home, and as a result, were probably aware of group allocation during the 30‐week period

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "...by name draw without replacement"
Comment: N = 33 in each group. Assume drawn names were allocated alternately to each group

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No blinding of participants

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Low risk

All evaluators blind to group assignment

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Low risk

All evaluators blind to group assignment

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

12 participants died, and 2 were not stable on medications ‐ data from these 14 eliminated from final data analysis

Selective reporting (reporting bias)

High risk

MOSES outcomes not reported

Other bias

Unclear risk

Risk of contamination: randomisation of individual residents, but intervention involved some staff training, so possibility of confounding

Cheung 2008

Methods

Design: RCT
Duration: 12 weeks
Follow up: no

Participants

Characterisation: visually‐impaired elderly
Country: Hong Kong
Setting: care and attention homes
Randomised: 50
% women = 100%
Age details (mean (SD)): experimental group = 83 (4.7) years; control group = 84.4 (6.5) years
Inclusion criteria: visually‐impaired people (people with no light perception or with visual acuity of 6/120 or worse on the better eye with corrective device), aged 65 years or older. All participants were independently mobile
Exclusion criteria: those who suffered from painful conditions that affected their mobility or balance, neurological disorders, musculoskeletal problems, cardiovascular disease, unstable blood pressure associated with posture or mental conditions, which limited them from following the exercise instructions
ADL status details: There were no significant differences between the training and control groups in age (P = 0.377) and pre‐training scores of the BBS, CST, and TUG
Cognitive status details: excluded neurological disorders that limited following instructions
Significant comorbidities: not reported
Assessed: not reported
Excluded: not reported

Interventions

Study aim or objective: to examine the effects of an exercise programme, which focused on improvement of the functional balance of visually‐impaired elderly people
2 groups:

Intervention: exercise training (experimental) (N = 27)
Format: group; delivered by: designed and conducted by 2 physiotherapists
Session length: 45 minutes, 3 times weekly
Protocol included:
(1) warm up ‐ range of motion and stretching exercises for the upper limbs in a sitting position, lower limb warm‐up exercise including quadriceps and calf stretching, and ankle circumduction in a standing position
(2) lower limbs strengthening exercises ‐ chair stand exercise (sets of 5 repetitions progressing to 10 repetitions), quadriceps strengthening in a sitting position, strengthening of hip extensors and abductors in a standing position, with cuff weights in 3 sets of 10 repetitions with progressive weights (e.g. 10 repetitions with 3 lbs, then 5 lbs, followed by 7 lbs, based on the capacity of the individual participant)
(3) balance exercises ‐ supervised stool‐stepping exercise, tandem standing, and single‐leg standing
(4) cool down exercises ‐ general stretching and mobility exercise
Balance exercise was progressed based on the participant's needs and according to the ability of the participant

Control: control (N = 23)
General exercise (upper limb and lower limb mobilization exercises using shoulder pulley and floor bike/static bike) per week

Outcomes

Physical function in ADL: TUG (Timed Up and Go) test (seconds) (Podsiadlo 1991)
Physical function (other): sit‐to‐stand (up and down 5 times)
Balance: BBS

Falls, risk and fear of falling: falls (any episodes for participant)

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

No information provided on random sequence generation

Allocation concealment (selection bias)

Low risk

Quote: "Participants were randomly assigned...by drawing from a sealed opaque envelope that contained the number that determined the allocation"

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Both control and experimental exercise programmes were designed and conducted by two physiotherapists

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Low risk

Quote: "Assessment of the functional status of the subjects was conducted by a third physiotherapist who was blinded to the grouping of the subjects"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No losses to follow up in either group

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Chin A Paw 2004

Methods

Design: RCT
Duration: 6 months
Follow up: no

Participants

Characterisation: older adults
Country: Netherlands
Setting: long‐term care facilities, i.e. homes for the aged with services ranging from independent living to skilled nursing
Randomised: 224
% women = 80%
Age details: mean (SD) = 81.7(5.4); range = 64 to 94 years
Inclusion criteria:

  1. aged 65 or older

  2. living in a nursing home or residential care facility

  3. able to walk six metres or more (with or without a walking aid)

  4. able to comprehend the study procedures

  5. no medical contraindication for study participation

  6. no rapidly progressive or terminal illness

  7. not moving away from the home within the 6‐month intervention period

(5 and 6 were evaluated by their general practitioner)
Exclusion criteria: ADL status details: number of participants with ADL disability: 27
Number of participants using a walking aid indoors: 23
Cognitive status details: not reported
Significant comorbidities: not reported
Assessed: not reported
Excluded: 17 on eligibility criteria, 5 other

Interventions

Study aim or objective: to examine the effect of different training protocols on quality of life, vitality, and depression of older adults living in long‐term care facilities
4 groups:

Intervention: combined training (N = 56)
Format: group; delivered by: trained physical therapist and assistant
Session length: 40 to 60 minutes, twice weekly
A complete strength training session (2 x 12 reps of 5 exercises, once weekly) and a complete functional training session (once weekly)

Strength: resistance increased until 2 sets of 8 to 12 reps possible. Progressively increased when 2 x 12 reps achieved at 2 sessions. Warm‐up of 10 to 20 reps at minimal resistance. The 5 exercises were leg press; latissimus pull down; biceps curl and triceps press on TechnoGym equipment; and heel raises with dumbbells (1 to 5 kg each), or ankle or wrist weights (1 and 2 kg per pair), or some combination of these. For the heel raises, the number of repetitions were increased if the participants could lift the maximum weight (2 × 5 kg dumbbells + 2 × 2 kg ankle weights)
Functional: warm‐up of walking and movement to music, followed by 30 to 35 minutes of skills training in game‐like and co‐operative activities, such as throwing and catching a ball while standing up and sitting down on a chair, musical chairs, and team pursuit races

Control 1 (of 3): functional‐skills training (N = 60)
Program designed to improve muscle strength, speed, endurance, co‐ordination and flexibility to improve functional performance of common daily activities. An emphasis was placed on skills training, meaning that the specific activities required for independence in daily activities were practiced. Classes started with 5 to 10 minutes of warm‐up activities: walking (whenever possible), exercise‐to‐music routines, becoming familiar with the equipment, followed by 30 to 35 minutes of skills training in game‐like and co‐operative activities, such as throwing and catching a ball while standing up and sitting down on a chair, musical chairs, and team pursuit races. The cool‐down period (5 to 10 minutes) consisted of stretching and relaxation activities (e.g. finger and wrist rolls, shoulder rolls, reaching, leg stretches). Exercises adjusted to individual mobility level. The intensity was gradually increased: the number of repetitions increased, exercises were performed more often standing up straight, and the use of wrist and ankle weights (1 and 2 kg per pair) was stimulated

Control 2 (of 3): strength training (N = 57)
Program designed to improve muscle strength of major muscle groups of both upper and lower body, important for functional performance on common daily activities. 5 exercises: leg press, latissimus pull down, biceps curl and triceps press on TechnoGym equipment, and heel raises with dumbbells (1 to 5 kg each); ankle or wrist weights, or both (1 and 2 kg per pair). In the first 2 weeks, participants were familiarised with the equipment and the technique of the exercises by exercising with minimal resistance. The following weeks, resistance increased until 2 sets of 8 to 12 repetitions were possible. Resistance was to be increased after the participant could complete 2 sets of 12 repetitions for 2 consecutive sessions. As a warm‐up, each exercise was first performed 10 to 20 repetitions with minimal resistance. Progression was monitored with exercise logs filled out by the supervising physical therapist and assistant. Sessions closed with stretching exercises

Control 3 (of 3): control (educational) (N = 51)
An 'educational' program designed to provide attention and social interaction (i.e. group discussions about topics of interest to older people, such as history of the 20th century, music, relaxation, etc)

Outcomes

Physical function in ADL: walking speed over 8 metres, disability in 17 ADLs (Chin A Paw 2006), putting on and off a coat, picking up a pen from the floor while standing
Physical function (other): eye‐hand co‐ordination (block‐transfer test for measuring manual dexterity), reaction time, sit‐to‐stand (up and down 5 times)
Muscle power (anaerobic): ankle dorsiflexor strength, elbow extensor strength
Mood related: GDS
Flexibility: 'Sit‐and‐Reach' test
Physical activity: physical activity (accelerometer data), LASA Physical Activity Questionnaire (Stel 2004)
Quality of life: Dementia Quality of Life Instrument (Brod 1999)
Perceived health status: Vitality Plus Scale, VPS (Myers 1999)
Continence: laxatives (number of participants using), constipation (number of participants with)
Anthropometry: body fat (%), BMI

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "The random allocation sequence was generated by computer"

Allocation concealment (selection bias)

Low risk

Two independent students assigned participants to their group ‐ implies allocation was concealed

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

No mention of blinding of participants, but there were four different groups so participants may not have been aware which ones were experimental and which was the control

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Low risk

Quote: "Data were collected at baseline and after 6 months intervention by three trained research assistants who were blinded to group assignment"

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Low risk

Quote: "Data were collected at baseline and after 6 months intervention by three trained research assistants who were blinded to group assignment"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Quote: "Dropout of participants was not significantly different among the four groups".

Similar reasons for dropout between groups

Selective reporting (reporting bias)

Unclear risk

Stated that they were going to report body composition measurements ‐ only referred to in text in associated paper (Chin A Paw 2006)

Other bias

Low risk

No other apparent risks of bias

Choi 2005

Methods

Design: Cluster RCT
Duration: 12 weeks
Follow up: none
Method of randomisation: randomly assigned to either the experimental or control group by coin tossing, cluster allocation of the 2 homes
Concealment of allocation: no
Outcome assessor blinding: not possible because of the non‐random participant assignment (homes were allocated)
Group comparability at entry: no, significant differences, P < 0.05

Strength of ankle dorsiflexors (control group stronger)

Balance (control group had better balance both with eyes open and eyes closed)

Mobility (control group more mobile)

Losses to follow up: 9 (13.2%)

Participants

Country: South Korea
Setting: unclear ‐ based on the number of residents, location, and facilities; 2 facilities with similar characteristics were selected from list provided by Korean Council on social welfare
Randomised: 68
% women = 75
Age: mean = 77.86 years; range = 61 to 91 years
61% fall in the previous year

Consent: assent accepted

Inclusion criteria: ambulatory adults aged over 60 with at least 1 of the following: impaired gait (score of < 10 on gait sub‐scale (maximum score of 12) of the Performance Orientated Assessment of Mobility (POAM)), impaired balance (score of < 14 on POAM balance sub‐scale (maximum 16), history of falling in the previous year, postural hypotension (drop in systolic blood pressure of 20 mmHg from lying to standing, use of 4 or more prescription medications that may affect balance

Exclusion criteria: cognitive = severe dementia (score < 20 on Folstein MMSE); medical = inability to complete 12 weeks of exercise because of physical illness; functional = current involvement in any type of regular exercise

% Eligible within home: not reported
% Eligible that participate: not reported

Intervention: N = 29; % women = 79; age (mean) = 76.96 years ± 7.7 years

Control: N = 30; % women = 70; age (mean) = 78.73 years ± 6.9 years

Interventions

Study aim or objective: to determine changes in physical fitness (knee and ankle muscle strength, balance, flexibility, and mobility), fall avoidance efficacy, and fall episodes of institutionalised adults after participating in a 12‐week Sun‐style Tai Chi exercise programme

Number of experimental groups: 2
Group intervention delivery
Session duration: 35 minutes
Number of sessions per week: 3
Seated: unclear

Exercise features: Sun style Tai Chi, 10 minutes warming up, 20 minutes of 12 Tai Chi movements, 5 minutes of cooling down, done to music for soothing effect

Control: maintained routine activities; did not participate in any regular exercise classes

Outcomes

Falls: falls (any episodes for participant)
Fear of falling: Falls Efficacy Scale (Tinetti 1990) (10 item fear of falling)
Physical function in ADL: 6‐metre walk (time)
Muscle power (anaerobic): ankle plantar/flexor strength, ankle dorsiflexor strength, knee extensor muscle strength, knee flexor muscle strength
Balance: balance: time standing on 1 leg (eyes open), balance: time standing on 1 leg (eyes closed)
Flexibility: flexibility (touch toes) (Choi 2005)

Notes

Funding: not reported

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Selected two facilities (based on number of residents, location, and facilities) and randomly assigned them to either the experimental or control group by coin tossing

Allocation concealment (selection bias)

High risk

Coin toss ‐ allocation could have been foreseen by researchers

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Quote: "Participants were aware of their group assignment"

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Unclear risk

Quote: "Professional team rather than the research team measured physical fitness"
No report of blinding of assessors, although hinted at. Because of cluster assignment and non‐blinding of participants, all allocations could have been revealed by 1 participant

Incomplete outcome data (attrition bias)
All outcomes

Low risk

'As treated' analysis done ‐ measures not reported for all participants initially included, but only two departed from allocation

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Christofoletti 2008

Methods

Design: RCT
Duration: 6 months
Follow up: no

Participants

Characterisation: institutionalised elderly people with mixed dementia
Country: Brazil
Setting: residential care
Randomised: 54
% women = 69%
Age details (mean (SD)): 74.3 (1.4)
Inclusion criteria: (a) a primary diagnosis of dementia, based on ICD‐1011 Classification of Mental and Behavioral Disorders, and confirmed by the participant's performance on the MMSE and on Katz Activities Daily Living Scale; (b) no other neurological diagnosis or neuropsychiatric conditions associated to cognitive impairment; (c) medically fit in order to participate in therapy; (d) no prescriptions of antidepressant medications with central anticholinergic or sedation actions; (e) no drug‐related impairment of cognition or balance; (f ) residing in a long‐term psychiatric institution
Exclusion criteria: included above
ADL status details: Katz ADL means (SD), N =
5.0 (0.3), N = 17
4.6 (0.5), N = 17
4.5 (0.5), N = 20
Cognitive status details: MMSE means (SD), N =
18.7 (1.7), N = 17
12.7 (2.1), N = 17
14.6 (1.2), N = 20
Significant comorbidities: not reported
Assessed: not reported
Excluded: 8 on criteria, 1 other

Interventions

Study aim or objective: to analyse the effects of multidisciplinary or physiotherapeutic rehabilitation interventions on the cognition and balance of institutionalised elderly people with mixed dementia
3 groups:

Intervention: Group 1 (physiotherapy + occupational therapy + physical exercise) (N = 17)
Format: group; delivered by: physiotherapy, occupational therapy, and physical exercise professionals
Session length: 120 minutes, 5 times per week
An interdisciplinary programme that consisted of physiotherapy, occupational therapy, and physical exercise
Physiotherapy: individualised kinesiotherapeutic exercises that stimulated strength, balance, and cognition using bars, Bobath balls, elastic ribbons, and proprioceptive stimulation plates
Occupational therapy: arts and crafts activities (pictures, paintings, drawings, and embroidering)
Physical exercise: walking and upper and lower limb exercises

Control 1 (of 2): Group 2 (physiotherapy) (N = 17)
Physiotherapy sessions involving the same kinesiotherapeutic exercises as detailed for group 1

Control 2 (of 2): Group 3 (control) (N = 20)
Control without motor intervention

Outcomes

Physical function in ADL: TUG test (steps) (Christofoletti 2008), TUG test (seconds) (Podsiadlo 1991)
Balance: BBS
Cognition: Brief Cognitive Screening Battery (BCSB: includes Identification/nomination, incidental memory, immediate memory, learning memory, delayed memory, clock drawing test, verbal fluency test, recognition), MMSE

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "A sealed envelope with an identification number was assigned to each subject, each one filled with a slip giving the group. When a patient was registered and given a number, the appropriate envelope was opened"

Allocation concealment (selection bias)

Low risk

Quote: "A sealed envelope with an identification number was assigned to each subject, each one filled with a slip giving the group. When a patient was registered and given a number, the appropriate envelope was opened"

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Quote: "As a common bias presented on most rehabilitation trials, it was not possible to 'blind' the subjects regarding the treatments"

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Low risk

Quote: "Assessors were 'masked' with respect to the data collected and to those patients that were included or not in this trial"

Incomplete outcome data (attrition bias)
All outcomes

High risk

Because of small initial group sizes (mean = 18), the loss of 5 from each intervention group compared with the loss of 3 from the control group may present potential bias

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Clark 1975

Methods

Design: RCT
Duration: 12 weeks
Follow up: 4 weeks
Method of randomisation: not described
Concealment of allocation: unclear
Outcome assessor blinding: not described
Group comparability at entry: unclear
Losses to follow up: 2 participants (8.7%) failed to complete the study; both in the social activity group

Participants

Country: USA
Setting: 4 long‐stay psychiatric wards, of which 3 were secure
Randomised: 23
% women = 52
Age: mean = 69 years; range = 50 to 77 years

Consent: assent accepted

Inclusion criteria: capable of communicating and following simple instructions

Exclusion criteria: hypertension, debilitating arthritic impairment, requiring cardiac medication

% Eligible within home: not reported
% Eligible that participate: not reported

Activity group: N = 10; 5 women

Social group: N = 6; 4 women

Control group: N = 7; 3 women

Interventions

Study aim or objective: hypothesised that 12‐week physical activity programme would (1) increase total daily activity level, (2) upgrade participant self care, and (3) increase activity tolerance levels

Number of experimental groups: 3
Group intervention delivery
Session duration: 60 minutes
Number of sessions per week: 5
Seated: no

Activity group: stretching and postural exercise, modified weight and circuit training, dancing and walking; led by a therapist trained in physical education instruction and an assistant, for 1 hour, 5 sessions per week for 12 weeks

Social group: recreational activities involving no physical exertion, e.g. board games, arts and crafts; led by a recreational therapist and an assistant, for 1 hour, 5 sessions per week for 12 weeks

Control group: usual care

Outcomes

Physical function in ADL: self‐care personal neatness evaluation (NOSIE‐30)
Balance: balance (beam stand), balance (one foot stand), balance (toe stand)
Endurance (physical other): heart rate
Physical activity: Total Daily Activity Level Assessment (TDAL)

Notes

Funding:

National Institute of Mental Health (NIMH)

U.S. Department of Health, Education, and Welfare (DHEW) Hospital improvement grant

Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) grant

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Quote: "Subjects were assigned randomly to one of three groups"
No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

RCT with obvious control

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Unclear risk

No information reported

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Unclear risk

No information reported

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Quote: "Only two subjects failed to complete the 12‐week experimental period, both in the social activity group"

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Cott 2002

Methods

Design: RCT
Duration: 16 weeks
Follow up: none
Method of randomisation: randomly assigned to 1 of 3 groups using a table of random numbers
Concealment of allocation: yes
Outcome assessor blinding: yes, maintained
Group comparability at entry: yes, no significant differences, P > 0.05
Losses to follow up: N = 12 (8.7%), 5 lost from talk‐only group and 7 lost from control group
Reasons stated: death and surgery; no separate data reported

Participants

Country: Canada
Setting: 3 long‐term care facilities
Randomised: 86
% women = 53
Age: mean = 82 years ± 8 years; range = not reported
Consent: assent accepted

Inclusion criteria: diagnosis of Alzheimer's disease, MMSE less than 20, MMSE item 8 score of less than 3, ability to walk 5 metres with or without walking aid or supervision

Exclusion criteria: medical: cardiac conditions precluding ambulation

% Eligible within home: not reported
% Eligible that participate: 81.5

Walk and talk group: N = 30; mean age = 83.23 years (SD 8.34); 16 women

Talk‐only group: N = 30; mean age = 81.68 years (SD 7.36); 15 women

Control group: N = 26; mean age = 79.78 years (SD 8.30); 8 women

Interventions

Study aim or objective: to investigate the effects of a walking/talking programme on communication, ambulation, and level of function on people with Alzheimer's disease

Number of experimental groups: 3
Group intervention delivery
Session duration: 30 minutes
Number of sessions per week: 5
Seated: no

Exercise features: walking

Non‐exercise features: talking

Walk‐and‐talk group: to walk and talk as much as possible with rest as necessary (guided conversation), 30‐minute sessions, 5 sessions per week for 16 weeks, led by a research assistant

Talk‐only group: guided conversation only, 30 minutes, 5 sessions per week for 16 weeks, led by a research assistant

Control group: usual care

Outcomes

Physical function in ADL: 2‐minute walk test (Cooper 1968; Cooper 1970)
Communication: Functional Assessment of Communication Skills for Adults (Frattali 2003)
Psychosocial and physical functioning: London Psychogeriatric Rating Scale (LPRS) (Hersch 1978)

Notes

Funding: Alzheimer's Society of Canada

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "Residents were assigned within each site to one of three groups using a table of random numbers"

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Research assistants were blind to the group membership of the residents when completing the measures, but not to the study design
No report of blinding of participants, but usual care so intervention would have been obvious

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Low risk

Does not specifically report blinded assessment for this measurement. However, it does report 1 measure where they were not used, so assume blinded RAs used for measurement

 

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

High risk

The nurses caring for the residents completed the LPRS. They were not blind to group membership

Incomplete outcome data (attrition bias)
All outcomes

High risk

Losses from each group significantly different P = 0.01 (talk‐only = 5, control = 7, and talk‐and‐walk = 0)

Selective reporting (reporting bias)

High risk

Not all observed ADL measures (i.e. LPRS in this study) were reported

Other bias

Low risk

No other apparent risks of bias

Crilly 1989

Methods

Design: RCT
Duration: 12 weeks
Follow up: none
Method of randomisation: not described
Concealment of allocation: unclear
Outcome assessor blinding: not described
Group comparability at entry: yes, no significant differences, P > 0.05
Losses to follow up: N = 3 (6%)

Participants

Country: Canada
Setting: sheltered apartments, rest homes, and nursing homes
Randomised: 50
% women = 100
Age: mean = 82.2 years; range = 71 to 91 years

Consent: fully‐informed consent

Inclusion criteria: ability to ambulate independently without walking aid, eyesight sufficiently good to read large new print, hearing sufficiently good to hear instructions in normal speaking voice, ability to understand instructions, and ability to participate in exercise programme

Exclusion criteria: see inclusion criteria

% Eligible within home: 69
% Eligible that participate: 43

Intervention: N = 25
Control: N = 25

Interventions

Study aim or objective: to test the hypothesis that increase in postural sway is due to nervous system deterioration, and as a consequence, no improvement is possible – irreversible loss of function

Number of experimental groups: 2
Group intervention delivery
Session duration: 25 minutes
Number of sessions per week: 3
Seated: no

Exercise features: exercise class delivered by physiotherapists, activities conducted aim to improve breathing, single and double limb balance, co‐ordination, flexibility, antigravity strength, trunk and ankle strength, and promote general relaxation

Control: usual care

Outcomes

Balance: postural sway (measured on a force platform; lateral and anteroposterior sway measured with eyes open and eyes closed)

Notes

Funding: Canadian Geriatrics Society

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "Subjects were randomized into an exercise or control group using the Rand Corporation random tables"

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No mention of blinding of participants, but usual care in same setting, so intervention would have been obvious

Incomplete outcome data (attrition bias)
All outcomes

Low risk

2 participants dropped out of the exercise group ‐ may be related to intervention, but less than 10% of group

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

de Bruin 2007

Methods

Design: RCT
Details: participants were matched in pairs of 2 and then randomised because participants were expected to train with a regular partner (participants were allowed to choose their preferred training partner)
Duration: 12 weeks
Follow up: no

Participants

Characterisation: senior hostel residents
Country: Switzerland
Setting: senior residents hostel
Randomised: 32
% women = 64%
Age details: mean (SD)
Strength group: 86.5 (4.9)
Strength and balance group: 85.39 (5.4)
Inclusion criteria: residential status, age over 70 years, signed informed consent statement, ability to walk 6 metres
Exclusion criteria: severe cognitive impairment, rapidly progressive or terminal illness, acute illness or unstable chronic illness, myocardial infarction, fracture of a lower extremity within 6 months prior to study beginning, insulin‐dependent diabetes mellitus, undergoing resistance training at the time of enrolment, musculoskeletal or cardiovascular abnormalities (revealed by muscle strength test)

ADL status details: not reported
Cognitive status details: MMSE, mean (SD)
Strength group: 26.5 (3.8)
Strength and balance group: 27.3 (2.2)
Significant comorbidities: not reported
Assessed: not reported
Excluded: 6 on eligibility criteria, 0 other

Interventions

Study aim or objective: to evaluate the additional effect of functional exercises on balance and lower extremity function among hostel‐dwelling elderly people partaking in strength training
2 groups

Intervention: strength and balance group (N = 16)
Format: group, delivered by: physical therapist and exercise trainer
Session length: 45 minutes strength exercises twice a week plus half‐hour balance training on same day as second weekly strength training. Twice weekly strength exercises as reported in strength group, plus an additional half‐hour of balance training on the same day as the second weekly strength training. Classes started with 5 to 10 minutes of warm‐up activities, followed by 20 to 25 minutes of skills training in game activities, such as throwing and catching a ball while standing on a foam surface. All exercise adjusted to individual mobility level. The intensity was gradually increased and previously formulated recommendations were applied with progressive difficulty as tolerated
Control: Strength group (N = 16)
A regimen of progressive resistance training of the hip and knee extensors, the hip abductors, and the foot plantar flexors. The total training period was divided into 2 phases of 6 weeks each. In phase 1, participants performed progressive resistance. The first set performed with no weight or with 50% of maximal exercise weight and 15 repetitions. In the 2nd set, 100% of the maximal exercise weight was taken with the aim of 8 to 12 repetitions. In the 2nd training phase, participants trained in high‐intensity progressive resistance training

Outcomes

Physical function (other): functional test for physical performance (Guralnik 1994), Tinetti Mobility Scale (gait and balance) (Tinetti 1986)
Muscle power (anaerobic): isometric knee extensor muscle force (maximal)
Balance: dynamic postural stability

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Stated used random number table

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Stated that all exercise sessions were undertaken by a single exercise trainer. As a result he/she would have been aware of group status

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Similar numbers lost for similar reasons

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

DeKuiper 1993

Methods

Design: RCT, repeated measures cross‐over design
Duration: n/a, one‐off intervention
Follow up: n/a
Method of randomisation: not described
Concealment of allocation: unclear
Outcome assessor blinding: no
Group comparability at entry: n/a
Losses to follow up: none

Participants

Country: USA
Setting: nursing home and retirement home
Randomised: 28
% women: not reported
Age: mean = 84.86 years ± 6.08 years; range = 76 to 98 years

Consent: unspecified

Inclusion criteria: score of 25 to 40 points on the Paracheck Geriatric rating scale

Exclusion criteria: see inclusion criteria

% Eligible within home: not reported
% Eligible that participate: not reported

Group 1: N = 10
Group 2: N = 8
Group 3: N = 10

Interventions

Study aim or objective: (1) materials‐based intervention would elicit more repetitions and greater distance of movement than imagery‐based occupation and rote exercise; (2) imagery‐based occupation would elicit more repetitions and greater distance of movement during physical activity than rote exercise

Number of experimental groups: 3
Single, individual session
Session duration: not reported
Number of sessions per week: n/a
Seated: yes

Exercise features: materials‐based occupation involved kicking a balloon; imagery‐based occupation involved kicking an imaginary balloon; rote exercise involved being asked to kick your foot as in a demonstration; participants were asked to kick with the same foot as many times as possible before becoming tired

Group 1: materials‐based occupation, followed by imagery‐based occupation, followed by rote exercise
Group 2: imagery‐based occupation, followed by rote exercise, followed by materials‐based occupation
Group 3: rote exercise, followed by materials‐based occupation, followed by imagery‐based occupation

Outcomes

Physical function (other): vertical kicking speed, vertical kicking distance
Endurance (physical other): kicking repetitions

Notes

Funding: not reported
Replication and extension of Lang 1992

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Quote: "Subjects were randomly assigned to three groups"
No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Cross‐over design ‐ all participants received all interventions ‐ it is likely that participants would have been able to tell which was the intervention under experiment and which was the control

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No missing outcome data

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

Cross‐over design, but intervention unlikely to produce a carry‐over effect

Donat 2007

Methods

Design: RCT
Duration: 8 weeks
Follow up: no

Participants

Characterisation: ambulatory independent
Country: Turkey
Setting: nursing home
Randomised: 42
% women = 68%
Age details: median years (range):
UHE group = 79 (21)
SGE group = 81 (19)
Drop‐outs = 79 (20)
Inclusion criteria: > 65 years and being non‐obese (i.e. BMI B/30), increased risk of falling.
Exclusion criteria: psychological disease
Score of > 52 on the BBS or if they had attended an exercise programme regularly in the 2 months prior to the study, not recently suffered a stroke or recovery from an acute illness, no unstable or uncontrolled medical conditions (e.g. diabetes mellitus, hypertension), no resting angina, no recurrent heart failure or arrhythmias, no uncontrolled seizure disorder, no progressive neurological disease, no blindness or deafness, and no severe osteoporosis with 2 or more fractures
ADL status details: assistive device: cane inside (N = 1); cane outside (N = 3); 2 unilateral crutches, 2 canes outside (N = 4)
Cognitive status details: not reported.
Significant comorbidities: number of chronic diseases: 0 to 3 (N = 27), 4 to 6 (n = 15)
Assessed: 535
Excluded: overall = 493, 272 on criteria, 112 declined, 109 other

Interventions

Study aim or objective: to compare the effectiveness of unsupervised home and supervised group exercise on parameters related to risk of falling among older adults
2 groups

Intervention: Supervised group exercise (SGE) group (N = 21)
Format: group; delivered by: physiotherapist in exercise class
Session length: 45 minutes, 3 times per week
Exercise programme based on balance training, strengthening and stretching of the lower limbs, increasing flexibility, posture exercises, and functional activities
Sessions consisted of warm‐up, posture exercises, balance and lower limb co‐ordination exercises, sit‐to‐stands, walking training, stretching, strengthening, and cool down (details in Table 1)
Body weight was used for strengthening of the lower limbs. Balance exercises progressed from being undertaken with eyes open to eyes closed and from undertaken with a support to without a support. For each exercise, the duration and number of repetitions increased as the participants' tolerance increased and as time progressed

Control: Unsupervised home exercise (UHE) group (N = 21)
Same exercise programme as SGE group
The physiotherapist demonstrated the exercises to the participants and then observed them practising the exercises once to ensure they understood how to do them properly. Participants were given a written exercise programme with a weekly chart to help them keep a record of what they had accomplished. On this chart the participants marked the exercises they completed on the various days. Furthermore, they were asked to come to meet the physiotherapist at the end of the second and fourth weeks in order to ensure the exercise programme was being performed properly and to discuss any problems encountered. At these meetings, the participants were also instructed on how to make the appropriate progressions to higher level exercises

Outcomes

Physical function in ADL: TUG test (seconds) (Podsiadlo 1991)
Muscle power (anaerobic): leg strength (leg dynamometer)
Balance: balance: time standing on 1 leg (eyes open), balance: time standing on 1 leg (eyes closed), balance: tandem stance (up to 30 seconds, eyes open), balance: tandem stance (up to 30 seconds, eyes closed), BBS
Flexibility: 'Sit‐and‐Reach' test
Falls, risk and fear of falling: fear of falling (VAS) (Wolf 2001a)
Proprioception: lower limb matching task (position sense of knee joint)

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Quote: "...code number of each subject was written on a card and placed in an envelope, and the envelopes were then put in two groups by a person with no knowledge of the codes"
No report of shuffling of envelopes; therefore, unclear risk of bias

Allocation concealment (selection bias)

Low risk

Quote: "...code number of each subject was written on a card and placed in an envelope, and the envelopes were then put into two groups by a person with no knowledge of the codes"

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Participants were in the same home; 1 group supervised, and 1 unsupervised so knowledge of allocation likely

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Low risk

Quote: "The physiotherapist, who carried out all measurements, both at baseline and after the exercises, was also unaware of the group the subjects were in"

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Slight imbalance in number of participants lost to follow up between groups (more in UHE group than in SGE group), although similar reasons across groups

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Dorner 2007

Methods

Design: RCT
Details: to achieve statistically‐similar groups, participants of the same sex, similar age, and comparable MMSE scores and degree of muscle strength were sorted in pairs. Then each pair was divided randomly; 1 participant assigned to training group and other to control group
Duration: 10 weeks
Follow up: no

Participants

Characterisation: frail, long‐term care facility residents, aged 75 years or older
Country: Austria
Setting: geriatric long‐term care facility
Randomised: 42
% women = 77%
Age details: mean (SD) = 86.8 (5.8); range = 77 to 98
Inclusion criteria: > 75 years, physical ability to take part in strength and balance training (assessed as the ability to walk 5 metres or more, with or without the assistance of walking aids)
Exclusion criteria: high degree of dementia (MMSE score < 10), severe acute diseases
ADL status details: not reported
Cognitive status details: MMSE score, mean (SD): 20.9 (5.2)
Range: 11 to 28
Significant comorbidities: most participants were multi‐morbid people with several diagnosed illnesses: osteoporosis: 52%, dementia: 45%, depression: 42%, history of stroke: 39%, coronary heart disease: 29%
Assessed: not reported
Excluded: not reported

Interventions

Study aim or objective: to examine the effects of structured strength and balance training in frail, elderly long‐term care residents
2 groups

Intervention: Training group (N = 21)
Format: group; delivered by: sports scientist
Session length: 50 minutes 3 times weekly
Structured strength and balance training: warm up (10 minutes), strength training (25 minutes), performed with elastic resistance bands and soft weights, 1 set per muscle group, 10 to 15 repetitions

Balance training (10 minutes): exercise balls, balance discs and blocks (20 cm high) used
Cool down (5 minutes)

Control: Control group (N = 21)
At baseline, according to their skills and deficits, some participants received rehabilitative physical, occupational, psychotherapy, speech therapy, or both (possible contamination)

Outcomes

Physical function in ADL: BI (0 to 100 scale), FIM
Physical function (other): Tinetti Mobility Scale (gait and balance) (Tinetti 1986)
Muscle power (anaerobic): muscle function (upper and lower extremity)
Mood related: GDS
Cognition: MMSE
Anthropometry: lean body mass (kg), lean body mass (%), BMI

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Matched pairs "divided randomly"
No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No mention of blinding of participants, but RCT in same home and usual care as alternative

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Unclear risk

Neither the psychologist nor the physiotherapist, who tested muscle function, were informed by the study organisers to which group participants were assigned. Unclear who assessed BI and FIM and if assessors were blinded to allocation

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Same number of losses to follow‐up in each group, but unclear if reasons for losses to follow‐up were different between groups

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Faber 2006

Methods

Design: cluster RCT
Duration: 20 weeks
Follow up: 52 weeks
Method of randomisation: participating homes allocated to 1 of 2 exercise interventions using sealed envelopes. Participants in those homes were then randomly assigned to exercise programme or control using computer‐generated random numbers. Maximum size of exercise group at each home is 12 and control at least 5
Concealment of allocation: yes
Outcome assessor blinding: not specified
Group comparability at entry: yes, no significant differences, P > 0.05
Losses to follow up: recruited 278 participants; 40 (14.4%) dropped out immediately after randomisation (equally distributed across both groups), 6 excluded from fall analyses because no reliable data, 30 excluded from physical function and disability analyses because they did not come to the post‐intervention assessment, 4 perceived their health to be too poor, 4 lost interest, 1 suffered fracture, 5 hospitalised > 2 weeks; 4 died, and 6 were ill

Participants

Country: the Netherlands
Setting: 15 homes for the elderly
Randomised: 278
% women = 79
Age: mean = 84.9 years; range = 63 to 98 years
Consent: fully‐informed

Inclusion criteria: see exclusion criteria

Exclusion criteria: cognitive: impaired cognition to the extent that they could not process information provided during the testing and exercising; medical = GP judged whether there was a medical contraindication to exercising; functional = unable to walk more than 6 metres independently (aids allowed)

% Eligible within home: not reported
% Eligible that participate: not reported

Functional walking: N = 130 (7 residences); 80 allocated intervention, 50 allocated control

In balance: N = 148 (8 residences); 94 allocated intervention, 54 allocated control

Interventions

Study aim or objective: to determine the effects of moderate intensity group‐exercise programme on falls, functional performance, and disability in older adults, and to investigate the effect of frailty on outcome

Number of experimental groups: 4
Group intervention delivery
Session duration: 90 minutes
Number of sessions per week: 2
Seated: no

All participants (including control) required to report levels of physical activity to monitor and control contamination from the intervention

Interventions: 2 exercise programmes, both with evidence that they were effective in preventing falls, 1 session per week for 4 weeks followed by bi‐weekly sessions for 16 weeks, 90‐minute sessions including 30‐minute social element intended to increase motivation; all groups had their own instructor and assistant

Functional walking: 10 exercises: balance, mobility, and transfer training
In balance: (derived from Tai Chi) elements of Tai Chi most beneficial to elderly people
Control: there was a control group for each exercise type; details not reported

Outcomes

Risk of falling: time to first fall
Falls: falls (any episodes for participant), fall rate (falls per person years), number of falls
Physical function in ADL: GARS (Groningen Activity Restriction Scale)
Physical function (other): Physical Performance Score (PPS) (Faber 2006), Performance Orientated Mobility Assessment (POMA)

Notes

Funding: not reported; no commercial party had any financial interests

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Quote: "The participating homes were randomly assigned to one of the two exercise intervention programs, using sealed envelopes. Participants in each of the homes were then randomly distributed across an intervention and a control group, using computer‐generated random numbers. The maximum size of the exercise group in each home was set at 12, with the provision that the control group should contain at least 5 participants"
Unclear whether size of participant groups was constrained using a truly random process

Allocation concealment (selection bias)

Unclear risk

Quote: "The participating homes were randomly assigned to one of the two exercise intervention programs, using sealed envelopes"
Unclear if second allocation of participants was concealed

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Quote: "The outcome of the randomization was notified to the participants in a letter after baseline assessment"

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Unclear risk

Insufficient information ‐ no information included about who undertook the outcome measures

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Unclear risk

Insufficient information ‐ no information included about who undertook the outcome measures

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

ITT analysis stated. However, baseline figures do not match number of participants initially randomised. 6 participants excluded from analyses of fall data because there was no reliable data available; 30 participants excluded from analyses of physical function and disability data because of missing post‐intervention assessment (24 of whom had dropped out of the study). Reasons not given per group and unclear impact on outcomes

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Fiatarone 1994

Methods

Design: RCT
Duration: 10 weeks
Follow up: none
Method of randomisation: unclear
Concealment of allocation: unclear
Outcome assessor blinding: partial ‐ measurements of muscle function were made by a single observer who was aware of group assignments, but not involved in training. CT evaluation of the mid‐thigh was conducted by a single investigator in a blinded fashion; no details of blinding were described for the other outcomes
Group comparability at entry: no, significant differences, P < 0.05

Baseline difference in strength: exercise + nutrition participants significantly weaker than exercise‐alone participants

Losses to follow up: 3 lost from exercise‐only group (1 lack of interest, 1 musculoskeletal pain, 1 pneumonia), 2 from supplement‐only group (1 death, 1 lack of interest), and 1 lost from control group because of death

Participants

Country: USA
Setting: elderly long‐term care facility
Randomised: 100
% women = 63
Age: 38% older than 90 years; mean = 87.1 years ± 0.6 years; range = not reported

Consent: not specified

Inclusion criteria: aged over 70 years, residential status, ability to walk 6 metres

Exclusion criteria: cognitive = severe cognitive impairment; medical = rapidly progressive or terminal illness, acute illness, unstable chronic illness, myocardial infarction, fracture of a lower extremity within 6 months before the study, insulin‐dependent diabetes mellitus, if they were on a weight loss diet or undergoing resistance training at the time of enrolment, if test of muscle strength revealed a musculoskeletal or cardiovascular abnormality

% Eligible within home: 26.7
% Eligible that participate: 28.7

Exercise‐only group: N = 25; mean age = 86.2 years ± 1.0 mean SE; range = 72 to 95 years; 64% women

Supplement‐only group: N = 24; mean age = 85.7 years ± 1.2 mean SE; range = 75 to 97 years; 71% women

Exercise and supplement group: N = 25; mean age = 87.2 years ± 1.2 mean SE; range = 76 to 98 years; 64% women

Control group: N = 26; mean age = 89.2 years ± 0.8 mean SE; range = 78 to 98 years; 54% women

Interventions

Study aim or objective: hypothesis: physical frailty is partially mediated by skeletal‐muscle disuse and marginal nutritional intake, and should therefore be reduced by interventions designed to reverse those deficits

Number of experimental groups: 4
Individualised intervention
Session duration: 45 minutes
Number of sessions per week: 3
Seated: no

A therapeutic recreation specialist delivered the exercise components

Exercise‐only group: high‐intensity progressive resistance training of the hip and knee extensors, commencing at 80% of 1 repetition max and progressing as able

Supplement‐only group: 240 ml Exceed micronutrient supplement drink daily, representing 360 kilocalories, delivered in an unmarked container

Exercise and supplement group: comprised both interventions

Control group: 240 ml of a minimally nutritive liquid delivered in the same way, plus 3 activities of the participants' choice offered by the same service, but excluding resistance training

Outcomes

Physical function in ADL: gait velocity over a 6.1 metre course (Fiatarone 1994)
Physical function (other): Stair Climbing Power (Bassey 1992)
Muscle power (anaerobic): leg press (Fiatarone 1994), hip extensor muscle strength, knee extensor muscle strength
Physical activity: physical activity (GMM activity monitor)
Anthropometry: thigh‐muscle area (Fiatarone 1994), weight
Physiology: whole body potassium (Cohn 1980)
Energy consumption: energy intake (kCal/day)

Notes

Funding:

National institute of Ageing

Agricultural Research Service

Public Health Service of Hebrew Rehabilitation Centre, Massachusetts

Brookdale Foundation

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Study performed in one home. As a result, it would have been difficult to blind participants and would have been obvious which groups they were assigned to

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Unclear risk

Not clear who performed mobility outcome assessments

Incomplete outcome data (attrition bias)
All outcomes

High risk

Outcome data missing for some participants because of technical problems or illness at time of testing

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Gillies 1999

Methods

Design: cluster RCT
Duration: 12 weeks
Follow up: none
Method of randomisation: by residential home
Concealment of allocation: unclear
Outcome assessor blinding: no
Group comparability at entry: yes, no significant differences, P > 0.05
Losses to follow up: N = 5 (25%)
Intervention group: N = 4 (2 due to illness, 1 loss of interest, 1 out with relatives on day of classes)
Control group: N = 1 (refused test)

Participants

Country: UK
Setting: 2 residential homes
Randomised: 20
% women = 95 (only data from women analysed)
Age: mean = approximately 88 years; range = not reported

Consent: fully‐informed

Inclusion criteria: > 70 years, mobile, able to participate in test battery, no medical conditions that would interfere with safety regarding training program

Exclusion criteria: 6 participants were excluded, but no reasons given

% Eligible within home: 76.9
% Eligible that participate: not reported

Intervention group: N = 10; mean age = 88 ± 5 years; all women

Control group: N = 10; mean age = 87 years ± 4 years; 9 women

Interventions

Study aim or objective: study question: is it possible to improve functional ability in older people by getting them to practise the functional tasks themselves?

Number of experimental groups: 3
Group intervention delivery
Session duration: unclear
Number of sessions per week: 2
Seated: unclear

Exercise features: circuit of 8 functional exercises for 30 seconds initially progressing to a maximum of 1 minute, then increasing difficulty of task

Control: reminiscence and recreational sessions; gentle, seated range of movement exercises (trunk and upper limbs only)

Personnel delivering interventions not specified

Outcomes

Physical function in ADL: stair ascent/descent, walking distance in 15 seconds
Physical function (other): sit‐to‐stand (fastest time to stand up)
Anthropometry: weight

Notes

Funding: not reported

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

This was a cluster randomised trial. No evidence as to how randomisation was determined

Allocation concealment (selection bias)

Unclear risk

No evidence to demonstrate if individuals were recruited into the trial before/after the homes had been randomised to intervention or control

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

No evidence of blinding

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Unclear risk

No evidence of blinding

Incomplete outcome data (attrition bias)
All outcomes

High risk

Missing outcome data (5 dropouts; 4 from intervention)

Selective reporting (reporting bias)

Unclear risk

In the results, confidence intervals are only reported for some results (not clear why)

Other bias

Low risk

No other apparent risks of bias

Hruda 2003

Methods

Design: RCT
Duration: 10 weeks
Follow up: none
Method of randomisation: randomly assigned using a 1:2 ratio in a lottery format to control group or exercise group
Concealment of allocation: unclear
Outcome assessor blinding: unclear
Group comparability at entry: yes, no significant differences, P > 0.05
Losses to follow up: N = 5 (17%), dropped out because of health reasons (exercise = 2, control = 3)

Participants

Country: Canada
Setting: long‐term care facility
Randomised: 30
% women = 80
Age: mean = approximately 83 years; range = 75 to 94 years

Consent: assent accepted

No participants were currently involved in any physical exercise programme or had any recent exercise history

Inclusion criteria: ability to follow directions; ability to walk across a room (with or without assistive device); no recent history of cardiovascular, cerebral vascular, respiratory, systemic, muscular, or uncontrolled metabolic disease

Exclusion criteria: see inclusion criteria

% Eligible within home: not reported
% Eligible that participate: not reported

Control: N = 10; 75 to 87 years
Exercise: N = 20; 76 to 94 years

Interventions

Study aim or objective: examine the effect of an onsite and simple progressive lower body training programme designed to improve muscle power on functional abilities in frail older adults

Number of experimental groups: 2
Group intervention delivery
Session duration: 20 to 60 minutes
Number of sessions per week: 3
Seated: If necessary

Exercise features: 10‐minute warm‐up and stretch, strengthening components utilised seated and standing components focusing in lower‐body muscle groups, Thera‐Bands® gradually introduced to increase resistance, number of exercise repetitions were gradually increased and a speed element introduced, 10‐minute cool‐down, personnel delivering interventions not specified

Control: no active or placebo intervention, asked to perform no more or no less activity than normal on a daily basis

Outcomes

Physical function in ADL: six‐metre walk (time), TUG test (modified to 8 feet) (Bassey 1992; Rikli 1999)
Physical function (other): sit‐to‐stand (average number in 30 seconds)
Muscle power (anaerobic): knee extensor muscle strength

Notes

Funding: not reported

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "Subjects were randomly assigned in a lottery format"

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

RCT with usual care control, so obvious group assignment

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Unclear risk

No report of blinding

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Differential loss to follow up but seems unlikely to be related to intervention

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Karl 1982

Methods

Design: RCT
Duration: 4 weeks
Follow up: none
Method of randomisation: not described
Concealment of allocation: unclear
Outcome assessor blinding: unclear
Group comparability at entry: unclear
Losses to follow up: none stated

Participants

Country: USA
Setting: long‐term residents of an intermediate care facility
Randomised: 19
% women = 16
Age: mean = not reported; median = 73 years; range = 62 to 95 years

Consent: assent accepted

Inclusion criteria: > 65 years old, some deficits in self care – requiring assistance with dressing, grooming, and feeding

Exclusion criteria: see inclusion criteria

% Eligible within home: not reported
% Eligible that participate: 47.5

Interventions

Study aim or objective: to test the assumption that elderly individuals participating in a range of motion exercise programme will show more of an increase in self care in hygiene and eating than those who do not
Number of experimental groups: 2
Group intervention sessions
Session duration: 30 minutes
Number of sessions per week: 2
Seated: If necessary

Exercise features: upper limb and lower limb range of movement exercises; personnel delivering the intervention were not described

Control: movies only

Outcomes

Physical function in ADL: Performance Test of Activities of Daily Living (PADL)

Notes

Funding: not reported

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No mention of blinding of participants, but control group watched movies, and outcome measure was physical so intervention would have been obvious

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Unclear risk

No details provided

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

No information about losses to follow up

Selective reporting (reporting bias)

High risk

Results for pre and post PADL not reported

Other bias

Low risk

No other apparent risks of bias

Kerse 2008

Methods

Design: cluster RCT
Clustering accounted for
Duration: 6 months
Follow up: yes

Participants

Characterisation: elderly care‐home residents
Country: New Zealand
Setting: low‐level dependency residential care homes
Randomised: 682
% women = 74%
Age details: mean (SD) = 84.3 (7.2)
Inclusion criteria: residents aged 65 years and over, able to engage in a conversation about a goal, remember the goal, and participate in a programme to achieve the goal (a proxy for cognitive state)
Exclusion criteria: residents unable to communicate to complete the study measures, anxiety as their main diagnosis, were acutely unwell, or in a terminal state
ADL status details: Late Life Function and Disability Instrument (LLFDI) total disability score, mean (SD) = 37.7 (6.3)
Cognitive status details: Abbreviated Mental Test Score (AMTS), mean (SD) = 7.2 (2.4)
Significant comorbidities: total number of diagnoses, mean (SD) = 4.9 (2.2)
No (%) Depression (GDS > 4): 215/614 (35%)
Assessed: 1584
Excluded: overall = 902; 762 on criteria, 140 declined, 0 other

Interventions

Study aim or objective: to assess the effectiveness of an activity programme in improving function, quality of life, and falls in older people in residential care
2 groups

Intervention: activity group (N = 330)
Format: individual, delivered by gerontology nurses and healthcare assistants
Session length: not reported. Daily
Trained nurses delivered the promoting independence in residential care (PIRC) intervention. The resident set a goal to promote physical activity. The nurse then designed an individualised programme of physical activities based on ADLs (daily or several times a day). The gerontology nurse trained healthcare assistants in implementing the plan and provided ongoing support. Exercise activities were undertaken several times daily

Control: social group (N = 352)
Received usual care and were offered 2 social visits by a social science researcher to control for the attention received by the resident from the gerontology nurse visits

Outcomes

Physical function in ADL: Late Life Function and Disability Instument (LLFDI) (Sayers 2004), TUG test (seconds) (Podsiadlo 1991), Elderly Mobility Scale (EMS) (Smith 1994)
Balance: FICSIT‐4 balance test
Mood related: GDS
Quality of life: Life Satisfaction Index (Neugarten 1961)
Perceived health status: EuroQoL (Brooks 1996)
Falls, risk and fear of falling: fear of falling (modified) (Hill 1996), falls (any episodes for participant)
Acute health events: adverse effects, hospitalisations

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Randomised homes to the intervention or control group using computer generated random numbers

Allocation concealment (selection bias)

Low risk

Quote: "...a biostatistician not involved in recruitment randomized homes to the intervention or control group..."

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Cluster design so potential for blinding, but not specifically reported

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Low risk

Quote: "...research nurses blinded to the group allocation of the homes used standardised methods to assess outcomes..."

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Low risk

Quote: "...research nurses blinded to the group allocation of the homes used standardised methods to assess outcomes..."

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Large losses, but balanced and similar reasons

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Kinion 1993

Methods

Design: RCT
Duration: 8 weeks
Follow up: none
Method of randomisation: not described
Concealment of allocation: unclear
Outcome assessor blinding: unclear
Group comparability at entry: unclear
Losses to follow up: none

Participants

Country: USA
Setting: assisted‐living home for the aged
Randomised: 24
% women = 75
Age: mean = approximately 85 years; range = 72 to 101 years

Consent: fully‐informed consent

Inclusion criteria: permission of participants' physicians was sought; no participants had any acute illness

Exclusion criteria: see inclusion criteria

% Eligible within home: not reported
% Eligible that participate: not reported

Intervention group: N = 12; mean age = 87 year; range = 72 to 101 years; 9 women

Control group: N = 12; mean age = 82 years; range = 74 to 100 years; 9 women

Interventions

Study aim or objective: the programme addressed physical activity and psychosocial needs, such as learned helplessness and sadness, without placing additional strain on the hectic schedules of staff

Number of experimental groups: 2
Group session delivery
Session duration: 30 minutes
Number of sessions per week: 3
Seated: yes

Exercise features:
Sit‐and‐get‐fit group: performed seated range of movement exercises, included measures to promote psychosocial well‐being; programme was delivered by a paraprofessional

Control: participated in usual home activities, with opportunity to participate in sit and get fit programme after the study period

Outcomes

Flexibility: ankle dorsiflexion and plantarflexion (range of motion), shoulder abduction, hip flexion and extension, elbow flexion and extension, shoulder anterior flexion, knee flexion (range of movement)
Feasibility and acceptability: subjective experience data

Notes

Funding: not reported

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No information provided, but RCT with obvious intervention/control

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No attrition

Selective reporting (reporting bias)

High risk

Pre and post data not reported in an appropriate format (only reported as percentage change; no absolute figures)

Other bias

Low risk

No other apparent risks of bias

Lang 1992

Methods

Design: RCT
Duration: n/a (one‐off intervention)
Follow up: n/a
Method of randomisation: unclear ‐ according to a counter‐balanced design
Concealment of allocation: unclear
Outcome assessor blinding: unclear
Group comparability at entry: n/a
Losses to follow up: none

Participants

Country: USA
Setting: 2 nursing homes
Randomised: 15
% women = not reported
Age: mean = 76.3 ± 9.95 years; range = 56 to 93 years

Consent: not specified

Inclusion criteria: Parachek score > 25

Exclusion criteria: see inclusion criteria

% Eligible within home: not reported
% Eligible that participate: not reported

Interventions

Study aim or objective: tested the hypothesis that materials‐based occupation elicits a greater number of repetitions during physical activity in elderly persons than rote exercise

Number of experimental groups: 3
Delivered to groups of participants
Session duration: n/a
Number of sessions per week: n/a

Exercise features: materials‐based occupation (kicking balloon); imagery‐based occupation (kicking imaginary balloon); rote exercise (kicking foot as demonstrated)

Group 1: materials‐based occupation, then imagery‐based occupation, then rote exercise
Group 2: imagery‐based occupation, then rote exercise, then materials‐based occupation
Group 3: rote exercise, then materials‐based occupation, then imagery‐based occupation

Participants were instructed to kick as many times as possible and stop when too tired to continue

All interventions were supervised by a research assistant, conducted in one‐off sessions, with 3 days in between each 1

Outcomes

Endurance (physical other): kicking repetitions

Notes

Funding: not reported

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Quote: "Subjects were randomly assigned..."
No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Not addressed; all three groups received each intervention in different orders

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No incomplete outcome data

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

Cross‐over design, but intervention unlikely to produce a carry‐over effect

Lazowski 1999

Methods

Design: RCT
Duration: 4 months
Follow up: none
Method of randomisation: table of random numbers; participants were stratified into 2 levels of mobility, based on their scores and the Timed Up and Go test. Within each mobility category at each site, residents were randomly assigned to either the functional fitness for long‐term care (FFLTC) or range of motion (ROM) condition
Concealment of allocation: yes ‐ maintained
Outcome assessor blinding: yes ‐ maintained
Group comparability at entry: unclear
Losses to follow up: N = 28 (29%): FFLTC group N = 19, ROM group N = 9
Similar reasons for both groups: too busy N = 15, medical reasons N = 8, unable to follow exercise N = 3, moved away N = 2

Participants

Country: Canada
Setting: long‐term care institution
Randomised: 96
% women = 84
Age: mean = 80 years ± 0.9 years; range = not reported

Consent: assent accepted

Inclusion criteria: able to stand with minimal assistance, ability to follow simple instructions

Exclusion criteria: medical = recent cardiovascular event, vestibular disorder, uncontrolled hypertension, uncontrolled epilepsy, fracture within 4 months, total blindness/deafness, surgery planned for within the next 4 months; functional = holidays planned for within the next 4 months, recent admission (less than 3 months)

% Eligible within home: not reported
% Eligible that participate: not reported

FFLTC (functional fitness for long‐term care) group: N = 55; mean age = 79.7 years; 29 women

ROM (range of motion) group: N = 41; mean age = 80.4 years; 30 women

Interventions

Study aim or objective: this study compared traditional range of motion to a 'functional fitness for long‐term care' programme designed to improve strength, balance, flexibility, gait, functional capacity, and strength

Number of experimental groups: 2
Group intervention delivery
Session duration: 45 minutes
Number of sessions per week: 3
Seated: not specified

Exercise features:
FFLTC group: comprised walking, strengthening and balance exercises, tailored to meet each of the 2 groups (high mobility/low mobility), conducted by recreation staff

ROM group: comprised seated exercise to improve range of movement (fingers, hands, arms, knees, ankles), relaxation, vocal exercise, and word/memory games

Groups were of mixed ability, supervised by recreation staff

Outcomes

Physical function in ADL: gait speed over 7 metres (self‐selected normal pace), gait speed over 7 metres (fast pace), TUG test (seconds) (Podsiadlo 1991), FIM
Physical function (other): stair climbing power (Bassey 1992)
Muscle power (anaerobic): lower extremity strength, total hip strength, upper extremity strength, isometric strength (elbow flexion; shoulder abduction; knee extension; hip ab/adduction, flexion/extension), hand grip strength, isotonic strength of knee extensors (Connelly 1995)
Balance: BBS
Flexibility: 'Sit‐and‐reach' test (modified) (Lazowski 1997), upper body flexibility (Leighton flexometer)

Notes

Funding: grants from the Canadian Fitness and Lifestyle Research Institute, The Walter J. Blackburn Family Foundation, The Richard Ivey Foundation, and the Ontario Ministry of Health Long‐term Care

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Stated used a random number table

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Blinding attempted, but potential that blinding was broken as participants were from the same setting
However, ROM and FFLTC groups, so questionable whether it was important

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Low risk

TUG: stated research assistant blind to study condition

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Low risk

FIM: stated research assistant blind to study condition

Incomplete outcome data (attrition bias)
All outcomes

High risk

Much higher attrition rate in FFLTC than ROM, 19/55 (35%) versus 9/41 (22%), and large numbers

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Lee 2009

Methods

Design: cluster RCT
Clustering not accounted for
Details: a non‐equivalent pre‐test‐post‐test control‐group design
Duration: 26 weeks
Follow up: no

Participants

Characterisation: nursing‐home residents
Country: Hong Kong
Setting: nursing homes
Randomised: 175
% women = 68%
Age details: mean (SD) = 82.7 (7.1); range = 66 to 101 years

Inclusion criteria: (a) Chinese, (b) > 65 years of age, (c) intact cognitive function (Abbreviated Mental Test score > 6/10), (d) able to walk independently, (e) able to communicate in Cantonese
Exclusion criteria: (a) experiencing acute symptoms of medical problems, (b) having a pre‐existing psychological disorder, (c) having previous Tai Chi training
ADL status details: not reported
Cognitive status details: not reported
Significant comorbidities: mean (SD) number of comorbidities = 2.9 (3.1)
Assessed: not reported

Excluded: not reported

Interventions

Study aim or objective: to examine the effect of Tai Chi on health‐related quality of life in nursing‐home residents
2 groups

Intervention: Tai Chi group
Format: group, delivered by: Tai Chi instructor
Session length: 8 to 10 minutes to perform entire sequence, 3 times weekly
Chen‐style Tai Chi was taught. This short‐form incorporated essential elements of Tai Chi and was relatively gentle
During the sessions, the instructor demonstrated the Tai Chi movements, and participants imitated the motions and postures. New Tai Chi movements were introduced each session, and participants learned the sequence at the end of 26 weeks

Control: Control group
Usual daily activities

Outcomes

Balance: balance (Single Limb Stand Timed test)
Flexibility: 'Sit‐and‐reach' test
Perceived health status: SF‐12 health‐related quality of life (mental component), SF‐12 health‐related quality of life (physical component)
Energy expenditure: Physical Activity Questionnaire (PAQ) (Liu 2001)
Other: satisfaction with Nursing Home Instrument Chinese version (Lee 2006)

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Author reports homes as randomised, but no information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Stated that the instructor was blind to outcome measures. However, participants could not have been

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Figures not provided for loss to follow up (hospitalisation, death, or move to other home) for intervention or control group (presented as combined data only)

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

MacRitchie 2001

Methods

Design: RCT
Duration: 54 weeks
Follow up: none
Method of randomisation: participants were stratified by every 5 years of age and then randomly assigned by computer
Concealment of allocation: unclear
Outcome assessor blinding: no, but objective assessments were performed (assessors were unaware of pre‐test scores when collecting post‐test data)
Group comparability at entry: yes, no significant differences, P > 0.05
Losses to follow up: N = 6 (7%)

Participants

Country: USA
Setting: 2 nursing homes
Randomised: 88
% women = 80.7
Age: mean = 84.1 years ± 6.9 years; range = 65 to 98 years

Consent: informed consent from participant or relative and from their doctor

Inclusion criteria: nursing home long‐term care resident, physically capable of safe bilateral lower extremity weight‐bearing with supervision or minimal assistance, cognitively able to follow simple directions

Exclusion criteria: cognitive = unable or generally unwilling to follow simple directions; medical = inability or medical restriction to bear weight on both lower extremities, less than 65 years of age; functional = participating in skilled rehabilitation (physical therapy or occupational therapy) immediately prior to study

% Eligible within home: unclear
% Eligible that participate: unclear, possibly N = 88 of 294 residents (30%)

Group breakdown: not given, 29 to 30 participants in each group

Interventions

Study aim or objective: investigation of the effect of a standing exercise programme on the number of falls and the severity of intrinsic fall risk factors (functional losses of strength, balance and endurance, depression and number of infections)

Number of experimental groups: 3
one‐to‐one sessions with each participant being supervised by a care assistant 'buddy'
Session duration: 20 minutes
Number of sessions per week: 5 ‐ both interventions were conducted daily Monday to Friday, for 54 weeks
Seated: no

Intervention group: (group 1): comprised exercises in standing and walking activities, triggered when energetic music was played over intercom
Control group (group 2): consisted of talking and listening to music only
Control group (group 3): listened to the music alone

Outcomes

Falls: number of falls
Physical function in ADL: 30‐feet walk (time s), TUG test (seconds) (Podsiadlo 1991)
Balance: Duncan Functional Reach (DFR) test
Mood related: GDS
Acute health events: infections (average number per month)

Notes

Funding: unclear
Unpublished PhD thesis

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "Assignment to specific activities will be randomized by computer"
Comment: assume this means a computer random‐number generator was used

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Blinding of participants would not have been possible ‐ participants would have been aware of which group they were in

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Unclear risk

Unclear if assessor was blinded

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Author states that the 6 participants who were unable to complete the post‐tests were "dispersed among the groups, with reasons for dropping out unrelated to the intervention"

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Makita 2006

Methods

Design: RCT
Details: stratified by care level (determined on base of total time required for assistance with ADLs, instrumental ADLs, functional training, and medical services)
Duration: 3 months
Follow up: no

Participants

Characterisation: frail elderly women
Country: Japan
Setting: special nursing homes for the elderly
Randomised: 149
% women = 100%
Age details: mean (SD):
Exercise group: 84.85 (7.3)
Control group: 86.25 (6.59)
Inclusion criteria: women and stable health
Exclusion criteria: not reported
ADL status details: length of time of care per day (number of participants):
30 to 50 minutes: 9
50 to 70 minutes: 19
70 to 90 minutes: 36
90 to 110 minutes: 33
110 minutes or longer: 48
Cognitive status details: not reported
Significant comorbidities: not reported
Assessed: 226
Excluded: Overall = 77

Interventions

Study aim or objective: to evaluate the effects of exercise therapy using the Takizawa Program
2 groups

Intervention: Exercise group (N = 74)
Format: group, delivered by nurses and care workers as physical exercise instructors
Session length: not reported, 3 times weekly
Takizawa program: following exercises performed while sitting or standing:
1. upper limb range of motion exercise using a movable pulley
2. trunk flexion and twisting exercise with abdominal breathing
3. ankle plantar‐dorsal flexion exercise using the instrument 'PATA'
4. knee flexion‐extension exercise using the instrument 'KORO'
5. shoulder and elbow flexion‐extension exercise
6. knee extension exercise
7. hip flexion exercise

Outcomes

Physical function in ADL: FIM
Flexibility: range of motion (shoulder flexion; knee extension; ankle dorsal flexion/plantar flexion)

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No report of blinding of participants, but usual care so intervention would have been obvious

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Low risk

Quote: "The evaluators of FIM in this study were the care workers who provided daily care to the patients, and were blind to the patient’s assignments to the Ex or Co group"

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Slightly more losses to follow up in exercise group than in control group, although same reason provided across groups

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

McMurdo 1993

Methods

Design: cluster RCT
Duration: 7 months
Follow up: none
Method of randomisation: sealed envelopes supplied in sequence by the study co‐ordinator and prepared from a computer‐generated random numbers table
Concealment of allocation: yes ‐ maintained
Outcome assessor blinding: no
Group comparability at entry: unclear
Losses to follow up: N = 8 (16.3%): intervention group: N = 5 (3 deaths, 2 loss of interest), control group: N = 3 (3 deaths)

Participants

Country: Scotland, UK
Setting: 4 residential homes
Randomised: 49
% women = 80 (of completers)
Age: mean = 81 years; range = 64 to 91 years

Consent: assent accepted

Inclusion criteria: see exclusion criteria

Exclusion criteria: cognitive: severe communication difficulties

Residential homes all had identical entrance criteria, namely that residents should be able to toilet, dress, and walk independently

% Eligible within home: not reported
% Eligible that participate: not reported

Intervention group: N = 20; mean age = 82.3 years (SD 6.9); 12 women

Control group: N = 29; mean age = 79.3 years (SD 6.2); 21 women

Interventions

Study aim or objective: to evaluate whether participation in regular exercise was acceptable to residents of old people's homes, and whether it produced significant improvements in balance, flexibility, strength, or functional capacity compared with a control group who participated in reminiscence sessions

Number of experimental groups: 2
Group intervention delivery
Session duration: 45 minutes
Number of sessions per week: 2
Seated: yes
Personnel delivering the interventions were not described

Exercise features: full upper limb and lower limb range of movement; seated exercises to music, intended to promote strengthening; exercise groups lasted for 45 minutes, and were conducted twice weekly for 7 months

Control: music and reminiscence therapy designed to prompt social interaction

Outcomes

Physical function in ADL: BI (0 to 20)
Physical function (other): sit‐to‐stand (fastest time to stand up)
Muscle power (anaerobic): hand grip strength
Balance: postural sway (using Wright's ataxiameter) (Wright 1971 )
Mood related: GDS
Cognition: MMSE
Flexibility: spinal flexion (American Academy of Orthopaedic Surgeons 1965), knee extension (range of movement), knee flexion (range of movement)
Quality of life: Life Satisfaction Index (Neugarten 1961)
Anthropometry: BMI

Notes

Funding:

The Mathew Trust

The ICL Discretionary Trust
All of the residential homes exhibited identical admission criteria

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "Randomisation...prepared from a computer‐generated random numbers table"

Allocation concealment (selection bias)

Low risk

Quote: "Randomisation was by opening sealed envelopes supplied in sequence by the study co‐ordinator"

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

No report of blinding of participants ‐ although exercise groups and reminiscence groups were in different homes, so participants possibly weren't aware if they were intervention or control

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

High risk

All measurements made by the same observer that provided the interventions

Incomplete outcome data (attrition bias)
All outcomes

High risk

More losses to follow up in exercise group (25%) than in control group (10%), and losses from exercise group include lack of interest

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

McMurdo 1994

Methods

Design: cluster RCT
Duration: 6 months
Follow up: none
Method of randomisation: sealed envelopes supplied in sequence by the study co‐ordinator, prepared from a computer‐generated random number table
Concealment of allocation: yes ‐ maintained
Outcome assessor blinding: partial
Group comparability at entry: yes, no significant differences, P > 0.05
Losses to follow up: N = 10 (15.4%): intervention group: N = 4 (3 deaths, 1 fractured neck of femur); control group N = 6 (4 deaths, 2 hospital admissions)

Participants

Country: Scotland, UK
Setting: 4 residential homes
Randomised: 65
% women = 83%
Age: mean = 83 years; range = 67 to 98 years

Consent: assent accepted

Inclusion criteria: volunteers were not excluded on the basis of any medical condition

Exclusion criteria: cognitive = severe communication difficulties

% Eligible within home: not reported
% Eligible that participate: not reported
Intervention group: N = 36; mean age = 83.7 years (6.6); 29 women

Control group: N = 29; mean age = 82.0 years (9.6); 25 women

Residential homes all had identical entrance criteria, namely that residents should be able to toilet, dress, and walk independently

Interventions

Study aim or objective: (1) what are the mechanisms of improvement seen in McMurdo 1993?, (2) in the institutionalised elderly, does participation in regular seated exercise strengthen the quadriceps muscles?, (3) is participation in such exercise associated with improved psychomotor or cognitive function?

Number of experimental groups: 2
Group intervention sessions
Session duration: 45 minutes
Number of sessions per week: 2
Seated: yes

Exercise features: performed seated exercise to music, number of repetitions and gravity‐resisted exercises were increased during the course of the study, group format, supervised by research physiotherapist

Control group: reminiscence therapy designed to prompt social interaction and group discussion, 45 minutes in duration, conducted twice weekly for 6 months, facilitated by research physiotherapist

Outcomes

Physical function in ADL: step test
Physical function (other): reaction Time
Muscle power (anaerobic): quadriceps muscle strength
Cognition: MMSE

Notes

Funding: not reported

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "Randomization...prepared from a computer‐generated random table"

Allocation concealment (selection bias)

Low risk

Quote: "Randomization was by opening sealed envelopes supplied in sequence by the study coordinator"

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Quote: "Pre‐study measurements were undertaken by the research physiotherapist at the same time of day in both groups. Post‐study measurements were undertaken by an independent, blinded observer who was not otherwise involved in the project"
No information about blinding of participants and personnel involved in recording outcome measures

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Low risk

Quote: "Done by an independent, blinded observer who was not otherwise involved in the project"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Missing outcome data relatively balanced across the groups (all participants accounted for)

Selective reporting (reporting bias)

High risk

Only Quadriceps, MMSE and reaction time data reported

Other bias

Low risk

No other apparent risks of bias

Meuleman 2000

Methods

Design: RCT
Duration: 4 to 8 weeks
Follow up: 1 year
Method of randomisation: groups were determined by computer algorithm stratified by site of care (GEM or nursing home); assignments were in sealed envelopes that were opened after the pre‐test was completed (see notes)
Concealment of allocation: yes ‐ maintained
Outcome assessor blinding: yes
Group comparability at entry: no significant differences, P < 0.05

Significantly more training participants had their primary medical problem disability from cerebrovascular accident

Losses to follow up: N = 20 (25.6%) (at initial post‐test): training group N = 13 (6 discharged home, 4 due to illness, 2 deaths, 1 withdrew because of shoulder strain); control group N = 7 (4 discharged home, 1 because of illness, 2 deaths)

Participants

Country: USA
Setting: 1 Veteran's Affairs nursing home and geriatric evaluation and management unit, and 1 community nursing home
Randomised: 78
% women = 12
Age: mean = 75 years; range = 60 to 97 years

Consent: assent accepted

Inclusion criteria: > 60 years, impaired functional status (requiring assistance with 1 or more physical activities of daily living) with potential for improvement, able to follow simple commands, wheelchair participants must be able to transfer with modest assistance at most, Veteran's Affairs participants must have an expected length of stay > 4 weeks

Exclusion criteria: severe dementia, uncontrolled hypertension, unstable angina, medical condition that would interfere with safety of training protocol, stroke in previous 3 weeks, pacemaker, chronic atrial fibrillation

% Eligible within home: not reported
% Eligible that participate: not reported

Training group: N = 39; mean age = 74.1 years; range = 60 to 90 years; 2 women (7.7%)

Control group: N = 39; mean age = 76.9 years; range = 60 to 97 years; 7 women (21.9%)

Interventions

Study aim or objective: to establish whether moderate‐intensity endurance training results in short‐term improvements in strength, endurance, and function

Number of experimental groups: 2
Group intervention delivery
Session duration: 30
Number of sessions per week: 2
Seated: no

All participants participated in training for 4 to 8 weeks, and a minimum of 10 resistance sessions in the 4‐week period were ensured

The interventions were delivered in‐group format and led by a physiotherapist and an aide

Exercise features:
Training group: progressive resistance and endurance training regime, comprised a minimum of 10 minutes of endurance training, up to a maximum of 30 minutes before resistance was increased, endurance training took place on a Tuesday and Thursday, resistance training occurred on Monday, Wednesday, and Friday, and comprised 15 repetitions for each muscle group

Control group: usual care

Outcomes

Physical function in ADL: walking speed over 20‐foot, self‐selected (Friedman 1988), Performance Test of Activities of Daily Living (PADL), Instrumental Activities of Daily Living (IADL, 7 items)
Muscle power (anaerobic): isokinetic eccentric strength (knee extension/flexion; shoulder extension/flexion; elbow extension/flexion; ankle dorsi/plantarflexion), isokinetic concentric strength (knee extension/flexion; shoulder extension/flexion; elbow extension/flexion; ankle dorsi/plantarflexion), isometric strength (knee extension/flexion; shoulder extension/flexion; elbow extension/flexion; ankle dorsi/plantarflexion)
Mood related: GDS
Endurance (physical other): heart rate after 6 minutes of endurance testing (using either an upper extremity ergometer, a stationary cycle, or a recumbent stepper)
Acute health events: hospitalisations

Notes

Funding: Veterans affairs health services research and development service

Transportation logistics precluded more than 2 participants from the community nursing home from training at any given time. As a result, the randomisation scheme for these participants was done using a flip coin every time 2 participants had completed the pre‐test. Though the assessor was blinded to the participants' group assignment, the assessor was not questioned to ascertain the success of blinding

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "The randomization scheme for the VA participants was determined by a computer algorithm stratified by site of care"

Allocation concealment (selection bias)

Low risk

Quote: "Assignments to the study groups were concealed in sealed envelopes that were opened after the pretest was completed"

Blinding of participants and personnel (performance bias)
All outcomes

High risk

RCT in same setting with usual care, so intervention would be obvious

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Unclear risk

Regarding strength tests: "The assessor was blinded to the subjects' group assignments (training or control)"
No information on blinding of mobility tests

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Unclear risk

Quote: "Whenever possible, the subject's primary nurse was interviewed to provide information for the PADL and IADL scale."

No mention of blinding

Incomplete outcome data (attrition bias)
All outcomes

High risk

Almost double the attrition rate in the training group. 25% overall

Selective reporting (reporting bias)

High risk

Quote "When post‐hoc we stratified the subjects into most dysfunctional score..." (re: ADL)

Other bias

Low risk

No other apparent risks of bias

Mihalko 1996

Methods

Design: cluster RCT
Duration: 8 weeks
Follow up: 1 week
Method of randomisation: randomised by residence ‐ no further details given
Concealment of allocation: unclear
Outcome assessor blinding: unclear
Group comparability at entry: no, significant differences, P < 0.05

Participants in the strength training programme had significantly greater strength and ADL scores
Losses to follow up: none

Participants

Country: USA
Setting: senior citizen or residential nursing home
Randomised: 58
% women = 83%
Age: mean = 82.67 years ± 7.72 years; range = 71 to 101 years

Consent: not specified

Inclusion criteria: sedentary for at least 6 months prior to commencing programme

Exclusion criteria: none stated

% Eligible within home: not reported
% Eligible that participate: not reported

Experimental group: N = 29
Control group: N = 29

Interventions

Study aim or objective: (1) effects of upper body high‐intensity training on muscular strength, ADLs, and subjective well‐being; (2) whether changes in strength were related to subsequent changes in subjective well‐being and ADLs

Number of experimental groups: 2
Group intervention delivery
Session duration: 30 minutes
Number of sessions per week: 3
Seated: yes

Exercise features:
Experimental group: progressive resistance exercise regime targeting 5 upper body muscle groups, led by an exercise specialist

Control group: comprised fluid movements that incorporated non‐stress exercise and mild stretching activities

Groups were led by the same exercise specialist

Outcomes

Physical function in ADL: Instrumental Activities of Daily Living Scale (modified) (Mihalko 1996)
Muscle power (anaerobic): upper body strength (for each of pectorals, shoulders, back, biceps, triceps), upper body power (sum of strength scores for 5 muscle groups: pectorals, shoulders, back, biceps, triceps)
Mood related:Positive and Negative Affect Schedule (PANAS) (Watson 1988)
Quality of life: Satisfaction with Life Scale (SWLS) (Diener 1985)
Feasibility and acceptability: Subjective Exercise Experiences Scale (SEES) (McAuley 1994)

Notes

Funding: not reported

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Stated "subjects were assigned by residence"

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided.

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

No information provided

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Unclear risk

No information provided

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Unclear risk

No information provided

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

The number of participants who completed intervention/control not reported

Selective reporting (reporting bias)

High risk

Subjective Exercise Experiences Scale not presented. Comparative statistics for IADL not presented

Other bias

Low risk

No other apparent risks of bias

Morris 1999

Methods

Design: cluster RCT
Duration: 10 months
Follow up: 40 weeks
Method of randomisation: 2 nursing homes were randomly assigned to be control sites, 4 as experimental sites. Homes were matched into sets of triplets, from which sites were randomised to the 3 study conditions. Randomisation procedure not detailed
Concealment of allocation: unclear
Outcome assessor blinding: unclear
Group comparability at entry: yes
Losses to follow up: 76 (16.2%): Fit for your life group N = 18 (12 deaths, 6 refusals), Self care for seniors group N = 27 (deaths), Control group N = 31 (28 deaths, 3 refused)

Participants

Country: USA
Setting: 6 nursing homes
Randomised: 468
% women = 79
Age: mean = 84.7 years; range = not reported

Consent: assent accepted

Inclusion criteria: see exclusion criteria

Exclusion criteria: cognitive = severe cognitive disability (Cognitive Performance Scale < 5); medical = unstable cardiac condition (excluded from exercise component only), terminal prognosis, length of stay < 90 days, health complications that prohibited contact

% Eligible within home: 55.1
% Eligible that participate: not reported

Fit for your life group: N = 142
Self‐care for seniors group: N = 171
Control group: N = 155

Interventions

Study aim or objective: to evaluate how weight training or nursing‐based rehabilitation programmes in nursing homes impact on resident performance of ADLs and objective tests of physical performance

Number of experimental groups: 3
Individualised intervention delivery
Session duration: 20 minutes
Number of sessions per week: 3
Seated: unclear

Fit for your life group: progressive resistance training of major muscle groups related to function and mobility; led by staff, family, and volunteers; walking for 1 to 5 minutes initially, up to a maximum of 20 minutes continuous walking; resistance training comprised 2 sets of 8 repetitions, with progressively heavier weights; resistance training was conducted 3 times per week, non‐consecutive days, with walking on alternate days, for a minimum of 4 months over a 10‐month study period

Self‐care for seniors group: Nursing rehabilitation intervention tailored to individual, with aim of maintaining function or preventing decline

Control group: usual care

Outcomes

Physical function in ADL: number of feet walked in 6 minutes ‐ scale score (Morris 1999), MDS: Locomotion (on and off unit items) (Morris 1999), MDS: Late loss ADL (transfer, toilet use, bed mobility, and eating) (Morris 1999), MDS:early loss ADL (dressing and personal hygiene) (Morris 1999), MDS: ADL summary (8 items) (Morris 1999)
Physical function (other): sit‐to‐stand (scale based on time required to stand up 5 times in a row) (Morris 1999)
Balance: balance (time able to stand normally in 5‐feet positions) (Morris 1999)
Mood related: GDS

Notes

Funding: Grant from National Institute of Health, National Institute on Ageing

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Facilities were "randomly designated" to be control or experimental sites
No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Not mentioned (although, different homes were assigned to different interventions, so participants would not have been aware of which group they were in)

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Unclear risk

Not clear who performed observed ADL outcome assessments

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Low risk

ADL summary: "Assessments were completed by trained research staff, all of whom were blinded to the intervention status of the study subjects"

Incomplete outcome data (attrition bias)
All outcomes

High risk

Performance ‐ large number of residents were unable to start to initiate these activities

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Mulrow 1994

Methods

Design: RCT
Duration: 1 year
Follow up: none
Method of randomisation: performed by calling a central number, randomisation was blocked into groups of 4, and stratified by nursing‐homes site
Concealment of allocation: unclear
Outcome assessor blinding: unclear
Group comparability at entry: yes
Losses to follow up: N = 14 (7.2%): Intervention group N = 5 (deaths); control group: N = 9 (7 deaths)

Participants

Country: USA
Setting: 1 academic nursing home and 8 community nursing homes
Randomised: 194
% women = 71
Age: mean = approximately 80 years; range = not reported

Consent: not specified

Inclusion criteria: > 60 years of age, residence in nursing home > 3 months, dependent in 2 or more activities of daily living

Exclusion criteria: cognitive = severe dementia, inability to follow 2‐step command; medical = terminal illness/acute medical condition; functional = assaultive behaviour, receiving physiotherapy currently, or within last 2 months

% Eligible within home: 7.3
% Eligible that participate: 77

Intervention group: N = 97; mean age = 79.7 years (8.5); 70% women

Control group: N = 97; mean age = 81.4 years (7.9); 71 % women

Interventions

Study aim or objective: to assess whether a physical therapy programme tailored to long‐stay residents' disabilities improved their physical function and long‐term health

Number of experimental groups: 2
Individualised intervention delivery
Session duration: 30 minutes
Number of sessions per week: 3
Seated: unclear

Exercise features:
Intervention group: physical therapy tailored to the individual, incremental programme, used algorithm for treatment priorities, a specific number of repetitions were performed for each exercise category, sessions conducted on an individual basis, in either Spanish or English, by a physiotherapist

Control group: friendly visits, reading to participants in language of their choice, activities avoided exercise and psychosocial interventions, personnel not described

Outcomes

Falls: number of falls
Physical function in ADL: Physical Disability Index (Mobility Score) (Gerety 1993), Katz ADL Scale (Katz 1963)
Physical function (other): Physical Disability Index (Summary Score) (Gerety 1993)
Muscle power (anaerobic): Physical Disability Index (Strength Score) (Gerety 1993)
Balance: Physical Disability Index (Balance Score) (Gerety 1993)
Mood related: GDS (short version) (Sheikh 1986)
Cognition: MMSE
Flexibility: Physical Disability Index (Range of Motion Score) (Gerety 1993)
Perceived health status: Sickness Impact Profile (Total Score) (Bergner 1981), Sickness Impact Profile (Psychosocial Score) (Bergner 1981), Sickness Impact Profile (Physical Score) (Bergner 1981)
Medications: medications (number)
Acute health events: adverse effects, emergency department and physician visits, hospitalisations
Feasibility and acceptability: compliance
Cost: cost

Notes

Funding: grants from the National Institute on Ageing and Veterans Affairs Health Services Research and Development
San Antonio nursing‐home policy routinely prohibits independent bathing, which results in de facto classification of all residents as dependent in at least 1 ADL

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

No information provided on random sequence generation procedure

Allocation concealment (selection bias)

Low risk

Quote: "Randomization was performed after baseline assessments by calling a central number" ‐ central allocation

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

No report of blinding of participants. RCT in same setting, but friendly visits could have blinded intervention/control

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Unclear risk

Unclear if Katz ADL scale was performed by a blinded assessor

Incomplete outcome data (attrition bias)
All outcomes

Low risk

More losses to follow up in control group (N = 9) than in intervention group (N = 5) but all for same reason (death). Total = 194 participants

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Naso 1990

Methods

Design: RCT
Duration: 1 year
Follow up: none
Method of randomisation: not described
Concealment of allocation: unclear
Outcome assessor blinding: unclear
Group comparability at entry: unclear
Losses to follow up: N = 4 (26.7%)

Participants

Country: USA
Setting: nursing home
Randomised: 15
% women: not reported
Age: mean = not reported; range = 64 to 97

Consent: fully‐informed

Inclusion criteria: see exclusion criteria

Exclusion criteria: cognitive = mental impairment (unable to understand programme description); medical = serious cardiac disease (CCF, angina), other active illness, significant

% Eligible within home: 10
% Eligible that participate: 100

Intervention group: N = 8; age range = 66 to 97 years

Control group: N = 7; age range = 64 to 87 years

Interventions

Study aim or objective: to examine the effectiveness of an upper extremity and lower extremity exercise programme on endurance

Number of experimental groups: 2
Individual session delivery
Session duration: 15 minutes
Number of sessions per week: 3
Seated: unclear

Exercise features:
Intervention group: upper and lower body endurance programme based on target heart rates; personnel not described

Control group: usual care

Outcomes

Endurance (physical other): heart rate after 2 minutes of exercise, duration of exercise

Notes

Funding: not reported

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No mention of blinding of participants, but usual care so intervention would have been obvious

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Moderate loss to follow up, but balanced across groups with similar reasons

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Ouslander 2005

Methods

Design: randomised controlled cross‐over trial
4 phases: (1) participant screening and enrolment; (2) baseline assessment and randomisation by computer‐generated random numbers into immediate intervention (group 1) or delayed intervention (group 2); (3) immediate intervention phase for which group 2 acted as group 1's control; (4) delayed intervention phase ‐ group 2 receive the intervention and group 1 cross over to no intervention to assess the durability of the intervention's effects
Duration: 16 weeks ‐ after 8 weeks the groups switched
Method of randomisation: computer‐generated random numbers
Outcome assessor blinding: assessor masked to treatment group, but at some treatment sites, the group assignment became apparent in a small number of participants
Group comparability at entry: yes
Losses to follow up: (N = 29, 27%) 61 of 107 allocated, and 178 eligible completed all assessments

Participants

Country: USA
Setting: 4 Veterans Affairs medical‐centre nursing homes in the South‐East of the USA (Atlanta, Georgia; Durham, North California; Salisbury, North Carolina; West Palm Beach, Florida) selected because of their proximity to the researcher's home institution in Atlanta, willingness to participate, and size of potential population
All residents at each facility screened
Randomised: 107
% women = 10
Age: mean = approximately 78 years; range = not reported
75% white
More than three‐quarters of participants had at least 1 psychiatric diagnosis

Consent: informed consent from participant where capable, if not, from facility staff or from a responsible party ‐ assent

Inclusion criteria: long‐stay resident (at least 30 days and not initially admitted for short‐term care), able to state their name, or in the presence of aphasia, capable of reliably pointing to 2 objects, required assistance by 2 or fewer people for transfer from bed to chair, incontinent of urine or stool, or would be without assistance from staff, not severely behaviourally disturbed, not known to be terminally ill, life expectancy of at least 6 months, not receiving active physical therapy, aged 60 and older

Exclusion criteria: see inclusion criteria

% Eligible within home: 44
% Eligible that participate: 60

Intervention: N = 52; % women = 53; age: mean = 77.8 years ± 7.6 years

Control: N = 55; % women = 50; age: mean = 78.8 years ± 6.3 years

N = 528 assessed for eligibility
N = 350 did not meet criteria
Unable to obtain consent for: N = 21
Attrition before assessment complete: N = 50
N = 107 randomised
Allocated to intervention (group 1): N = 52
Allocated to delayed intervention (group 2): N = 55

Interventions

Study aim or objective: to test the effects of a rehabilitative intervention directed at continence, mobility, endurance, and strength (FIT) in older people living in nursing homes

Number of experimental groups: 2
Individualised intervention delivery
Session duration: n/a
Number of sessions per week: n/a
Seated: yes

Functional incidental training intervention: trained research aides provided opportunities to participate in FIT for 4 to 5 participants every 2 hours between 8am and 4pm Monday to Friday for 8 weeks, so each participant could participate in 4 FIT sessions a day; the intervention included prompted voiding and functionally‐orientated endurance and strengthening exercises; individualised exercise programmes created from baseline data and modified every 2 weeks; goal for 3 sessions of FIT to involve endurance exercise (sit‐to‐stands, walking or wheelchair mobility to a goal time) and 4 sessions to involve strengthening exercises (bicep curls, straight arm exercises, knee extensions, and hip abductions and flexions); daily adherence recorded; supervisors conducted periodic process observations and provided additional training and reinforcement on the protocol where needed to endure quality and consistency

Control: usual care

Outcomes

Physical function in ADL: transfer time (seconds; chair to chair and back), FIM (toileting score), FIM (locomotion score), Walk or Wheel Total Time (seconds) during a 10 minute trial, Walk or Wheel (time over 6 metres), Walk or Wheel (total distance in up to 10 minutes (feet)
Physical function (other): sit‐to‐stand (time for first, seconds), sit‐to‐stand (maximum number in 30 seconds), sit‐to‐stand (average number in 30 seconds)
Muscle power (anaerobic): lower body strength (right hip flexion), upper body strength (right biceps curl)
Continence: appropriate toileting ratio (urine), appropriate toileting ratio (stool), fecal incontinence frequency, urinary incontinence frequency

Notes

Funding: grant from the Department of Veterans Affairs Rehabilitation Services Research Service
Baseline significant difference between the intervention and control group in number of sit‐to‐stand exercises, with immediate intervention group able to do more

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "Randomisation by computer‐generated random numbers"

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Cross‐over design, so participants would have been aware of each intervention

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

High risk

Project manager (outcome assessor) was masked, but allocation revealed in some cases

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

High risk

Project manager (outcome assessor) was masked, but allocation revealed in some cases

Incomplete outcome data (attrition bias)
All outcomes

High risk

17/35 (49%) in immediate intervention lost versus 12/43 (28%) from control

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

This was a cross‐over trial of an intervention likely to have long‐term effects. Therefore, high risk of carry‐over effects. However, only the first period used in this review; therefore, low risk of bias

Peri 2008

Methods

Design: cluster RCT
Clustering accounted for
Details: matched wings allocated by coin toss by independent researcher
Duration: 6 months
Follow up: no

Participants

Characterisation: ambulatory, need minimal assistance with transferring, independent in eating, but dependent in instrumental ADLs
Country: New Zealand
Setting: residential care homes
Randomised: 149
% women = 85%
Age details (mean (SD)):
Control: 84.7 (6.7)
Intervention: 86.8 (5.5)
Overall mean 85.7
Overall SD 6.2
Calculated from N = 149
Inclusion criteria: none
(All other residents regardless of cognitive or physical ability were eligible for participation and were invited to take part by research staff)
Exclusion criteria: under the age of 65 years, admission for respite or terminal care, quadriplegia
ADL status details: BI Score (mean, SD):
Control: 17.5 (2.7)
Intervention: 17.8 (2.2)
Cognitive status details: Abbreviated Mental Test Score (mean, SD):
Control: 7.0 (2.8)
Significant comorbidities: not reported
Assessed: 208

Interventions

Study aim or objective: to determine whether a repetitive ADL activity programme improves health status, life satisfaction, and mobility for older people living in residential care
2 groups

Intervention: intervention group (N = 73)
Format: individual, delivered by gerontology nurse; healthcare assistant within the care home and the community
Session length: not reported, daily
Goal‐setting physical activity programme
(1) goal setting phase ‐ goal encompassing physical functionality set with the resident (e.g. gardening, attending a community‐based senior citizens' club)
(2) gerontological nursing assessment
(3) development of Promoting Independent Plan (PIP) ‐ using info from assessment, a prescriptive activity programme was developed and tailored to meet the identified goal. Activities designed to increase strength, balance, and endurance through increased ADLs. Repetitive activities included bed mobility, sitting to standing, and transfers. Longer walking routes
(5) healthcare assistant training ‐ individualised programme explained to resident and healthcare assistant. Care plan displayed in resident's room and included in medical record. Healthcare assistant responsible on a daily basis for ensuring that residents carried out their activity programme
The residents' individualised plan was reviewed monthly at a staff meeting attended by the research staff, healthcare assistants, and nurse manager. Goals were modified or reset by the resident, if requested, following the review meeting

Control: control group (N = 76)
Usual care, waiting list for goal setting physical activity intervention

Outcomes

Physical function in ADL: TUG test (seconds) (Podsiadlo 1991), Elderly Mobility Scale (EMS) (Smith 1994)
Physical function (other): SF‐36 Physical Function
Quality of life: Life Satisfaction Index (Neugarten 1961)
Perceived health status: SF‐36 Mental Health
Falls, risk and fear of falling: falls (any episodes for participant)
Acute health events: adverse effects

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Toss of a coin used for allocation (between two wings of a home)

Allocation concealment (selection bias)

Low risk

Coin toss performed by independent researcher ‐ suggests allocation concealment

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Quote: "Care delivery in each wing was administered independently with no crossover of staff or residents during the study period"
No report of blinding of participants, although intervention and control groups were in separate wings, so may not have been aware of which group they were in

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Low risk

Quote: "A research nurse blinded to the allocation then collected baseline, 3‐ and 6‐month outcome measures"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Slight imbalance in number of participants lost to follow up between groups (more in control than in intervention), although reasons similar between groups

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

High risk

Contamination: "Observations of research staff indicated that in two homes the control group residents were observed participating in activities with intervention group residents in the lounge or during walking group outings"
Quote: "The mobility measures used may not have been sensitive enough to show small but important changes"

Pomeroy 1993

Methods

Design: RCT
Duration: 15 weeks
Follow up: none
Method of randomisation: randomised cross‐over design, using a random numbers table; participants were allocated to either group 1 or group 2 until 1 group contained 12 participants; the remaining participants were then allocated to the other group
Concealment of allocation: unclear
Outcome assessor blinding: unclear
Group comparability at entry: n/a
Losses to follow up: N = 8 (33%) Group 1: N = 4 (1 discharged home because of improvement with treatment, 2 deaths, 1 hip fracture during control phase); Group 2: N = 4 (2 general deteriorations, 1 circulation problems, 1 death)

Participants

Country: UK
Setting: long‐stay psychiatric hospital participants
Randomised: 24
% women = 67
Age: mean = not reported; range = 61 to 91 years

Consent: not specified

Inclusion criteria: diagnosis of dementia, resident of facility, requiring assistance of 1 to 2 persons for transfers, weight‐bearing not precluded by hip/knee contractures, < 18 mobility score, unable to stand/mobilise independently, medically fit to participate

Exclusion criteria: medical = signs of severe osteoarthritis, cardiovascular disease, alcoholism, neurological pathology

% Eligible within home: not reported
% Eligible that participate: not reported

Group 1: N = 12
Group 2: N = 12

Interventions

Study aim or objective: Does provision of physiotherapy input improve or maintain mobility skills in elderly people with dementing illness?

Number of experimental groups: 2
Individual sessions
Session duration: 30 minutes
Number of sessions per week: 3
Seated: yes

Group 1: physiotherapy followed by no intervention
Group 2: no intervention followed by physiotherapy

Physiotherapy comprised movement, music, body awareness, and individual functional mobility training; sessions were conducted by a physiotherapist in individual format, 3 times per week for 12 weeks, followed by 3 weeks of videoing

Outcomes

Physical function (other): Southampton Assessment of Mobility (Pomeroy 1990)
Cognition: CAPE (Clifton Assessment Procedures for the Elderly) information/orientation score (Pattie 1981)

Notes

Funding: Research into Ageing grant
Pilot study

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Used a random numbers table

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Cross‐over design ‐ all participants experienced the intervention and a control phase. The control phase consisted of no intervention. Therefore, it would have been apparent to the participants what the intervention under study was

Incomplete outcome data (attrition bias)
All outcomes

High risk

Missing data for participants who did not complete all phases ‐ "these were equally distributed between groups 1 and 2". However, 8/24 (33%) lost to follow up

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

This was a cross‐over trial of an intervention with the potential for carry‐over effects. However, only the first period used in this review so low risk of bias

Przybylski 1996

Methods

Design: RCT
Duration: 2 years
Follow up: none
Method of randomisation: not described, but participants were stratified a priori by severity of their condition using the resident classification system (RCS)
Concealment of allocation: unclear
Outcome assessor blinding: yes ‐ maintained
Group comparability at entry: unclear
Losses to follow up: N = 52 (45%) (29 deaths/discharges, 3 unable to complete tests, 20 insufficient test results)
Individual group data not described

Participants

Country: Canada
Setting: nursing Home
Randomised: 115
% women = approximately 77
Age: mean = approximately 85 years (for original participants); range = 62 to 101 years

Consent: fully‐informed consent

Inclusion and exclusion criteria: not reported

% Eligible within home: not reported
% Eligible that participate: not reported

Intervention group: N = 58; age range = 62 to 97 years; women:men ratio = 3.5:1

Control group: N = 57; age range = 63 to 101; women:men ratio = 3.1:1

Interventions

Study aim or objective: to determine whether there is a difference in functional status among residents receiving 1 full‐time physiotherapist and occupational therapist per 50 beds (enhanced) or per 200 beds (control)

Number of experimental groups: 2
Individualised intervention delivery
Session duration: not reported
Number of sessions per week: not reported
Seated: n/a

Intervention group: enhanced therapy (physiotherapy/occupational therapy), i.e. increased hours of service on a 1.0 FTE/50 bed ratio, therapy tailored to individual, content/frequency not described

Control group: usual treatment comprising minimal therapy input on a 1.0 FTE/200 bed ratio; no further details given

Outcomes

Physical function in ADL: FIM, Functional Assessment Measure, Clinical Outcomes Variables Scale
Cost: cost

Notes

Funding: not reported; states that no commercial parties had any interest
Physical and occupational therapists and their assistants operated conjointly on the programmes. No differentiation between these 2 disciplines was made in this study. Treatment was offered in a restorative, consultative, monitoring, low/high maintenance programme format, as suited each participant's needs

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

High risk

No information provided on initial sequence generation. Intervention was implemented over two years, with 29 new participants recruited throughout to replace participants who died or were discharged. The researchers had no control over who died, was discharged, or recruited to the groups, and made the assumption that this was a random process
Inadequate as there is a non‐random component

Allocation concealment (selection bias)

High risk

No information provided on concealment during initial allocation. The replacement process may have been visible to staff, so allocation could not have been concealed

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Stated that the testers and the staff were all blind to which group residents had been assigned. However, potential contact between residents and the occupational therapy and physiotherapy staff with other staff members means unlikely that blinding was achieved

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Low risk

Stated that the testers and the staff were all blind to which group residents had been assigned

Incomplete outcome data (attrition bias)
All outcomes

High risk

Large numbers lost including due to non‐testing, not clear which groups they came from

Selective reporting (reporting bias)

High risk

Pre‐intervention outcome scores were not provided (only 6 months, 12 months, 18 months, and 24 months)

Other bias

Low risk

No other apparent risks of bias

Resnick 2009

Methods

Design: cluster RCT
Clustering accounted for
Duration: 12 months
Follow up: no

Participants

Characterisation: care‐home residents
Country: USA
Setting: 12 nursing homes (8 'for profit' and 4 'not for profit')
Randomised: 487
% women = 80%
Age details: mean (SD) = 83.8 years (8.2); range = 65 to 102 years
Inclusion criteria: residents were eligible to participate if they were aged 65 and older, had a MMSE score of 11 or greater (level II eligibility ‐ criteria applied post‐consent), had a life expectancy of longer than 6 months, and were not receiving skilled rehabilitation services
ADL status details: not reported
Cognitive status details: mean MMSE score: 20.4 +/‐ 5.3
Significant comorbidities: not reported
Assessed: 2058
Excluded: overall = 1571, 1266 on eligibility criteria, 305 declined, 0 other

Interventions

Study aim or objective: to test the effectiveness of a restorative care (Res‐Care) intervention on function, muscle strength, contractures, and quality of life of nursing‐home residents, with secondary aims focused on strengthening self‐efficacy and outcome expectations
2 groups

Intervention: Res‐Care Intervention group (N = 256)
Format: not reported, delivered by nursing assistants
Session length: not reported
Res‐Care was a 2‐tiered self‐efficacy‐based intervention focused on motivating nursing assistants and residents to engage in functional and physical activities. Restorative care is a philosophy of care that focuses on restoring and maintaining, residents to their highest possible functional and physical status, given comorbidities. Examples include using verbal cues during bathing, transfers, mobility, so the resident performs the tasks, rather than the nursing assistant. Homes in the Res‐Care intervention group were also provided with a research restorative care nurse as a prompt to nursing assistants and residents to engage in functional physical activities and to develop short‐ and long‐term goals for residents

Control: Control group (N = 231)
A single in‐service program on managing difficult behaviours. The control site did not receive any information about restorative care, and they were not provided with a restorative care nurse

Outcomes

Physical function in ADL: BI (0 to 100 scale)
Physical function (other): Tinetti Mobility Scale (gait and balance) (Tinetti 1986), self‐efficacy for functional ability (Resnick 1999; Resnick 2003)
Muscle power (anaerobic): hand grip strength
Flexibility: muscle contractures (upper extremities (fingers, wrist, elbow, and shoulders) and lower extremities (hip, knee, and ankle)
Quality of life: Dementia Quality of Life Instrument (Brod 1999)
Expectations of effects of exercise: Outcome Expectation for Functional Ability Scale (Resnick 1999; Resnick 2003)

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Staff involved in delivering intervention were not blind to participants in study/not in study

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Low risk

Quote: "A team of evaluators who were blinded to randomization and unfamiliar with the details of the Res‐Care intervention measured all outcomes"

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Low risk

Quote: "A team of evaluators who were blinded to randomization and unfamiliar with the details of the Res‐Care intervention measured all outcomes"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Large numbers lost to follow up, but balanced with similar reasons

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Riccio 1990

Methods

Design: RCT
Duration: n/a (one‐off intervention)
Follow up: n/a
Method of randomisation: in accordance with a counterbalanced design; no further details given
Concealment of allocation: unclear
Outcome assessor blinding: no
Group comparability at entry: n/a
Losses to follow up: none

Participants

Country: USA
Setting: nursing home, residential retirement home, foster care home
Randomised: 30
% women = 100
Age: mean = 80.9 years ± 9.2 years; range = 62 to 96 years

Consent: not specified

Inclusion criteria: Parachek score > 25

Exclusion criteria: see inclusion criteria

% Eligible within home: not reported
% Eligible that participate: not reported

Interventions

Study aim or objective: to examine the effects of verbally‐elicited imagery in the encouragement of exercise in elderly women

Number of experimental groups: 4
Group intervention delivery
Session duration: not reported
Number of sessions per week: n/a
Seated: yes

Exercise features:
Order 1: control condition followed by imaging
Order 2: imaging followed by control condition

Imaging: added‐purpose activity, e.g. reach down as if you are picking up something from the floor

Control: rote exercise activity, e.g. reach down to the floor with both hands

2 exercises were performed as above – a reaching‐up exercise and a reaching‐down exercise. Interventions were one‐offs, supervised by a researcher

Outcomes

Endurance (physical other): duration of exercise, frequency of repetition

Notes

Funding: not reported

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Quote: "...subjects randomly assigned to different orders in accordance with a counterbalanced design"
No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

No information given. Participants received both interventions

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Three lost from group 1; zero from group 2. Reasons unlikely to be related to intervention‐conflicting appointments and refused to participate (cross‐over)

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

Cross‐over design, but intervention unlikely to produce a carry‐over effect

Rolland 2007

Methods

Design: RCT
Details: multi‐centre
Duration: 12 months
Follow up: no

Participants

Characterisation: ambulatory participant with Alzheimer's disease
Country: France
Setting: nursing homes
Randomised: 134
% women = 75%
Age details: mean (SD) = 83 years (7.4); range = 62 to 103 years
Inclusion criteria: meet the National Institute of Neurological and Communicative Diseases and Stroke/Alzheimer's Disease and Related Disorders Association criteria for probable or possible Alzheimer's disease
Resident in the nursing home for at least 2 months
Able to transfer from a chair and walk at least 6 metres without human assistance
Exclusion criteria: evidence of vascular dementia or Parkinson's disease, planned transfer from the nursing home for surgery in the year to come, a cardiac condition that might deteriorate during exercise, diagnosis of a terminal illness with a life expectancy of less than 6 months
ADL status details: Katz ADL mean (SD) = 3.1 (1.3)
Cognitive status details: MMSE 8.8 (6.6)
Significant comorbidities: comorbidities, N (%) exercise group and routine‐care group
1 comorbidity: 9 (13.4) + 16 (23.9) = 25 (18.7%)
2 comorbidities: 21 (31.3) + 15 (22.4) = 36 (26.9%)
3 or more comorbidities: 26 + (38.9) 12 (17.9) = 38 (28.4%)
Assessed: 429
Excluded: overall = 295, 187 on eligibility criteria, 65 declined, 43 other

Interventions

Study aim or objective: to investigate the effectiveness of an exercise program in improving ability to perform ADLs, physical performance, and nutritional status and decreasing behavioral disturbance and depression in participants with Alzheimer's disease
2 groups

Intervention: Physical exercise program (N = 67)
Format: group, delivered by occupational therapist in care home
Session length: 60 minutes, twice weekly
Personalised walk, strength, balance, and flexibility training to music: A walking route was established around each home passing all participants' rooms. Participants were paired and encouraged to walk fast enough to become somewhat breathless. Around the trail were stations for strength, balance, and flexibility training. Strength training included squats, heel raises and leg lifts; balance training involved 1 or 2 leg balance exercises and a small step test with cones and hoops; flexibility training involved repetition of demonstrated exercises

Control: control (N = 67)
Usual care

Outcomes

Physical function in ADL: Katz ADL Scale (Katz 1963), Get Up and Gotest (Mathias 1986), six‐metre walk (speed m/s)
Balance: one‐leg balance test (Vellas 1997)
Mood related: depression (Montgomery‐Assberg Depression Rating Scale; MADRS)
Anthropometry: weight
Nutrition: Mini‐Nutritional Assessment (MNA)
Psychiatric status: Neuropsychiatric Inventory (NPI) (Cummings 1994)

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "Staff not involved in intervention or assessment performed separate randomization at each site by lottery draw"

Allocation concealment (selection bias)

Unclear risk

Quote: "Staff not involved in intervention or assessment performed separate randomization at each site by lottery draw"

However, unclear if drawing was concealed, e.g. open hat

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Quote: "...single‐blind study..."
Residents assigned to exercise or usual care so assignment obvious

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Low risk

A single geriatrician who was blinded to the intervention assignment measured outcomes at baseline, 6 months, and 12 months on different days from the intervention

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Low risk

A single geriatrician who was blinded to the intervention assignment measured outcomes at baseline, 6 months, and 12 months on different days from the intervention

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Missing outcome data balanced across groups (13 control, 11 exercise) with similar reasons

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Rosendahl 2006

Methods

Design: cluster RCT
Duration: approximately 3 months (13 weeks) ‐ 29 occasions
Follow up: 12 weeks
Method of randomisation: after inclusion of participants and baseline assessments, 34 clusters of 3 to 9 participants living on the same floor, wing, or unit were randomly assigned to exercise or control activity
Randomisation was stratified in order to have both groups in each facility; within each cluster, the nutrition intervention was randomised individually
Randomisation using lots in sealed envelopes
Concealment of allocation: yes
Outcome assessor blinding: yes, checked at 3 months ‐ if they correctly guessed the participant's group, they were replaced ‐ the case for 11% of participants; checked again at 6 months (1%)
Group comparability at entry: no, significant differences, P < 0.05 for perception of health and prescriptions for proton pump inhibitors
Losses to follow up: 28 (15%)

Participants

Country: Sweden (Umeå) ‐ frail older people ‐ activity and nutrition study (FOPANU study)
Setting: 9 residential care facilities
Randomised: 191 (of 487 screened)
% women = 73
Age: mean = 84.7 years ± 6.5 years; range = 65 to 100 years

Consent: assent accepted

Inclusion criteria: aged 65 years, dependent on assistance from a person in 1 or more ADL according to the Katz index, able to stand up from a chair with arm rests with help from no more than 1 person, MMSE score of 10 or higher, approval from the resident's physician

Exclusion criteria: see inclusion criteria

% Eligible within home: 39
% Eligible that participate: not reported

Exercise + protein drink: 85.0 years ± 6.7 years; women = 78%

Exercise + placebo drink: 85.5 years ± 5.5 years; women = 69%

Control + protein drink: 82.9 years ± 6.4 years; women = 70%

Control + placebo drink: 85.6 years ± 7.0 years; women = 74%

Interventions

Study aim or objective: to determine whether a high‐intensity functional exercise programme improves balance, gait ability, and lower limb strength in activities of daily living, and if an intake of protein‐enriched energy supplement immediately after the exercise increases the effects of the training

Number of experimental groups: 4
Group intervention delivery
Session duration: no longer than 45 minutes
Number of sessions per week: 5
Seated: unclear
Groups: both an exercise intervention compared with control activity and a nutrition intervention compared with a placebo in a 2 x 2 factorial model
Both exercise and control held within the facility; similar distance from where participants stayed; where a participant did not attend the session, individual activity was offered where possible

Exercise features: groups of 3 to 9 participants, supervised by 2 physiotherapists
Exercise intervention: based on the high‐intensity functional exercise programme (HIFE programme of Littbrand 2006), functional exercises consisting of everyday tasks challenging leg strength, postural stability, and gait ability; exercises selected for each participant according to their deficits; all performed in weight‐bearing positions; encouraged to exercise at high intensity and to increase load and difficulty progressively, considering changes in function and health status; tasks followed up after 3 months by asking staff about compliance during the previous 2 weeks

Control: developed by occupational therapists and involved activities while sitting watching films, reading, singing, and conversing; groups of 3 to 9 participants, supervised by 1 occupational therapist; based on themes ‐ the old country shop, famous persons, games from the past; designed to be stimulating, even to people with cognitive impairment

Nonexercise features:
Nutrition intervention: protein enriched energy supplement, placebo‐drink control packaged in the same way as the intervention drink and had similar flavours

Outcomes

Falls: falls (any episodes for participant), fall rate (falls per person years)
Physical function in ADL: Modified Chair Stand (Guralnik 1994), BI (0 to 20), gait speed (self paced) 2.4 metres, gait speed (maximum) 2.4 metres
Muscle power (anaerobic): lower‐limb strength (1 repetition‐maximum)
Balance: BBS
Adverse events (other): adverse event rate (within intervention)
Feasibility and acceptability: performance of high‐intensity strength training and balance exercises, attendance

Notes

Funding: grants from the City Council of Västerbotten, the Vårdal foundation, the Magnus Bergvalls Foundation, the Äldrecentrum Västerbotten, the Umeå University Foundation for Medical research, the Gun and Bertil Stohne Foundation, Erik and Anne‐Marie Detlof’s foundation, the Loo and Hans Ostermans Foundation, the Borgerskapet in Unmeå Research foundation, the Swedish Research Council and the Swedish Council for Working Life and Social Research and Norrmejerier

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Stated that researchers not involved in the study performed the randomisation using lots in sealed non‐transparent envelopes

Allocation concealment (selection bias)

Low risk

Stated that researchers not involved in the study performed the randomisation using lots in sealed non‐transparent envelopes

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Even though the clusters were in separate flats, they were within the same facilities. As a result, there may have been contact between the exercise intervention group and the control group

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Low risk

Trained physiotherapists blind to group allocation undertook assessment for mobility/balance outcome measures

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Stated ITT, but results appear to be 'as treated' (N at 3 months and 6 months is different to N randomised)
N lost = 14 in both groups, but twice as many died in the exercise group

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Sackley 2006

Methods

Design: cluster RCT
Duration: 12 weeks
Follow up: 12 weeks
Method of randomisation: carried out independently by a statistician, homes grouped into 4 strata, using combinations of type (residential, nursing, both), funding source (private or local authority), and setting (urban or rural). Within each stratum, pairs of homes were allocated randomly, using computer‐generated random numbers
Concealment of allocation: yes
Outcome assessor blinding: yes
Group comparability at entry: yes
Losses to follow up: N = 13 (11%)

Participants

Country: UK
Setting: 12 care homes, (approached the managers of 14 homes: 1 refused, 1 home used as a pre‐pilot) 12 entered into the study in 3 groups of 4 to control therapists' workload
Randomised: 118
% women = 82
Age: mean: approximately 87 years; range = 44 to 102 years

Consent: not specified

Inclusion criteria: residents with stroke, staff asked to screen people with the BI, information on stroke history and cognitive status for the purpose of consent

Exclusion criteria: medical = acute illness, terminally ill

% Eligible within home: 46
% Eligible that participate: 61.8

Intervention: 88.6 years ± 6.5 years (62 to 102 years); 83% women
Control: 86.3 years ± 8.8 years (44 to 99 years); 82% women

Intervention: 6 homes; 63 residents, (3 months: 59 assessed, 3 died; before occupational therapy: 1 died during/after treatment; 6 months: 53 assessed, 6 died) lost 10 to follow up.
Control: 6 homes; 55 residents (3 months: 46 assessed, 9 died; 6 months: 35 assessed, 11 died) lost 20 to follow up

Interventions

Study aim or objective: evaluation of occupational therapy intervention to improve self‐care independence for residents with stroke related disability living in care homes

Number of experimental groups: 2
Individualised intervention delivery
Session duration: n/a
Number of sessions per week: n/a
Seated: n/a

Intervention: provided by experienced occupational therapist delivered to the individual, targeted at improving independence in personal activities of daily living, frequency and duration dependent on resident's and therapist's agreed goals, took place over a 3‐month period, intervention group given interview of 1 hour to establish functional ability and agree goals

Control: usual care

Outcomes

Physical function in ADL: RMI (Collen 1991), BI (0 to 20)
Death and physical deterioration (chronic): poor global outcome (deterioration in BI or death)

Notes

The Stroke Association, Health Foundation, Department of Health Research Capacity Development Program
Pilot study

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "Homes were allocated randomly, using computer‐generated random numbers"

Allocation concealment (selection bias)

Low risk

Quote: "Randomisation was carried out independently by a statistician"

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Quote: "Allocation was revealed only to the occupational therapist, not to the assessors"
Control was usual care, so participants could not be blinded to allocation

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Low risk

Quote: "Allocation was revealed only to the occupational therapist, not to the assessors"
Quote: "Assessments were completed...by 1 of 4 research staff masked to the trial allocation"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Imbalance in numbers lost to follow up between intervention and control group, but this was largely due to many deaths in the control group, and unlikely to be related to intervention

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Sackley 2008

Methods

Design: cluster RCT
Clustering not accounted for.
Details: phase II, exploratory randomised controlled trial with cluster randomisation (at the level of care home)
Duration: 4 weeks
Follow up: yes

Participants

Characterisation: care‐home residents with a range of functional, cognitive, and continence impairments
Country: UK
Setting: 6 care homes (2 provided nursing)
Randomised: 34
% women = 88%
Age details: mean (SD) = 86 (9); range = 76 to 101 years
Inclusion criteria: staff used their knowledge of residents' functional, cognitive, and continence status to select 10 residents with a range of functional, cognitive, and continence impairments
Exclusion criteria: none stated
ADL status details: BI ADL, mean (SD): Intervention: 10.7 (5.3); Control: 9.8 (4.4)
Cognitive status details: Short Orientation‐Memory‐Concentration test < 22: 23 (70%)
Significant comorbidities: incontinent of urine: 21 (64%)
Assessed: 211
Excluded: overall = 177, 0 on criteria, 26 declined, 151 other

Interventions

Study aim or objective: to assess feasibility, acceptability and potential efficacy of group exercise and staff education intervention to promote continence in older people residing in care homes. To establish measures and information to inform a larger trial.
2 groups

Intervention: Intervention (N = 17)
Format: group, delivered by physiotherapist
Session length: 60 minutes, twice weekly
Mobility training protocol ‐ participants were encouraged to walk or wheel to class. They then practised the task‐related training of functional ADLs (e.g. practising standing up from a chair) and strength, balance, endurance, and flexibility exercises. Music played during the class, and exercises were fun, making use of balloons and balls
Pre‐training and post‐training prompted voiding and fluid intake were included to promote continence
Residents set their own pace but were encouraged to improve on previously achieved goals. Residents’ progress was reviewed and their views were gathered
The staff education component comprised separate 2‐hour workshops on continence care and mobility care. The continence training was delivered by specialist nurses from the local Primary Care Trust Continence Team and the mobility training by a qualified physiotherapist and occupational therapist

Control: control (N = 17)
Standard care which involved very little expert care

Outcomes

Physical function in ADL: RMI (Collen 1991)
Continence: continence (urodynamic questionnaire) (Matharu 2005)

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

An independent statistician randomly allocated three care homes to each study group, using computer‐generated random numbers

Allocation concealment (selection bias)

Low risk

An independent statistician randomly allocated three care homes to each study group, using computer‐generated random numbers

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No report of blinding of participants; those in control group received usual care, so would have been obvious that they weren't receiving an intervention

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Low risk

Quote: "Study outcomes were assessed...by an assessor who was masked to allocation"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Imbalance in number of participants lost to follow up between groups (more in control than in intervention ‐ unlikely to be related to the intervention)

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable. Mean mobility scores (RMI) reported without providing SD or CI

Other bias

Low risk

No other apparent risks of bias

Sackley 2009

Methods

Design: cluster RCT
Clustering accounted for
Duration: 3 months
Follow up: yes

Participants

Characterisation: care home residents with mobility limitations and limitations in ADLs
Country: UK
Setting: care homes providing care for physical disability and older people with more than 5 beds
Randomised: 249
% women = 74%
Age details: mean = 85, SD = 9
Inclusion criteria: 5 ≤ BI score ≤ 16
Exclusion criteria: admitted to hospital with acute illness
Admitted to the care home for end‐of‐life care
ADL status details: none stated
Cognitive status details: MMSE scores:
< 21: 168 (67%)
21 to 23: 21 (8%)
> 24: 60 (24%)
Significant comorbidities: 56% with arthritis
23% with cardiovascular problems
40% dementia
36% diabetes
22% with at least 1 confirmed stroke (conservative, also reported as 24% and 46%)
Assessed: not reported
Excluded: not reported

Interventions

Study aim or objective: to compare effectiveness of physiotherapy and occupational therapy with standard care in care‐home residents who have mobility limitations and are dependent in performing ADLs
2 groups

Intervention: intervention (physiotherapy + occupational therapy) (N = 128)
Format: individual, delivered by 2 qualified physiotherapists, occupational therapists, staff training providers unstated
Session length: not reported, but therapy customised to the individual, not reported

Physiotherapy and occupational therapy intervention:
Physiotherapy aimed at enhancing mobility and ability to perform ADLs independently through practising functional tasks and therapy for components (e.g. flexibility, balance). Customised to the individual
Occupational therapy aimed at increasing independence in ADL through routine assessment, treatment, and reassessment. In addition, staff were trained in promoting independence and use of therapeutic aids

Control: control (N = 121)
Standard care as before the trial. Occupational therapy not routinely used by any of the homes and physiotherapy only accessed by GP referral

Outcomes

Physical function in ADL: TUG test (seconds) (Podsiadlo 1991), RMI (Collen 1991), BI (0 to 20)

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "Randomisation was performed by an independent principal statistician who used a computer‐generated randomisation list"

Allocation concealment (selection bias)

Low risk

Quote: "Randomisation was performed by an independent principal statistician who used a computer‐generated randomisation list"

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Quote: "Treatment arm was revealed to the treating therapists only, thereby ensuring that allocation was concealed from the independent assessors responsible for all subsequent assessments"
Control group received usual care

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Low risk

Quote: "Treatment arm was revealed to the treating therapists only, thereby ensuring that allocation was concealed from the independent assessors responsible for all subsequent assessments"

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Low risk

Quote: "Treatment arm was revealed to the treating therapists only, thereby ensuring that allocation was concealed from the independent assessors responsible for all subsequent assessments"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Missing outcome data balanced in numbers across intervention groups, with similar reasons for missing data across groups
Note: If TUG had been analysed and reported it probably would have led to an assessment of high risk of bias due to incomplete outcome data (see selective reporting)

Selective reporting (reporting bias)

High risk

HADS‐D was described as an outcome measure, but not reported post‐intervention and its exclusion not discussed. TUG was not analysed or reported because so few participants were able to complete it

Other bias

Low risk

No other apparent risks of bias

Santana‐Sosa 2008

Methods

Design: RCT
Details: blocked randomisation (by gender)
Single‐blind
Duration: 12 weeks
Follow up: no

Participants

Characterisation: people with Alzheimer's disease
Country: Spain
Setting: residential nursing home
Randomised: 16
% women = 38%
Age details: mean (SD):
Training group: 76 (4)
Control group: 73 (4)
Inclusion criteria: diagnosed by a trained geriatrician; with Alzheimer's disease of low‐medium grade, i.e. score ranging between 18 to 23 in the Spanish; validated version for the general geriatric population of the MMSE; to have lived in the nursing home for at least 4 months; free of neurological (other than Alzheimer's disease), vision, muscle, or cardiorespiratory disorders
Exclusion criteria:
ADL status details: not reported
Cognitive status details: mean (SD) MMSE score:
Training group: 20.1 (2.3)
Control group: 19.9 (1.7)
Significant comorbidities: Alzheimer's disease
Assessed: not reported
Excluded: not reported

Interventions

Study aim or objective: to determine the effects of a 12‐week training program for Spanish participants with Alzheimer's disease on their (1) overall functional capacity (muscle strength and flexibility, agility and balance while moving, and endurance fitness), and (2) ability to perform ADLs
2 groups

Intervention: training group (N = 8)
Format: group, delivered by exercise scientist in a room inside the nursing home
Session length: approximately 75 minutes, 3 times weekly
36 programmed training sessions
Each session started and ended with a 15‐minute warm‐up and 15‐minute cool‐down period, respectively, consisting of walking without reaching breathlessness (on an inside walking trail) and "gentle" stretching exercises for all major muscle groups. The core portion of the training session was divided into joint mobility, resistance, and co‐ordination exercises. Joint mobility exercises focused on shoulder, wrist, hip, knee, and ankle joints. Resistance training included 9 exercises with elastic medium‐resistance bands (3 sets of 15 repetitions each) engaging some of the major muscle groups: chest, biceps, triceps, shoulder, knee extensors, abductor and adductor muscles, and calf muscles. All exercises were performed through the full range of motion normally associated with correct technique for each exercise. Stretching exercises of muscles were performed at the end of each set of resistance exercises. Co‐ordination exercises were performed with foam balls of gradually decreasing size over the program, e.g. bouncing a ball with both hands, tossing and catching a ball, etc. Music (from the participants' youth years) accompanied each session

Control: Control group (N = 8)
Routine nursing/medical care
Did not perform any type of programmed physical activity, except those necessary for daily living, i.e. normal ambulation inside the nursing home

Outcomes

Physical function in ADL: TUG test (modified to 8 feet) (Bassey 1992; Rikli 1999), Katz ADL Scale (Katz 1963), BI (0 to 100 scale)
Physical function (other): sit‐to‐stand (average number in 30 seconds), Tinetti Mobility Scale (gait and balance) (Tinetti 1986), 2‐minute step in place
Muscle power (anaerobic): arm curl
Flexibility: Back Scratch test (Rikli 1999), 'Sit‐and‐reach' test

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Unclear if participants were blinded, but they all came from the same nursing home, and the control group did not receive any intervention so would probably have been obvious which group they were in

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Low risk

Reported that the study was single‐blind, and the exercise scientist performing the evaluations was different to the 1 delivering the intervention, implying that the assessor was blind to allocation

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Low risk

Reported that the study was single‐blind, and the exercise scientist performing the evaluations was different to the one delivering the intervention, implying that the assessor was blind to allocation

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

No losses to follow up reported

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Sauvage 1992

Methods

Design: RCT
Duration: 12 weeks
Follow up: none
Method of randomisation: not specified
Concealment of allocation: unclear
Outcome assessor blinding: unclear
Group comparability at entry: yes
Losses to follow up: N = 2 (16.7%)

Participants

Country: USA
Setting: VA Medical Centre nursing unit
Randomised: 14 (12 individuals) (reports for I = 8, C = 6, but 2 participants were lost from the initial intervention group; these were later replaced by 4 control participants; therefore, outcome data are only reported for different 10 individuals, with 4 completing both intervention and control conditions)
% women = 0
Age: mean = 73 ± 4 years; range = not reported

Consent: fully‐informed

Inclusion criteria: > 60 years, independently mobile without aid, evidence of gait/balance difficulties (Tinetti Score 30 or less), lower limb weakness (quadriceps/hamstrings < 5), isokinetic quadriceps and hamstrings < 80% of age‐predicted normal

Exclusion criteria: cognitive = moderate‐severe dementia (MMSE < 22); medical = asymmetrical focal neurological deficit, lower limb amputation, lower limb discrepancy > 1 inch, significant systematic disease, e.g. cancer; functional = refusal of consent

% Eligible within home: 12
% Eligible that participate: 52.2

Intervention group: N = 6; mean age = 73.38 years ± 4.04 years; all male

Control group: N = 6; mean age = 73.83 years ± 4.74; all male

Interventions

Study aim or objective: to determine whether a moderate to high intensity strengthening and aerobic exercise programme can improve the strength, exercise capacity, gait, and balance of deconditioned nursing‐home residents

Number of experimental groups: 2
Group intervention delivery
Session duration: 60 minutes
Number of sessions per week: 3
Seated: unclear

Intervention group: progressive‐resistance lower‐limb weight training and aerobic conditioning, group format: 20 minutes of aerobic exercise, 10 repetitions per lower limb exercise, conducted 3 times per week for 12 weeks; personnel not described

Control group: usual care with maintenance physiotherapy when indicated

Outcomes

Physical function in ADL: gait speed/velocity (left and right each)
Physical function (other): Tinetti Test ‐ gait, stride length, steps per minute (step cadence), gait duration (step time, seconds)
Muscle power (anaerobic): isokinetic strength (quadriceps, hamstrings, knee flexion and extension; each and combined, left, right, and combined; Sauvage et al)
Balance: stance time (% of total time), Tinetti Test modified sub‐scale (6 items combining strength and balance) (Sauvage 1992), stance time (seconds), Tinetti Test ‐ Body Balance, balance (Sauvage 1992) (eyes open and eyes closed; average distance from centre of pressure and total distance travelled by centre of pressure (mm))
Endurance (physical other): heart rate, VO2 max, knee resistance repetitions (number of reps completed at 180 degrees/second before strength declined to < 50% of peak torque) (Sauvage 1992)
Acute health events: adverse effects, hospitalisations
Feasibility and acceptability: attendance

Notes

Funding: Department of Veterans Affairs Medical Research Service and Rehabilitation Research and Development Service
Because of resource limitations, it was not possible for all outcome measures to be assessed by blinded raters. However, raters who did not know the residents' group assignment did blinded ratings of FIT assessment performance during approximately 10% of the post‐intervention assessments in order to help minimise potential bias of un‐blinded raters

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

High risk

Quote: "...were then randomized." No details reported. However, randomisation not specified at all for subsequent reduction to 12 participants or for the 4 control participants crossed over

Allocation concealment (selection bias)

High risk

Quote: "...were then randomized." No details reported. However, randomisation not specified at all for subsequent reduction to 12 participants or for the 4 control participants crossed over

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Not reported, but control was usual care; therefore, obvious

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Unclear risk

No report of blinding of outcome assessment

Incomplete outcome data (attrition bias)
All outcomes

High risk

2 of 6 original exercise‐group participants (33%) lost to follow up. No control group participants lost (1st phase). Unknown number lost from original allocation when group reduced to 6

Selective reporting (reporting bias)

High risk

Original protocol not available, but outcomes reported in such a way that they could not be used in a meta‐analysis (mixing of related and independent participants)

Other bias

Low risk

No other apparent risks of bias

Schnelle 1995

Methods

Design: RCT
Duration: 8 weeks
Follow up: none
Method of randomisation: not described
Concealment of allocation: unclear
Outcome assessor blinding: partial (see notes)
Group comparability at entry: yes
Losses to follow up: intervention group N = 18 (19.1%)

Participants

Country: USA
Setting: 5 proprietary nursing facilities
Randomised: 94
% women = 78
Age: mean = 85.1 years ± 8.2 years; range = not reported

Consent: assent acceptable

Inclusion criteria: incontinent of urine, passing basic cognitive screen

Exclusion criteria: cognitive = severe cognitive impairment that precluded participation; medical = indwelling catheters; functional = unable to weight bear, unable to propel wheelchairs because of irreversible physical limitations, e.g. paralysis

% Eligible within home: 75
% Eligible that participate: 34.6

Intervention group: N = 36

Control group: N = 40

Interventions

Study aim or objective: to determine if an exercise intervention (FIT) results in improvements in mobility, endurance, and physical activity when compared with prompted voiding among cognitively and mobility impaired residents

Number of experimental groups: 2
Individualised intervention delivery
Session duration:
Number of sessions per week: 20
All components were conducted after each of 4 prompted voiding episodes per day, 5 days per week, and progressed over the 8‐week study period
Seated: unclear

Intervention group: prompted voiding and FIT exercise intervention, comprised incontinence care, and social interaction, 1 to 2 stands, 1 transfer, walking/wheeling exercises, and sit‐to‐stand

Intervention group received approximately 2 times greater input than the control group, delivered by research staff on an individual basis over 8 weeks

Control group: prompted voiding only, comprised incontinence care and social interaction, 1 to 2 stands, and 1 transfer, conducted every 2 hours, 4 times per day, 5 days a week for the 8‐week period, delivered by research staff on an individual basis

Outcomes

Physical function in ADL: wheelchair mobility endurance (wheel as long as he/she could) (Schnelle 1995), walking endurance (walk as long as he/she could (minutes)) (Schnelle 1995), wheelchair speed over maximal wheeling distance, wheelchair speed over 6 metres, walking speed over maximal walking distance, six‐metre walk (speed m/s)
Physical function (other): sit‐to‐stand (average number in 30 seconds)
Agitation: agitation (daytime behavioural observation)
Physical activity: behavioural observations (standing/walking)
Energy expenditure: physical activity (kCal/hour)
Feasibility and acceptability: adherence (percentage of sessions in which all, part, or none of the exercise goal was achieved), attendance

Notes

National Institute on Aging (NIA) Pepper Centre grant
Ratings of FIT assessment performance during approximately 10% of the post‐intervention assessments in order to help minimise potential bias of un‐blinded raters

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Authors state that the residents were randomised to receive either prompted voiding or prompted voiding plus FIT, but do not specify how random sequence was generated

Allocation concealment (selection bias)

Unclear risk

Authors state that the residents were randomised to receive either prompted voiding or prompted voiding plus FIT, but do not specify if allocation was concealed

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Blinding of participants and personnel not reported. Same setting, but two interventions so could have been blinded

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

High risk

Quote: "It was not possible for all outcome measures to be assessed by blinded raters"
Did manage to perform blinded ratings of approximately 10% of assessments

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Unclear if there was any missing outcome data ‐ number of residents on which outcome data were assessed was not reported

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Schnelle 1996

Methods

Design: RCT
Duration: 9 weeks
Follow up: none
Method of randomisation: not described
Concealment of allocation: unclear
Outcome assessor blinding: partial (50% of assessments were blind)
Group comparability at entry: yes
Losses to follow up: 26 (26.8%): intervention group N = 12 (8 deaths/transfers, 4 refused to comply); control group N = 14

Participants

Country: USA
Setting: 5 proprietary nursing facilities
Randomised: 97
% women = not reported
Age: mean = 84 years; range = not reported

Consent: not specified

Inclusion criteria: > 65 years of age, medical order for physical restraint or visual documentation of restraint use by research staff, basic cognitive and behavioural responsiveness

Exclusion criteria: medical: paralysis, contracture, foot drop, severe arthritic pain

% Eligible within home: 94
% Eligible that participate: 80.7

Intervention group: N = 47
Control group: N = 50

Interventions

Study aim or objective: to evaluate an exercise protocol designed to improve strength and mobility and decrease injury risk factors in physically restrained nursing‐home residents

Number of experimental groups: 2
Individual intervention delivery
Session duration: not reported
Number of sessions per week: 3
Seated: if necessary

Intervention group: exercise safety intervention protocol; comprised mobility exercise, safety practice, rowing endurance, and strengthening exercises; targeted pre‐set goals and progressed by 10% each week; conducted on an individual basis by a research staff member, 3 times per week for 9 weeks

Control group: usual care

Outcomes

Risk of falling: Safety Assessment for the Frail Elderly (SAFE)Transition Score (Schnelle 1994), SAFE Walk Score (Schnelle 1994), SAFE Total Score (Schnelle 1994), SAFE Judgement Score (Schnelle 1994)
Physical function in ADL: walk or wheel time per day (estimated from observations), walking endurance (walk as long as he/she could (seconds), Schnelle 1995), wheelchair speed over 6 metres, six‐metre walk (speed m/s), wheelchair mobility endurance (wheel as long as he/she could, Schnelle 1995)
Physical function (other): sit‐to‐stand (average number in 30 seconds), sit‐to‐stand (time for first, seconds)
Muscle power (anaerobic): row force (force produced during rowing, Schnelle 1996), hand grip strength
Flexibility: row range of motion (Schnelle 1996)
Endurance (physical other): row time (row as long as possible) (Schnelle 1996)
Other: restraint use
Feasibility and acceptability: attendance, adherence (percentage of sessions in which all, part, or none of the exercise goal was achieved)

Notes

NIA Pepper Centre grant
Blinded evaluation on all mobility assessments was accomplished in more than 50% of the observations in all homes but the first site; no significant inter‐site difference in outcome data was identified as a result of this

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Authors state that residents were randomised into 1 of the 2 groups, but do not indicate how random sequence was generated

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No report of blinding of participants, but usual care so intervention would have been obvious

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

High risk

Quote: "Blinding was accomplished on only 50% of the observations"

Incomplete outcome data (attrition bias)
All outcomes

High risk

Missing data ‐ standing and walking outcomes could only be measured in ambulatory residents; SAFE assessment not available for the first nursing home

Selective reporting (reporting bias)

Unclear risk

Figures not reported for all prespecified outcome measures, but commented upon in results section

Other bias

Low risk

No other apparent risks of bias

Schnelle 2002

Methods

Design: RCT
Duration: 8 months
Follow up: none
Method of randomisation: computerised randomisation program
Concealment of allocation: unclear
Outcome assessor blinding: partial ‐ 1 of 2 observers was blind
Group comparability at entry: yes
Losses to follow up: at 8 weeks N = 18 (22%)

Participants

Country: USA
Setting: 4 nursing homes (long‐stay beds)
Randomised: 190
N = 330 met inclusion criteria
N = 257 gave informed consent
N = 190 baseline assessments completed
% women = approximately 84
Age: mean = 87 years ± 8 years; range = not reported

Consent: assent accepted

Inclusion criteria: incontinent of urine (free of a catheter), able to follow a one‐step instruction

Exclusion criteria: medical: residents of post‐acute skilled care units, terminal illness, catheterised

% Eligible within home: 73
% Eligible that participate: 57.6

Intervention group: N = 9; age range = 71 to 95 years; 8 women

Control group: N = 7; age range = 65 to 70 years, 76 to 95 years; 4 women

Interventions

Study aim or objective: to examine clinical outcomes and describe the staffing requirements of an incontinence and exercise intervention

Number of experimental groups: 2
Individualised intervention delivery
Session duration: not reported
Number of sessions per week: every 2 hours up to a maximum of 4 episodes per day, 5 days per week for 32 weeks
Seated: where necessary

Intervention group: prompted voiding, walking/wheeling, sit‐stands, supervised by research staff, once daily upper limb resistance training

Control group: usual care

Outcomes

Physical function in ADL: walked maximum 10 minutes, wheeled (metres average) 10 minutes (Schnelle 2002), wheeled maximum 10 minutes, standing test (level of assistance) (Schnelle 2002), walked (metres average) 10 minutes (Schnelle 2002), 10‐minute walk/wheel (average distance), walked and wheeled (metres maximum) 10 minutes (Schnelle 2002)
Physical function (other): sit‐to‐stand (maximum number in 30 seconds), sit‐to‐stand (average number in 30 seconds)
Muscle power (anaerobic): arm curl (maximum lift in pounds), arm raise (maximum lift in pounds)
Physical activity: behavioural observations (standing/walking)
Continence: appropriate toileting ratio (stool), urinary incontinence frequency, appropriate toileting ratio (urine), bowel movement frequency (incontinent and continent), fecal incontinence frequency
Anthropometry: weight
Energy expenditure: energy expenditure by motion sensor
Nutrition: food and fluid intake during meals (average total per cent)
Pain: Geriatric Pain Measure (modified 13 items), pain (number of pain reports per metre of mobility), MDS: documentation of pain (Section J, item 2a: frequency)
Acute health events: acute healthcare conditions (episodes) (Schnelle 2003)
Cost: healthcare cost (Schnelle 2003)

Notes

"Supported by Grant AG13013 from the National Institutes of Health: Mobility and Incontinence Management Effects on Sickness, and Grant AG10415 from the National Institute on Aging: UCLA Claude D. Pepper Older Americans Independence Center"

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "Residents were randomized into intervention and control groups using a computerized randomization program completed after baseline assessments"

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Likely to have been incomplete blinding. Whilst attempts were made to blind staff involved in the trial "blinding observers to group assignment whenever possible", participants would probably have been aware of treatment allocation

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

High risk

Stated: "...blinding observers to group assignment whenever possible", suggesting this was not accomplished all of the time

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Loss to follow up moderate, but individual groups not reported (*Primarily* because of death or prolonged illness)

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Schoenfelder 2000

Methods

Design: RCT
Duration: 12 weeks
Follow up: 12 weeks
Method of randomisation: participants were matched in pairs, according to their Risk Assessment for Fall Scale II, and then randomly assigned within each pair to the intervention or control group
Concealment of allocation: unclear
Outcome assessor blinding: unclear
Group comparability at entry: yes
Losses to follow up: N = 0 at 12 weeks, at follow up: intervention group N = 2 (illness/death); control group: none

Participants

Country: USA
Setting: 2 long‐term care facilities
Randomised: 16
% women = 75
Age: mean = 82.8 years; range = 65 to 95 years

Consent: fully‐informed consent

Inclusion criteria: > 65 years of age, independently mobile (+/‐ aid), able to speak/understand English, MMSE score > 20

Exclusion criteria: medical = unstable physical condition, terminal illness; functional = abusive behaviour

% Eligible within home: not reported
% Eligible that participate: not reported

Intervention group: N = 9; age range = 71 to 95 years; 8 women

Control group: N = 7; age range = 65 to 95 years; 4 women

Interventions

Study aim or objective: to investigate the role of exercise in preventing falls, specifically assessing the effectiveness of an ankle strengthening and walking programme to improve balance, ankle strength, walking speed, and falls efficacy and to decrease falls and fear of falling

Number of experimental groups: 2
Unclear whether intervention delivery is group or individualised
Session duration: 20 minutes
Number of sessions per week: 3
Seated: no

Intervention group: ankle strengthening programme (heel raises), walking programme (increasing speed/distance), intervention delivered by a researcher

Control group: usual care

Outcomes

Risk of falling: Fall Risk Assessment (RAFS II) (Ross 1991)
Falls: number of falls
Fear of falling: fear of falling (single item 4‐point scale) (Tinetti 1990), Falls Efficacy Scale (modified) (Schoenfelder 2000) (10 item fear of falling)
Physical function in ADL: six‐metre walk (time)
Muscle power (anaerobic): ankle strength (number of heel raises in 30 seconds)
Balance: balance (tandem stance, up to 10 seconds), balance (semi‐tandem stance, up to 10 seconds), balance (parallel stance, up to 10 seconds)
Cognition: MMSE
Physical activity: behavioural observations (standing/walking)

Notes

Funding: Gerontological Nursing Interventions Research Center grant

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Quote: "Subjects were matched in pairs and assigned randomly within each pair"
No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No report of blinding of participants, but would probably have been obvious to the participants which group they were in. Control was usual care in same setting

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Unclear risk

No report of blinding of outcome measurement

Incomplete outcome data (attrition bias)
All outcomes

High risk

Missing outcome data for 2 (of 9) participants in the intervention group who could not complete 6‐month measures

Selective reporting (reporting bias)

High risk

Some outcome measures not reported
No results reported for the statistical analysis procedure reported to have been used in Data Analysis section, simply a comment that "statistical significance was not reached"

Other bias

Low risk

No other apparent risks of bias

Schoenfelder 2004

Methods

Design: RCT, matched‐pairs design
Duration: 3 months
Follow up: 3 months
Method of randomisation: matched in pairs by Risk Assessment for Falls Scale II scores (RAFS II)
Concealment of allocation: yes ‐ where participants were roommates or spouses, they were assigned to the same group to lessen the possibility of contamination
Outcome assessor blinding: yes ‐ no contact with participants other than assessments
Group comparability at entry: yes
Losses to follow up: at 3 months N = 15 (18.5%)

Intervention:
Baseline N = 42
3 months N = 33
6 months N = 30 (‐12)

Control:
Baseline N = 39
3 months N = 33
6 months N = 28 (‐11)

Participants

Country: USA
Setting: 10 private urban nursing homes in Eastern Iowa, ranging from 68 beds to 178 beds
Randomised: 81
% women = 77
Age: mean = 84.1 years; range = 64 to 100 years

Consent: fully‐informed

Inclusion criteria: = 65 years, able to ambulate independently or with an assistive device (so they could take part in an ankle strengthening and walking programme), could speak English, did not have an unstable physical condition, did not have evidence of an end‐stage terminal illness, no history of acting out or abusive behaviour, had score of 20 or above on MMSE, doctor's consent sought

Exclusion criteria: see inclusion criteria

% Eligible within home: not reported
% Eligible that participate: not reported

Intervention: N = 42, women N = 30
Control: N = 39, women N = 32

Interventions

Study aim or objective: to test a 3‐month ankle strengthening and walking programme designed to improve or maintain fall related outcomes

Number of experimental groups: 2
Individualised programme delivery
Session duration: 15 to 20 minutes
Number of sessions per week: 3
Seated: no

Intervention: 3‐month ankle strengthening and walking programme, 3 times weekly, 15 to 20 minutes, programme tailored to individual ability

Control: attention placebo to control for effects of attention and motivation, visited weekly by same research team member who conducted the exercise programme, devoted 30 minutes to an activity such as book reading or 'friendly visiting'

Outcomes

Fear of falling: fear of falling (single item 4‐point scale) (Tinetti 1990), Falls Efficacy Scale (modified) (Schoenfelder 2000) (10 item fear of falling)
Risk of falling: Fall Risk Assessment (RAFS II) (Ross 1991)
Physical function in ADL: six‐metre walk (time)
Muscle power (anaerobic): ankle plantar/flexor strength
Balance: balance (tandem stance, up to 10 seconds), balance (semi‐tandem stance, up to 10 seconds), balance (parallel stance, up to 10 seconds)
Cognition: MMSE

Notes

Funding: NIH grant

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Quote: "Subjects...randomly assigned within each pair to intervention or control group"

No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Blinding attempted, but may have been broken

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Low risk

Quote: "For all assessments conducted at 3 and 6 months, examiners doing the assessments had no contact with the participants other than the assessments once group assignments were made"

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Low risk

Quote: "For all assessments conducted at 3 and 6 months, examiners doing the assessments had no contact with the participants other than the assessments once group assignments were made"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Similar numbers and reasons for loss to follow up between groups.

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Sihvonen 2004

Methods

Design: RCT
Duration: 4 weeks
Follow up: 8 weeks
Method of randomisation: blocks due to 2 sites, randomised unequally into exercise group and control group in anticipation of greater drop‐out from exercise group, done by drawing lots
Concealment of allocation: unclear
Outcome assessor blinding: not specified
Group comparability at entry: yes
Losses to follow up: 1 participant at 4 weeks due to illness, 3 participants at 18 weeks (total 18%)

Participants

Country: Finland
Setting: 2 care homes for older people with 79 inhabitants (72 women, 7 men)
Randomised: 28
% women = 100
Age: mean = approximately 81 years; range = not reported

Consent: fully‐informed consent

Inclusion criteria: = 70, able to stand without a walking aid, able to see visual feedback from a computer screen, able to follow instructions for testing and training

Exclusion criteria: see inclusion criteria

% Eligible within home: 41% volunteered
% Eligible that participate: 88% of volunteers able to participate

Exercise group: N = 20; 80.7 years ± 6.1 years
Control group: N = 8; 82.9 years ± 4.2 years

Interventions

Study aim or objective: to investigate the effects of a 4‐week visual feedback‐based balance training on the postural control of frail elderly women living in residential care
Number of experimental groups: 2
Individual session delivery
Session duration: 20 to 30 minutes
Number of sessions per week: 3
Seated: no

Exercise features:
20‐ to 30‐minute individualised dynamic balance exercise sessions on a force platform balance measurement and training device (Good Balance), 3 times a week for 4 weeks
Goal: teach participants to control the movement of the centre of pressure during dynamic weight shifting, leaning and stepping tasks, and to manage these tasks in different stances, with higher spatial and temporal demands

Control: not specified

Groups: both groups told to continue their normal daily routines and not to change their physical activity

Outcomes

Balance: Dynamic Balance Test (3 tests), Standing Balance Test (6 tests), BBS

Notes

Funding:

Ministry of Education

Juhno Vainio Foundation in Finland

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Stated randomisation by the drawing of lots

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

As intervention and control group participants were from the same 2 homes, unlikely they could have been blinded to group allocation

Incomplete outcome data (attrition bias)
All outcomes

Low risk

25% (2/8) lost from control. 15% (3/20) lost from exercise. Limited difference unlikely to relate to intervention or lack of it

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

Stated participants were randomised unequally to exercise group in anticipation of greater dropouts. Heavily imbalanced groups not judged to cause systematic risk of bias

Stamford 1972

Methods

Design: RCT
Duration: 12 weeks
Follow up: none
Method of randomisation: not described
Concealment of allocation: unclear
Outcome assessor blinding: unclear
Group comparability at entry: unclear
Losses to follow up: none

Participants

Country: USA
Setting: 2 ambulatory geriatric mental wards at Woodville State Hospital
Randomised: 17
% women = 0
Age: mean = 69 years; range = not reported

Consent: assent accepted

Inclusion criteria: ambulatory, medical screening prior to inclusion

Exclusion criteria: Medical = cardiovascular abnormality – electrocardiograms carried out prior to inclusion

% Eligible within home: not reported
% Eligible that participate: not reported

Experimental group: N = 9; mean age = 71.5 years
Control group: N = 8; mean age = 65.2 years

Interventions

Study aim or objective: to investigate the effects of physical training on institutionalised old men

Number of experimental groups: 2
Unclear if group or individual intervention delivery
Session duration: 9 minutes +
Number of sessions per week: 5
Seated: no

Experimental group: performed treadmill walking with speed and gradient adjustment to maintain heart rate at 70% of age‐adjusted maximum; sessions lasted 9 minutes for the first 3 weeks, and increased by 3 minutes every subsequent 3 weeks; sessions were conducted daily, Monday to Friday for 12 weeks; persons delivering the intervention were not described

Control group: usual care

Outcomes

Endurance (physical other): heart rate
Physiology: systolic blood pressure, diastolic blood pressure

Notes

Funding: not reported

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Quote: "Twenty‐five male geriatric mental patients were selected... Patients adjudged eligible for participation were randomly placed in either an experimental or control group"
No information provided about random sequence generation

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No report of blinding of participants but usual care so intervention would have been obvious

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

No reporting of losses to follow up

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Stevens 2006

Methods

Design: RCT
Duration: 12 weeks
Follow up: 12 weeks
Method of randomisation: lottery method
Concealment of allocation: unclear
Outcome assessor blinding: unclear
Group comparability at entry: no
Losses to follow up: 75 complete data sets from 120 volunteers (63%) 37% dropout

Participants

Country: Australia
Setting: 6 aged‐care facilities
Randomised: 120
% women = 75
Age: mean 80.5 years; range = not reported

Consent: assent accepted

Inclusion criteria: mild to moderate dementia, assessments made by local Aged Care Assessment Team, level determined by MMSE < 23, resident in an aged care facility, legally and cognitively capable of providing informed consent to participate, able to respond appropriately to the majority of verbal requests, physically capable of undertaking some form of gentle but regular exercise, efforts to ensure participants were joining of their own free choice (frequent questioning where there were memory problems)

Exclusion criteria: cognitive = severe dementia, MMSE of 0 to 9

% Eligible within home: not reported
% Eligible that participate: not reported

Group 1: N = 30; women = 23; mean age = 81 years
Group 2: N = 21; women = 10; mean age = 81.5 years
Group 3: N = 24; women = 23; mean age = 79 years

Interventions

Study aim or objective: to measure the effects of exercise on cognitive symptoms related to dementia and disability levels

Number of experimental groups: 3
Group intervention delivery
Session duration: 30 minutes
Number of sessions per week: 3
Seated: if necessary

Groups:
(1) control group, no intervention
(2) control group, social visit from researcher; interactive group discussion on health‐related issues, but no exercise; visits of equivalent duration to the exercise
(3) 30‐minute group exercise programme 3 x week for 12 weeks

Intervention: based on joint and large muscle group movement with an intention to create gentle aerobic exertion, designed to include those in wheelchairs or with impaired movement, generation‐appropriate music, data only analysed where participant attended = 75% of sessions

Outcomes

Cognition: Clock‐drawing Tool (Shulman 1993)
Psychosocial and physical functioning: Revised Elderly Persons Disability Scale (Fleming 1993)

Notes

Funding: not reported

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Stated randomised by lottery method

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No blinding reported for participants or personnel. Outcome measurements could have been influenced by lack of blinding

Incomplete outcome data (attrition bias)
All outcomes

High risk

Data only provided for 75 participants who completed. Ill health, death, or lack of interest resulted in substantial dropouts (128 agreed to participate), but numbers from each groups not reported

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Sung 2009

Methods

Design: cluster RCT
Clustering not accounted for
Duration: 16 weeks
Follow up: no

Participants

Characterisation: elderly women of care facilities
Country: South Korea
Setting: long‐term assisted‐living facilities
Randomised: 40
% women = 100%
Age details: mean (SD) = 75.8 (5.6)
Inclusion criteria: older than 65 years
Able to walk alone
Not participated in regular exercise programs within the previous 6 months
No cognitive impairment (cognitive score > 23 on MMSE Korean version)
Exclusion criteria: stroke or cardiovascular event within past 6 months
Unstable chronic or terminal illness (e.g. diabetes mellitus, hepatic cancer, liver cirrhosis)
Severe cognitive impairment (MMSE Korean version < 24) or major depression (GDS > 20)
ADL status details: not reported
Cognitive status details: not reported
Significant comorbidities: 75% had chronic conditions including hypertension, arthritis or diabetes mellitus
Assessed: not reported
Excluded: not reported

Interventions

Study aim or objective: to compare the effects of a 16 week group exercise program on the physical function and mental health of older elderly women ( ≥ 75 years) compared with younger elderly women (<75 years)
2 groups

Intervention: exercise group (N = 20)
Format: group, delivered by: physical therapist supervised, and 2 research assistants led the functional exercise component
Session length: functional exercise: 40 minutes; health education: 30 minutes every 2 weeks, 3 times weekly
The program comprised of functional exercise and health education. Exercise was of low to moderate intensity. Exercise consisted of 10 minutes of warm up, 10 minutes of muscle strengthening, 20 minutes of exercise performed with music, and 10‐minute cool down. Health education was based on social cognitive theory and explained how to acquire and maintain behaviour changes, benefits and barriers to change

Control: control group (N = 20)
Usual care. Asked not to initiate any exercise or education program during the 16‐week period

Outcomes

Physical function (other): sit‐to‐stand (average number in 30 seconds)
Balance: static balance (Vellas 1997)
Mood related: GDS, self‐esteem (Rosenberg Self Esteem Scale) (Rosenberg 1965)
Flexibility: 'Sit‐and‐reach' test

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

There appears to have been random sequence generation. However, the process is unclear

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Cluster, but one group usual care

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Three lost from control, none from exercise; reasons not related to intervention

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Taboonpong 2008

Methods

Design: cluster RCT
Clustering not accounted for.
Details: quasi‐experimental design with controlled group
Duration: 12 weeks
Follow up: no

Participants

Characterisation: elderly residents
Country: Thailand
Setting: residential care facilities
Randomised: 70
% women = 58%
Age details: number of participants:
60 to 69 years: 18 (36%)
70 to 79 years: 24 (48%)
80 years and over: 8 (16%)
Inclusion criteria: over 60 years old; communicate in Thai language; able to practice Tai Chi; stayed in the residential facilities for at least 1 month; normal orientation to place, time, and person; no illnesses limiting movements, uncontrolled epilepsy and diabetes mellitus; not engaged in Tai Chi or other exercises except stretching exercise; in the past month, had at least 1 of the following common sleep problems, which occurred more than 2 times a week for at least 1 week: (1) shallow sleep, (2) sleep less than 5 hours a night, (3)awake more than twice at night, (4) take more than 30 minutes to fall asleep, (5) can not go back to sleep when awake at night, or (6) wake up too early and not refreshed
Exclusion criteria: during the study period, the participants were excluded from the study if they possessed any of the following exclusion criteria: participated in Tai Chi practice less than 3 times a week; felt discomfort or had symptoms such as dizziness, palpitation, dyspnoea, nausea, vomiting, fatigue, or severe muscle and joint pain; their prescription had been changed recently; developed an illness or had an injury that could interfere with sleep; significant change in daily physical activity
ADL status details: not reported
Cognitive status details: not reported
Significant comorbidities: not reported
Assessed: not reported
Excluded: not reported

Interventions

Study aim or objective: to investigate the effects of low‐intensity and short‐term Tai Chi practice on sleep quality, general well‐being, and physical performance
2 groups

Intervention: experimental group (N = 38)
Format: group, delivered by researcher (trained in Tai Chi)
Session length: 22 minutes, at least 3 times weekly
Tai Chi training program requiring the participants in the group to practice Tai Chi exercise at least 3 times a week, 22 minutes each time for 12 weeks starting from the beginning of the 2nd week through the end of the 13th week of the study. This requirement followed a recommended exercise for the elderly. The participants could join the session on any 3 days of their choice

Control: Control group (N = 32)
The participants in the controlled group were asked to continue their usual activities throughout 14 weeks of the study

Outcomes

Physical function (other): 2‐minute step in place
Flexibility: 'Sit‐and‐reach' test
Quality of life: General Well‐Being Scale
Anthropometry: lung capacity
Sleeping: Pittsburg Sleep Quality Index (PSQI)

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Two care facilities were selected. Assignment to experiment or control was done by simple drawing

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

No report of blinding of participants, although control and experimental groups were in different homes, so participants possibly were not aware if they were intervention or control

Incomplete outcome data (attrition bias)
All outcomes

High risk

Imbalance in number of participants lost to follow up between groups (more in intervention than in control)

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Tappen 1994

Methods

Design: RCT
Duration: 20 weeks
Follow up: none
Method of randomisation: not described
Concealment of allocation: unclear
Outcome assessor blinding: maintained
Group comparability at entry: yes
Losses to follow up: 9 (12.5%) (4 before pre‐testing completed, 1 transfer, 3 hospitalised); no individual group data provided

Participants

Country: USA
Setting: nursing home
Randomised: 72
% women = 75
Age: mean = 84 years ± 8.5 years; range = 59 to 102 years

Consent: not specified

Inclusion criteria: diagnosis of dementia (on MMSE), 6 or more errors out of 10 on Short Portable Mental Status Questionnaire, ability to stand with assistance of 2 people

Exclusion criteria: medical: evidence of stroke, head injury, major psychiatric problem, mental retardation

% Eligible within home: 80
% Eligible that participate: 37.5

Interventions

Study aim or objective: to compare the effects of skill training, a traditional stimulation approach, and regular care on the ability to perform basic activities of daily living of nursing‐home residents with dementia

Number of experimental groups: 3
Group intervention delivery
Session duration: 2.5 hours a day
Number of sessions per week: 5
Seated: unclear

Skill training group: focused on re‐gaining function in basic ADL through repeated practice, with graded assistance

Stimulation group: recreation‐orientated activities, group discussion, music, and relaxation

Control group: usual care

The interventions were delivered in group format by a clinical specialist in gerontological nursing, assisted by a rehabilitation aide, for 2.5 hours per day, 5 days a week, for 20 weeks

Outcomes

Physical function in ADL: Performance Test of Activities of Daily Living (PADL), Physical Self‐Maintenance Scale (Lawton 1969),
Feasibility and acceptability: Goal Attainment (Brody 1971)

Notes

Funding: The Robert Wood Johnson Foundation grant

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Stated "randomly assigned", but no information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No evidence that participants or people delivering the intervention were blinded

Blinding of outcome assessment (detection bias)
Reported ADL (e.g. Barthel, FIM)

Low risk

Data collectors were blind to group assignment

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Only 3 were lost to illness/hospitalisation following pre‐testing (4 overall). However, it could not be determined if they from intervention or control group

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Tappen 2000

Methods

Design: RCT
Duration: 16 weeks
Follow up: none
Method of randomisation: not described
Concealment of allocation: unclear
Outcome assessor blinding: yes ‐ maintained
Group comparability at entry: no
Losses to follow up: N = 6 (8.5%): Walking group N = 3, conversation group N = 2, walk and talk group N = 1, no causes specified

Participants

Country: USA
Setting: nursing home
Randomised: 71
% women = 84
Age: mean = 87 years; range = 70 to 105 years

Consent: assent accepted

Inclusion criteria: Alzheimer's disease, MMSE < 23, ability to stand, ability to mobilise with assistance +/‐ aid

Exclusion criteria: medical = vascular dementia, stroke, Parkinson's disease, major depression, schizophrenia

% Eligible within home: not reported
% Eligible that participate: not reported

Walking group: N = 26; mean age = 87.4 years (SD 5.87)

Conversation group: N = 24; mean age = 89.6 years (SD 6.53)

Walk and talk group: N = 21
Mean age: 84.3 years (SD 7.53)

Interventions

Study aim or objective: to examine the effect of a combination of exercise and conversation with walking‐only exercise and conversation‐only treatments on the functional mobility of frail nursing‐home residents with Alzheimer's disease

Number of experimental groups: 3
Individual intervention delivery
Session duration: 30 minutes
Number of sessions per week: 3
Seated: no

Walking group: self‐paced with rests as required, and physical assistance, a device or both as required, no conversation initiated, but researcher responded to communication

Conversation group: Holland's approach (aphasia) and facilitation for people with Alzheimer’s, used in natural conversation

Walk and talk group: both interventions simultaneously within a 30‐minute session

Outcomes

Physical function in ADL: modified 6‐minute walk (Tappen 1997)

Notes

Funding: National Institute for Nursing Research grant

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Quote: "Random assignment to treatment group"
No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

No information regarding blinding of participants. Control involved an intervention (talking), but the only measure was physical

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Low risk

Quote: "Raters were blinded to treatment group assignment"

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Reasonably balanced losses, but reasons per group not given

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Urbscheit 2001

Methods

Design: RCT
Duration: 8 weeks (see notes)
Follow up: 1 year
Method of randomisation: not described
Concealment of allocation: unclear
Outcome assessor blinding: yes ‐ maintained
Group comparability at entry: no
Losses to follow up: none

Participants

Country: USA
Setting: long‐term care facility
Randomised: 13
% women = 92
Age: mean = approximately 86 years; range = 73 to 95 years

Consent: fully‐informed consent

Inclusion criteria: able to walk approximately 250 feet independently with or without aid, Tinetti Score 14 to 24

Exclusion criteria: cognitive = dementia; medical = serious illness requiring medical intervention in previous 6 months

% Eligible within home: not reported
% Eligible that participate: not reported

Intervention group: N = 6; mean age = 89 years (SD 5.1); range = 81 to 95 years

Control group: N = 7; mean age = 82.2 years (SD 4.6); range = 73 to 88 years

Interventions

Study aim or objective: to determine the effects of 2 exercise programmes on balance in elderly ambulatory people

Number of experimental groups: 2
Group intervention delivery
Session duration: not reported
Number of sessions per week: 2
Seated: no

Exercise group I (control group): traditional exercise incorporating balance and strengthening exercises; no specific equipment used; included weight transference, walking, and lower limb strengthening

Exercise group 2 (intervention group): traditional exercise as above, plus Swiss ball exercises to improve dynamic balance and strengthening component

Both interventions delivered in group format by a physiotherapy student

Outcomes

Falls: falls (any episodes for participant)
Physical function in ADL: ambulatory (capable of walking approximately 250 feet)
Physical function (other): Tinetti Test ‐ gait, use of assistive devices (walker/cane), Tinetti Mobility Scale (gait and balance) (Tinetti 1986)
Balance: Tinetti Test ‐ Body Balance

Notes

Funding: grants from Kentucky Physical Therapy Association and the University of Louisville Graduate Research fund
Tinetti scores were assessed pre‐ and post‐test (8 weeks) for all 13 participants; 8 of the total 13 participants were able to be followed for 1 year post study, although were assessed only in terms of mobility and assistive devices used

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

No information provided; both groups received physical interventions

Blinding of outcome assessment (detection bias)
Observed ADL (e.g. TUG test, mobility)

Unclear risk

No report of blinding of outcome assessment

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

13 participants completed the intervention phase, but unclear if there were 13 at the onset

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

Yoder 1989

Methods

Design: RCT
Duration: n/a (one‐off intervention)
Follow up: n/a
Method of randomisation: not described
Concealment of allocation: unclear
Outcome assessor blinding: no
Group comparability at entry: n/a
Losses to Follow up: none

Participants

Country: USA
Setting: 2 nursing homes
Randomised: 30
% women = 100
Age: mean = 81.5 years ± 7.2 years; range = 70 to 92 years

Consent: not specified

Inclusion criteria: used the first 30 participants scoring > 25 on Parachek Geriatric Rating Scale, residential status

Exclusion criteria: see inclusion criteria

% Eligible within home: not reported
% Eligible that participate: not reported

Intervention:
Group A: N = 15
Group B: N = 15

Interventions

Study aim or objective: hypothesised that participants engaged in the added‐purpose, occupationally‐embedded exercise would engage in more repetitions, and exercise for a longer duration and with fewer stops than the participants engaged in rote exercise

Number of experimental groups: 2
Individual session delivery
Session duration: 30 minutes
Number of sessions per week: 2 to 3
Seated: unclear

Added‐purpose, occupationally‐embedded exercise condition designed, through materials and instructions, to elicit a rotary arm exercise with the added purpose of stirring cookie dough

Compared with an occupational form designed to elicit the rotary arm exercise with no added purpose

Outcomes

Endurance (physical other): duration of exercise
Feasibility and acceptability: frequency of discontinuities of exercise, frequency of rotations (repetitions of stirring)

Notes

Funding: not reported

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

No information provided on randomisation procedure

Allocation concealment (selection bias)

Unclear risk

Insufficient information provided

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Personnel unblinded

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Appears there were no losses to follow up

Selective reporting (reporting bias)

Unclear risk

Protocol unavailable

Other bias

Low risk

No other apparent risks of bias

ADL: activities of daily living
BBS: Berg Balance Scale
BI: Barthel Index
BMI: body mass index
CI: confidence interval
dB: decibels
FIM: Functional Independence Measure
FIT: Functional Incidental Training
GDS: Geriatric Depression Scale
GP: general practitioner
HADS‐D: Hospital Anxiety and Depression Scale (depression subscore)
ITT: intention‐to‐treat
MDS: Minimum Data Set
MMSE: Mini‐Mental State Examination
n/a = not applicable
RCT: randomised controlled trial
RMI: Rivermead Mobility Index
OSAI: Obstructive Sleep Apnea Index
SD: standard deviation
TUG test: Timed Up and Go test

Characteristics of excluded studies [ordered by study ID]

Study

Reason for exclusion

Alessi 1995b

Not primarily physical outcomes of interest (sleep‐orientated)

Alexander 2001

Review team consensus agreed that the study accommodation (congregate housing) was not synonymous with a long‐term care environment

Backman 1986

Participants were self‐caring within a long‐term care environment; interventions were of a psychological, rather than physical, nature

Beck 2009

Focus of study was compliance, rather than improving physical condition

Becker 2003

Multi‐faceted intervention included staff and resident education, advice on environmental adaptations, and hip protectors

Binder 1995

Comparison of the same exercise intervention; 1 group was provided with vitamin supplement

Blair 1996

Focus was behavioural management, rather than physical activity

Brill 1999b

Aimed to prevent admission to long‐term care

Carmeli 2000

Participants were not randomly allocated to study conditions

Collier 2007

The intervention was not primarily physical rehabilitation

de Carvalho Bastone 2004

Participants were assigned to exercise group or comparative group by personal choice (those who did, or did not, want to attend exercise sessions)

Dyer 2004

Multi‐factorial falls prevention programme including medication review, podiatry, and optometry

Eggermont 2009

The intervention was not aimed at improving physical condition

Evans 1995

A review paper that described an apparently relevant study, although insufficient information was provided, and no reference cited. The author was contacted for further information; however, we received no reply

Fisher 1991

Not a RCT

Fitzimmons 2001

Evaluated the effect of exercise on depression, rather than physical outcomes

Fox 2000

Review team consensus deemed passive interventions to reduce contractures to be beyond the scope of this review

Friedman 1991

Aimed to improve communication, rather than physical performance measures

Goldberg 1980

No physical outcomes evaluated

Hagen 2003

Participants not randomised

Hara 2007

The participants included visitors to the centre

Hopman‐Rock 1999

Interventions targeted cognitive, rather than physical, functioning

Ikezoe 2005

Non‐random allocation of participants

Jensen 2002

Multi‐faceted intervention to address falls prevention

Jensen 2004

Multi‐faceted intervention to address falls prevention

Judge 1993

Communication with the authors identified very few long‐term care residents for whom no separate data were available

Kapasi 2007

This was an abstract only for a poster and included no detailed results

Kelly 1983

Interventions were not aimed primarily at improving physical condition

Kerse 2004

Falls risk management programme

Koc 2008

Poster with insufficient data to assess inclusion and included no detailed results

Krishnamurthy 2007

The intervention was not intended to address their physical condition

Light 1984

Review team consensus deemed passive interventions to reduce contractures to be beyond the scope of this review

MacRae 1996

Non‐random allocation to the study conditions

McMurdo 2000

Multi‐faceted intervention to address falls risk

Moye 1996

Review team consensus excluded this paper on the basis that no objective physical outcomes measures were used

Mozley 2007

While the intervention was occupational therapy, the aim was to reduce depression, rather than affect physical condition

Nowalk 2001

Primary focus on reduction of falls

O'Hagan 1994

Non‐random allocation to the study conditions

Ray 1997

Multi‐facted falls prevention programme

Remsburg 1999

Non‐random allocation to the study conditions

Rydwik 2004

Non‐random allocation of participants

Sato 2007

Participants were visitors, rather than residents, of care homes

Sherrington 1997

Only a small proportion of participants were residing in institutional care; the majority were independently living in the community. The authors were contacted for separate data, but none were available

Shimada 2003

Participants were from out‐patient facilities and nursing homes

Shumway‐Cook 1997

Participants were community‐dwelling

Stasi 2004

Not a physical rehabilitation intervention

Steffen 1995

Not a RCT

Stones 1993

Focused on memory, rather than physical outcomes of interest

Tan 2004

Non‐random allocation of participants

Tseng 2006

Focus on contractures

van Heugten 2000

Particpants recruited from a variety of settings; no separate data available for long‐term care residents

Wolf 2001

Included independent living and residential‐care participants

Yip 2004

Non‐random allocation of participants

RCT: randomised controlled trial

Characteristics of studies awaiting assessment [ordered by study ID]

Cakar 2010

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Chang 2010

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Chen 2010a

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Ciairano 2010

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

de Greef 2006

Methods

RCT

Participants

N = 36

Frail older nursing‐home residents

Interventions

Low‐intensity exercise programme

Outcomes

Disability, strength, functional capacity, balance, agility, and walking speed
Performance in ADLs significantly improved

Notes

Translation needed

Dechamps 2010

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Dechamps 2010a

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Deschamps 2009

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Fonseca 2010

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Frändin 2009

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Gallon 2011

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Gerritsen 2011

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Holmerová 2010

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Hsu 2011

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Jeon 2009

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Kemoun 2010

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Lee 2007

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed. Unable to get.

Lee 2010

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Montgomery 2010

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Nalbant 2009

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Pan 2011

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Piedras‐Jorge 2010

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Resnick 2009 awaiting

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed. Reports associated with Resnick 2009.

Rosendahl 2006 awaiting

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed. Reports associated with Rosendahl 2006.

Sackley 2010

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Serra‐Rexach 2011

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Sung 2007

Methods

Participants

Interventions

Outcomes

Notes

Translation needed

Swiniarek 2009

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Takeuchi 2011

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Tse 2010

Methods

Participants

Interventions

Outcomes

Notes

Not yet assessed

Żak 2006

Methods

Participants

Interventions

Outcomes

Notes

Unable to get. Request sent to author [email protected] ‐ bounced

Characteristics of ongoing studies [ordered by study ID]

ISRCTN43769277

Trial name or title

Older people's exercise intervention in residential and nursing accommodation

Methods

Participants

Residents in nursing home, over 65 years, able to participate in baseline assessment, able to transfer

Interventions

Physical activation and group‐based exercise programme

Outcomes

Impact on depression, EQ‐5D, mobility, falls, cognitive function, pain, medication use, hospital admissions

Starting date

1 January 2008

Contact information

Martin Underwood

[email protected]

Notes

NCT00105807

Trial name or title

The effect of exercise on muscle, function and cost in VA nursing home residents

Methods

Participants

Residents in VA nursing home, 65 years or older, able to follow one‐step commands

Interventions

Low‐intensity exercise

Outcomes

Muscle mass, physical function, cost

Starting date

2002

Contact information

Notes

HSRP20071249

NCT00218842

Trial name or title

Physical and daily activity for residents in a nursing home setting ‐ A Nordic multi‐centre study

Methods

Participants

Residents expected to stay in nursing homes > 3 months

Interventions

Individually‐tailored enhanced activities of daily living training

Outcomes

Physical function, well‐being, amount of activity, falls

Starting date

August 2005

Contact information

Kerstin Frandin

[email protected]

Notes

Serra‐Rexach 2009

Trial name or title

Health enhancing strength training in nonagenarians (STRONG)

Methods

RCT

Participants

Sixty residents of a geriatric nursing home (age range = 90 to 102 years)

Interventions

Muscle strengthening and aerobic exercises over 6 months

Outcomes

SF‐12, Tinetti mobility scale, BI, 1RM leg press, hand grip strength, 8‐metre walk test, 4‐step stairs test, BMI, physical activity (Actigraph), MMSE, falls, and other adverse events

Starting date

March 2009

Contact information

Alejandro Lucia [email protected]

Notes

BI: Barthel Index
BMI: body mass index
MMSE: Mini‐Mental State Examinsation
RCT: randomised controlled trial

Data and analyses

Open in table viewer
Comparison 1. Rehabilitation versus control

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Barthel Index Show forest plot

7

857

Mean Difference (Random, 95% CI)

6.38 [1.63, 11.12]

Analysis 1.1

Comparison 1 Rehabilitation versus control, Outcome 1 Barthel Index.

Comparison 1 Rehabilitation versus control, Outcome 1 Barthel Index.

2 Functional Independence Measure (FIM) Show forest plot

4

303

Mean Difference (Random, 95% CI)

4.98 [‐1.55, 11.51]

Analysis 1.2

Comparison 1 Rehabilitation versus control, Outcome 2 Functional Independence Measure (FIM).

Comparison 1 Rehabilitation versus control, Outcome 2 Functional Independence Measure (FIM).

3 Rivermead Mobility Index (RMI) Show forest plot

3

323

Mean Difference (Random, 95% CI)

0.69 [0.04, 1.33]

Analysis 1.3

Comparison 1 Rehabilitation versus control, Outcome 3 Rivermead Mobility Index (RMI).

Comparison 1 Rehabilitation versus control, Outcome 3 Rivermead Mobility Index (RMI).

4 Timed Up and Go (TUG) Test Show forest plot

7

885

Mean Difference (Random, 95% CI)

‐4.59 [‐9.19, 0.01]

Analysis 1.4

Comparison 1 Rehabilitation versus control, Outcome 4 Timed Up and Go (TUG) Test.

Comparison 1 Rehabilitation versus control, Outcome 4 Timed Up and Go (TUG) Test.

5 Walking speed Show forest plot

9

590

Mean Difference (Random, 95% CI)

0.03 [‐0.01, 0.07]

Analysis 1.5

Comparison 1 Rehabilitation versus control, Outcome 5 Walking speed.

Comparison 1 Rehabilitation versus control, Outcome 5 Walking speed.

6 Death Show forest plot

25

3721

Risk Ratio (M‐H, Random, 95% CI)

0.95 [0.80, 1.13]

Analysis 1.6

Comparison 1 Rehabilitation versus control, Outcome 6 Death.

Comparison 1 Rehabilitation versus control, Outcome 6 Death.

7 Barthel Index (by risk of bias) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.7

Comparison 1 Rehabilitation versus control, Outcome 7 Barthel Index (by risk of bias).

Comparison 1 Rehabilitation versus control, Outcome 7 Barthel Index (by risk of bias).

7.1 lower risk of bias

2

275

Mean Difference (Random, 95% CI)

3.38 [‐2.10, 8.86]

7.2 higher risk of bias

5

582

Mean Difference (Random, 95% CI)

8.25 [1.15, 15.34]

8 Barthel Index (by duration of intervention) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.8

Comparison 1 Rehabilitation versus control, Outcome 8 Barthel Index (by duration of intervention).

Comparison 1 Rehabilitation versus control, Outcome 8 Barthel Index (by duration of intervention).

8.1 shorter (< 3 months intervention)

2

46

Mean Difference (Random, 95% CI)

17.55 [6.97, 28.13]

8.2 longer (3+ months intervention)

5

811

Mean Difference (Random, 95% CI)

3.08 [‐0.03, 6.19]

9 Barthel Index (by mode of delivery) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.9

Comparison 1 Rehabilitation versus control, Outcome 9 Barthel Index (by mode of delivery).

Comparison 1 Rehabilitation versus control, Outcome 9 Barthel Index (by mode of delivery).

9.1 group

4

256

Mean Difference (Random, 95% CI)

10.99 [1.51, 20.48]

9.2 individual

2

275

Mean Difference (Random, 95% CI)

3.38 [‐2.10, 8.86]

9.3 not reported

1

326

Mean Difference (Random, 95% CI)

2.19 [‐4.35, 8.73]

10 Barthel Index (by baseline Barthel Index score) Show forest plot

6

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.10

Comparison 1 Rehabilitation versus control, Outcome 10 Barthel Index (by baseline Barthel Index score).

Comparison 1 Rehabilitation versus control, Outcome 10 Barthel Index (by baseline Barthel Index score).

10.1 better (baseline Barthel Index score > median)

3

511

Mean Difference (Random, 95% CI)

7.94 [‐1.77, 17.64]

10.2 worse (baseline Barthel Index score < median)

3

305

Mean Difference (Random, 95% CI)

3.97 [‐0.83, 8.78]

11 Barthel Index (by age) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.11

Comparison 1 Rehabilitation versus control, Outcome 11 Barthel Index (by age).

Comparison 1 Rehabilitation versus control, Outcome 11 Barthel Index (by age).

11.1 younger (mean age < 85 years)

4

552

Mean Difference (Random, 95% CI)

8.02 [‐0.25, 16.30]

11.2 older (mean age 85+ years)

3

305

Mean Difference (Random, 95% CI)

3.97 [‐0.83, 8.78]

12 Barthel Index (by gender) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.12

Comparison 1 Rehabilitation versus control, Outcome 12 Barthel Index (by gender).

Comparison 1 Rehabilitation versus control, Outcome 12 Barthel Index (by gender).

12.1 < 80% female

4

402

Mean Difference (Random, 95% CI)

7.93 [0.18, 15.69]

12.2 80%+ female

3

455

Mean Difference (Random, 95% CI)

4.29 [‐1.25, 9.83]

13 Functional Independence Measure (by risk of bias) Show forest plot

4

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.13

Comparison 1 Rehabilitation versus control, Outcome 13 Functional Independence Measure (by risk of bias).

Comparison 1 Rehabilitation versus control, Outcome 13 Functional Independence Measure (by risk of bias).

13.1 lower risk of bias

0

0

Mean Difference (Random, 95% CI)

0.0 [0.0, 0.0]

13.2 higher risk of bias

4

303

Mean Difference (Random, 95% CI)

4.98 [‐1.55, 11.51]

14 Functional Independence Measure (by duration of intervention) Show forest plot

4

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.14

Comparison 1 Rehabilitation versus control, Outcome 14 Functional Independence Measure (by duration of intervention).

Comparison 1 Rehabilitation versus control, Outcome 14 Functional Independence Measure (by duration of intervention).

14.1 shorter (< 3 months intervention)

1

30

Mean Difference (Random, 95% CI)

2.0 [‐10.26, 14.26]

14.2 longer (3+ months intervention)

3

273

Mean Difference (Random, 95% CI)

5.85 [‐2.22, 13.93]

15 Functional Independence Measure (by mode of delivery) Show forest plot

4

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.15

Comparison 1 Rehabilitation versus control, Outcome 15 Functional Independence Measure (by mode of delivery).

Comparison 1 Rehabilitation versus control, Outcome 15 Functional Independence Measure (by mode of delivery).

15.1 group

3

240

Mean Difference (Random, 95% CI)

3.90 [‐3.08, 10.88]

15.2 individual

1

63

Mean Difference (Random, 95% CI)

11.76 [‐2.66, 26.18]

16 Functional Independence Measure (by baseline FIM score) Show forest plot

3

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.16

Comparison 1 Rehabilitation versus control, Outcome 16 Functional Independence Measure (by baseline FIM score).

Comparison 1 Rehabilitation versus control, Outcome 16 Functional Independence Measure (by baseline FIM score).

16.1 better (baseline FIM score > median)

2

95

Mean Difference (Random, 95% CI)

7.77 [1.39, 14.14]

16.2 worse (baseline FIM score < median)

1

145

Mean Difference (Random, 95% CI)

0.3 [‐1.73, 2.33]

17 Functional Independence Measure (by age) Show forest plot

4

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.17

Comparison 1 Rehabilitation versus control, Outcome 17 Functional Independence Measure (by age).

Comparison 1 Rehabilitation versus control, Outcome 17 Functional Independence Measure (by age).

17.1 younger (mean age < 85 years)

2

128

Mean Difference (Random, 95% CI)

9.91 [4.41, 15.42]

17.2 older (mean age 85+ years)

2

175

Mean Difference (Random, 95% CI)

0.35 [‐1.65, 2.34]

18 Functional Independence Measure (by gender) Show forest plot

4

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.18

Comparison 1 Rehabilitation versus control, Outcome 18 Functional Independence Measure (by gender).

Comparison 1 Rehabilitation versus control, Outcome 18 Functional Independence Measure (by gender).

18.1 < 80% female

2

93

Mean Difference (Random, 95% CI)

6.11 [‐3.33, 15.55]

18.2 80%+ female

2

210

Mean Difference (Random, 95% CI)

4.51 [‐4.56, 13.58]

19 Rivermead Mobility Index (by risk of bias) Show forest plot

3

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.19

Comparison 1 Rehabilitation versus control, Outcome 19 Rivermead Mobility Index (by risk of bias).

Comparison 1 Rehabilitation versus control, Outcome 19 Rivermead Mobility Index (by risk of bias).

19.1 lower risk of bias

3

323

Mean Difference (Random, 95% CI)

0.69 [0.04, 1.33]

19.2 higher risk of bias

0

0

Mean Difference (Random, 95% CI)

0.0 [0.0, 0.0]

20 Rivermead Mobility Index (by duration of intervention) Show forest plot

3

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.20

Comparison 1 Rehabilitation versus control, Outcome 20 Rivermead Mobility Index (by duration of intervention).

Comparison 1 Rehabilitation versus control, Outcome 20 Rivermead Mobility Index (by duration of intervention).

20.1 shorter (< 3 months intervention)

1

49

Mean Difference (Random, 95% CI)

0.6 [‐1.48, 2.68]

20.2 longer (3+ months intervention)

2

274

Mean Difference (Random, 95% CI)

0.69 [0.02, 1.37]

21 Rivermead Mobility Index (by mode of delivery) Show forest plot

3

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.21

Comparison 1 Rehabilitation versus control, Outcome 21 Rivermead Mobility Index (by mode of delivery).

Comparison 1 Rehabilitation versus control, Outcome 21 Rivermead Mobility Index (by mode of delivery).

21.1 group

1

49

Mean Difference (Random, 95% CI)

0.6 [‐1.48, 2.68]

21.2 individual

2

274

Mean Difference (Random, 95% CI)

0.69 [0.02, 1.37]

22 Rivermead Mobility Index (by baseline RMI score) Show forest plot

3

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.22

Comparison 1 Rehabilitation versus control, Outcome 22 Rivermead Mobility Index (by baseline RMI score).

Comparison 1 Rehabilitation versus control, Outcome 22 Rivermead Mobility Index (by baseline RMI score).

22.1 better (baseline RMI score > median)

2

235

Mean Difference (Random, 95% CI)

0.70 [0.01, 1.39]

22.2 worse (baseline RMI score < median)

1

88

Mean Difference (Random, 95% CI)

0.6 [‐1.17, 2.37]

23 Rivermead Mobility Index (by age) Show forest plot

3

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.23

Comparison 1 Rehabilitation versus control, Outcome 23 Rivermead Mobility Index (by age).

Comparison 1 Rehabilitation versus control, Outcome 23 Rivermead Mobility Index (by age).

23.1 younger (mean age < 85 years)

1

49

Mean Difference (Random, 95% CI)

0.6 [‐1.48, 2.68]

23.2 older (mean age 85+ years)

2

274

Mean Difference (Random, 95% CI)

0.69 [0.02, 1.37]

24 Rivermead Mobility Index (by gender) Show forest plot

3

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.24

Comparison 1 Rehabilitation versus control, Outcome 24 Rivermead Mobility Index (by gender).

Comparison 1 Rehabilitation versus control, Outcome 24 Rivermead Mobility Index (by gender).

24.1 < 80% female

2

235

Mean Difference (Random, 95% CI)

0.70 [0.01, 1.39]

24.2 80%+ female

1

88

Mean Difference (Random, 95% CI)

0.6 [‐1.17, 2.37]

25 TUG Test (by risk of bias) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.25

Comparison 1 Rehabilitation versus control, Outcome 25 TUG Test (by risk of bias).

Comparison 1 Rehabilitation versus control, Outcome 25 TUG Test (by risk of bias).

25.1 lower risk of bias

1

556

Mean Difference (Random, 95% CI)

0.6 [‐5.36, 6.56]

25.2 higher risk of bias

6

329

Mean Difference (Random, 95% CI)

‐5.92 [‐11.29, ‐0.54]

26 TUG Test (by duration of intervention) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.26

Comparison 1 Rehabilitation versus control, Outcome 26 TUG Test (by duration of intervention).

Comparison 1 Rehabilitation versus control, Outcome 26 TUG Test (by duration of intervention).

26.1 shorter (< 6 months intervention)

4

185

Mean Difference (Random, 95% CI)

‐7.34 [‐13.93, ‐0.75]

26.2 longer (6+ months intervention)

3

700

Mean Difference (Random, 95% CI)

0.13 [‐4.28, 4.53]

27 TUG Test (by mode of delivery) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.27

Comparison 1 Rehabilitation versus control, Outcome 27 TUG Test (by mode of delivery).

Comparison 1 Rehabilitation versus control, Outcome 27 TUG Test (by mode of delivery).

27.1 group

4

154

Mean Difference (Random, 95% CI)

‐4.98 [‐10.74, 0.77]

27.2 individual

3

731

Mean Difference (Random, 95% CI)

‐4.56 [‐14.02, 4.90]

28 TUG Test (by baseline TUG score) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.28

Comparison 1 Rehabilitation versus control, Outcome 28 TUG Test (by baseline TUG score).

Comparison 1 Rehabilitation versus control, Outcome 28 TUG Test (by baseline TUG score).

28.1 better (baseline TUG score < median)

4

185

Mean Difference (Random, 95% CI)

‐7.34 [‐13.93, ‐0.75]

28.2 worse (baseline TUG score > median)

3

700

Mean Difference (Random, 95% CI)

0.13 [‐4.28, 4.53]

29 TUG Test (by age) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.29

Comparison 1 Rehabilitation versus control, Outcome 29 TUG Test (by age).

Comparison 1 Rehabilitation versus control, Outcome 29 TUG Test (by age).

29.1 younger (mean age < 85 years)

5

741

Mean Difference (Random, 95% CI)

‐5.39 [‐10.77, ‐0.00]

29.2 older (mean age 85+ years)

2

144

Mean Difference (Random, 95% CI)

‐5.40 [‐25.75, 14.96]

30 TUG Test (by gender) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.30

Comparison 1 Rehabilitation versus control, Outcome 30 TUG Test (by gender).

Comparison 1 Rehabilitation versus control, Outcome 30 TUG Test (by gender).

30.1 < 80% female

3

594

Mean Difference (Random, 95% CI)

0.17 [‐3.90, 4.24]

30.2 80%+ female

4

291

Mean Difference (Random, 95% CI)

‐7.55 [‐14.28, ‐0.82]

31 Walking speed (by risk of bias) Show forest plot

9

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.31

Comparison 1 Rehabilitation versus control, Outcome 31 Walking speed (by risk of bias).

Comparison 1 Rehabilitation versus control, Outcome 31 Walking speed (by risk of bias).

31.1 lower risk of bias

1

75

Mean Difference (Random, 95% CI)

‐0.10 [‐0.21, 0.01]

31.2 higher risk of bias

8

515

Mean Difference (Random, 95% CI)

0.04 [0.01, 0.07]

32 Walking speed (by duration of intervention) Show forest plot

9

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.32

Comparison 1 Rehabilitation versus control, Outcome 32 Walking speed (by duration of intervention).

Comparison 1 Rehabilitation versus control, Outcome 32 Walking speed (by duration of intervention).

32.1 shorter (< 3 months intervention)

3

59

Mean Difference (Random, 95% CI)

0.24 [‐0.74, 1.22]

32.2 longer (3+ months intervention)

6

531

Mean Difference (Random, 95% CI)

0.02 [‐0.03, 0.08]

33 Walking speed (by mode of delivery) Show forest plot

9

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.33

Comparison 1 Rehabilitation versus control, Outcome 33 Walking speed (by mode of delivery).

Comparison 1 Rehabilitation versus control, Outcome 33 Walking speed (by mode of delivery).

33.1 group

7

475

Mean Difference (Random, 95% CI)

0.03 [‐0.02, 0.07]

33.2 individual

1

48

Mean Difference (Random, 95% CI)

0.26 [‐0.32, 0.83]

33.3 not reported

1

67

Mean Difference (Random, 95% CI)

‐0.03 [‐0.19, 0.13]

34 Walking speed (by baseline walking speed) Show forest plot

9

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.34

Comparison 1 Rehabilitation versus control, Outcome 34 Walking speed (by baseline walking speed).

Comparison 1 Rehabilitation versus control, Outcome 34 Walking speed (by baseline walking speed).

34.1 better (baseline walking speed > median)

5

198

Mean Difference (Random, 95% CI)

‐0.00 [‐0.15, 0.14]

34.2 worse (baseline walking speed < median)

4

392

Mean Difference (Random, 95% CI)

0.04 [0.01, 0.07]

35 Walking speed (by age) Show forest plot

9

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.35

Comparison 1 Rehabilitation versus control, Outcome 35 Walking speed (by age).

Comparison 1 Rehabilitation versus control, Outcome 35 Walking speed (by age).

35.1 younger (mean age < 85 years)

9

590

Mean Difference (Random, 95% CI)

0.03 [‐0.01, 0.07]

35.2 older (mean age 85+ years)

0

0

Mean Difference (Random, 95% CI)

0.0 [0.0, 0.0]

36 Walking speed (by gender) Show forest plot

9

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.36

Comparison 1 Rehabilitation versus control, Outcome 36 Walking speed (by gender).

Comparison 1 Rehabilitation versus control, Outcome 36 Walking speed (by gender).

36.1 < 80% female

5

437

Mean Difference (Random, 95% CI)

0.01 [‐0.04, 0.07]

36.2 80%+ female

4

153

Mean Difference (Random, 95% CI)

0.13 [‐0.02, 0.28]

37 Walking speed (by distance walked) Show forest plot

9

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.37

Comparison 1 Rehabilitation versus control, Outcome 37 Walking speed (by distance walked).

Comparison 1 Rehabilitation versus control, Outcome 37 Walking speed (by distance walked).

37.1 less far (< 6 metres)

2

185

Mean Difference (Random, 95% CI)

0.04 [0.01, 0.07]

37.2 further (6+ metres)

7

405

Mean Difference (Random, 95% CI)

0.01 [‐0.06, 0.09]

38 Death (by risk of bias) Show forest plot

25

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

Analysis 1.38

Comparison 1 Rehabilitation versus control, Outcome 38 Death (by risk of bias).

Comparison 1 Rehabilitation versus control, Outcome 38 Death (by risk of bias).

38.1 lower risk of bias

6

1366

Risk Ratio (M‐H, Random, 95% CI)

1.05 [0.76, 1.46]

38.2 higher risk of bias

19

2355

Risk Ratio (M‐H, Random, 95% CI)

0.88 [0.71, 1.10]

39 Death (by duration of intervention) Show forest plot

25

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

Analysis 1.39

Comparison 1 Rehabilitation versus control, Outcome 39 Death (by duration of intervention).

Comparison 1 Rehabilitation versus control, Outcome 39 Death (by duration of intervention).

39.1 shorter intervention (< 3 months)

10

663

Risk Ratio (M‐H, Random, 95% CI)

0.64 [0.18, 2.29]

39.2 longer intervention (3+ months)

15

3058

Risk Ratio (M‐H, Random, 95% CI)

0.95 [0.80, 1.14]

40 Death (by mode of delivery) Show forest plot

25

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

Analysis 1.40

Comparison 1 Rehabilitation versus control, Outcome 40 Death (by mode of delivery).

Comparison 1 Rehabilitation versus control, Outcome 40 Death (by mode of delivery).

40.1 group

12

1007

Risk Ratio (M‐H, Random, 95% CI)

0.82 [0.46, 1.49]

40.2 individual

9

2172

Risk Ratio (M‐H, Random, 95% CI)

0.91 [0.70, 1.19]

40.3 group and individual

1

24

Risk Ratio (M‐H, Random, 95% CI)

5.0 [0.27, 94.34]

40.4 not reported

3

518

Risk Ratio (M‐H, Random, 95% CI)

1.00 [0.73, 1.36]

41 Death (by age) Show forest plot

25

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

Analysis 1.41

Comparison 1 Rehabilitation versus control, Outcome 41 Death (by age).

Comparison 1 Rehabilitation versus control, Outcome 41 Death (by age).

41.1 younger (mean age < 85 years)

16

3001

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.81, 1.17]

41.2 older (mean age 85+ years)

9

720

Risk Ratio (M‐H, Random, 95% CI)

0.79 [0.49, 1.27]

42 Death (by gender) Show forest plot

25

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

Analysis 1.42

Comparison 1 Rehabilitation versus control, Outcome 42 Death (by gender).

Comparison 1 Rehabilitation versus control, Outcome 42 Death (by gender).

42.1 < 80% female

12

2366

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.77, 1.25]

42.2 80%+ female

12

1340

Risk Ratio (M‐H, Random, 95% CI)

0.91 [0.71, 1.18]

42.3 not reported

1

15

Risk Ratio (M‐H, Random, 95% CI)

0.88 [0.16, 4.68]

43 Sensitivity analysis: Barthel Index (fixed‐effect) Show forest plot

7

857

Mean Difference (Fixed, 95% CI)

4.54 [1.59, 7.49]

Analysis 1.43

Comparison 1 Rehabilitation versus control, Outcome 43 Sensitivity analysis: Barthel Index (fixed‐effect).

Comparison 1 Rehabilitation versus control, Outcome 43 Sensitivity analysis: Barthel Index (fixed‐effect).

44 Sensitivity analysis: Barthel Index (cluster trials) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.44

Comparison 1 Rehabilitation versus control, Outcome 44 Sensitivity analysis: Barthel Index (cluster trials).

Comparison 1 Rehabilitation versus control, Outcome 44 Sensitivity analysis: Barthel Index (cluster trials).

44.1 cluster (adjusted)

5

811

Mean Difference (Random, 95% CI)

3.08 [‐0.03, 6.19]

44.2 individual

2

46

Mean Difference (Random, 95% CI)

17.55 [6.97, 28.13]

45 Sensitivity analysis: Functional Independence Measure (fixed‐effect) Show forest plot

4

303

Mean Difference (Fixed, 95% CI)

1.46 [‐0.42, 3.34]

Analysis 1.45

Comparison 1 Rehabilitation versus control, Outcome 45 Sensitivity analysis: Functional Independence Measure (fixed‐effect).

Comparison 1 Rehabilitation versus control, Outcome 45 Sensitivity analysis: Functional Independence Measure (fixed‐effect).

46 Sensitivity analysis: Rivermead Mobility Index (fixed‐effect) Show forest plot

3

323

Mean Difference (Fixed, 95% CI)

0.69 [0.04, 1.33]

Analysis 1.46

Comparison 1 Rehabilitation versus control, Outcome 46 Sensitivity analysis: Rivermead Mobility Index (fixed‐effect).

Comparison 1 Rehabilitation versus control, Outcome 46 Sensitivity analysis: Rivermead Mobility Index (fixed‐effect).

47 Sensitivity analysis: TUG Test (fixed‐effect) Show forest plot

7

885

Mean Difference (Fixed, 95% CI)

‐3.66 [‐5.86, ‐1.45]

Analysis 1.47

Comparison 1 Rehabilitation versus control, Outcome 47 Sensitivity analysis: TUG Test (fixed‐effect).

Comparison 1 Rehabilitation versus control, Outcome 47 Sensitivity analysis: TUG Test (fixed‐effect).

48 Sensitivity anlaysis: TUG Test (cluster trials) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.48

Comparison 1 Rehabilitation versus control, Outcome 48 Sensitivity anlaysis: TUG Test (cluster trials).

Comparison 1 Rehabilitation versus control, Outcome 48 Sensitivity anlaysis: TUG Test (cluster trials).

48.1 cluster (adjusted)

2

Mean Difference (Random, 95% CI)

0.51 [‐3.93, 4.95]

48.2 individual

5

Mean Difference (Random, 95% CI)

‐7.85 [‐14.34, ‐1.37]

49 Sensitivity analysis: TUG Test (re‐including Christofoletti 2008) Show forest plot

8

914

Mean Difference (Random, 95% CI)

‐8.41 [‐15.53, ‐1.29]

Analysis 1.49

Comparison 1 Rehabilitation versus control, Outcome 49 Sensitivity analysis: TUG Test (re‐including Christofoletti 2008).

Comparison 1 Rehabilitation versus control, Outcome 49 Sensitivity analysis: TUG Test (re‐including Christofoletti 2008).

50 Sensitivity analysis: Walking speed (fixed‐effect) Show forest plot

9

590

Mean Difference (Fixed, 95% CI)

0.03 [0.00, 0.06]

Analysis 1.50

Comparison 1 Rehabilitation versus control, Outcome 50 Sensitivity analysis: Walking speed (fixed‐effect).

Comparison 1 Rehabilitation versus control, Outcome 50 Sensitivity analysis: Walking speed (fixed‐effect).

51 Sensitivity analysis: Walking speed (cluster trials) Show forest plot

9

Mean Difference (Random, 95% CI)

Subtotals only

Analysis 1.51

Comparison 1 Rehabilitation versus control, Outcome 51 Sensitivity analysis: Walking speed (cluster trials).

Comparison 1 Rehabilitation versus control, Outcome 51 Sensitivity analysis: Walking speed (cluster trials).

51.1 cluster (unadjusted)

1

Mean Difference (Random, 95% CI)

0.04 [0.01, 0.07]

51.2 individual

8

Mean Difference (Random, 95% CI)

0.01 [‐0.05, 0.08]

52 Sensitivity analysis: Death (random‐effects: odds ratio) Show forest plot

25

3721

Odds Ratio (M‐H, Random, 95% CI)

0.93 [0.75, 1.15]

Analysis 1.52

Comparison 1 Rehabilitation versus control, Outcome 52 Sensitivity analysis: Death (random‐effects: odds ratio).

Comparison 1 Rehabilitation versus control, Outcome 52 Sensitivity analysis: Death (random‐effects: odds ratio).

53 Sensitivity analysis: Death (random‐effects: risk difference) Show forest plot

25

3721

Risk Difference (M‐H, Random, 95% CI)

‐0.01 [‐0.02, 0.01]

Analysis 1.53

Comparison 1 Rehabilitation versus control, Outcome 53 Sensitivity analysis: Death (random‐effects: risk difference).

Comparison 1 Rehabilitation versus control, Outcome 53 Sensitivity analysis: Death (random‐effects: risk difference).

54 Sensitivity analysis: Death (fixed‐effect) Show forest plot

25

3721

Risk Ratio (M‐H, Random, 95% CI)

0.95 [0.80, 1.13]

Analysis 1.54

Comparison 1 Rehabilitation versus control, Outcome 54 Sensitivity analysis: Death (fixed‐effect).

Comparison 1 Rehabilitation versus control, Outcome 54 Sensitivity analysis: Death (fixed‐effect).

55 Sensitivity analysis: Death (fixed‐effect: Peto odds ratio) Show forest plot

25

3721

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.93 [0.75, 1.14]

Analysis 1.55

Comparison 1 Rehabilitation versus control, Outcome 55 Sensitivity analysis: Death (fixed‐effect: Peto odds ratio).

Comparison 1 Rehabilitation versus control, Outcome 55 Sensitivity analysis: Death (fixed‐effect: Peto odds ratio).

56 Sensitivity analysis: Death (cluster trials) Show forest plot

25

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

Analysis 1.56

Comparison 1 Rehabilitation versus control, Outcome 56 Sensitivity analysis: Death (cluster trials).

Comparison 1 Rehabilitation versus control, Outcome 56 Sensitivity analysis: Death (cluster trials).

56.1 cluster (unadjusted)

13

2644

Risk Ratio (M‐H, Random, 95% CI)

0.95 [0.79, 1.15]

56.2 individual

12

1077

Risk Ratio (M‐H, Random, 95% CI)

0.93 [0.60, 1.44]

57 Sensitivity analysis: Death (including Brittle 2009) Show forest plot

26

3777

Risk Ratio (M‐H, Random, 95% CI)

0.94 [0.79, 1.11]

Analysis 1.57

Comparison 1 Rehabilitation versus control, Outcome 57 Sensitivity analysis: Death (including Brittle 2009).

Comparison 1 Rehabilitation versus control, Outcome 57 Sensitivity analysis: Death (including Brittle 2009).

Open in table viewer
Comparison 2. Rehabilitation (experimental) versus rehabilitation (control)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 TUG Test Show forest plot

2

57

Mean Difference (Random, 95% CI)

‐7.95 [‐19.22, 3.31]

Analysis 2.1

Comparison 2 Rehabilitation (experimental) versus rehabilitation (control), Outcome 1 TUG Test.

Comparison 2 Rehabilitation (experimental) versus rehabilitation (control), Outcome 1 TUG Test.

2 Death Show forest plot

4

118

Risk Ratio (M‐H, Random, 95% CI)

2.67 [0.12, 60.93]

Analysis 2.2

Comparison 2 Rehabilitation (experimental) versus rehabilitation (control), Outcome 2 Death.

Comparison 2 Rehabilitation (experimental) versus rehabilitation (control), Outcome 2 Death.

3 Sensitivity analysis: TUG Test (fixed‐effect) Show forest plot

2

57

Mean Difference (Fixed, 95% CI)

‐7.19 [‐10.92, ‐3.46]

Analysis 2.3

Comparison 2 Rehabilitation (experimental) versus rehabilitation (control), Outcome 3 Sensitivity analysis: TUG Test (fixed‐effect).

Comparison 2 Rehabilitation (experimental) versus rehabilitation (control), Outcome 3 Sensitivity analysis: TUG Test (fixed‐effect).

Review update flow diagram
Figuras y tablas -
Figure 1

Review update flow diagram

'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies
Figuras y tablas -
Figure 2

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

Funnel plot of comparison: 1 Rehabilitation versus control, outcome: 1.1 Barthel Index.
Figuras y tablas -
Figure 3

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

Funnel plot of comparison: 1 Rehabilitation versus control, outcome: 1.4 TUG test
Figuras y tablas -
Figure 4

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

Funnel plot of comparison: 1 Rehabilitation versus control, outcome: 1.5 Walking speed
Figuras y tablas -
Figure 5

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

Funnel plot of comparison: 1 Rehabilitation versus control, outcome: 1.6 Death
Figuras y tablas -
Figure 6

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

'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study
Figuras y tablas -
Figure 7

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

Comparison 1 Rehabilitation versus control, Outcome 1 Barthel Index.
Figuras y tablas -
Analysis 1.1

Comparison 1 Rehabilitation versus control, Outcome 1 Barthel Index.

Comparison 1 Rehabilitation versus control, Outcome 2 Functional Independence Measure (FIM).
Figuras y tablas -
Analysis 1.2

Comparison 1 Rehabilitation versus control, Outcome 2 Functional Independence Measure (FIM).

Comparison 1 Rehabilitation versus control, Outcome 3 Rivermead Mobility Index (RMI).
Figuras y tablas -
Analysis 1.3

Comparison 1 Rehabilitation versus control, Outcome 3 Rivermead Mobility Index (RMI).

Comparison 1 Rehabilitation versus control, Outcome 4 Timed Up and Go (TUG) Test.
Figuras y tablas -
Analysis 1.4

Comparison 1 Rehabilitation versus control, Outcome 4 Timed Up and Go (TUG) Test.

Comparison 1 Rehabilitation versus control, Outcome 5 Walking speed.
Figuras y tablas -
Analysis 1.5

Comparison 1 Rehabilitation versus control, Outcome 5 Walking speed.

Comparison 1 Rehabilitation versus control, Outcome 6 Death.
Figuras y tablas -
Analysis 1.6

Comparison 1 Rehabilitation versus control, Outcome 6 Death.

Comparison 1 Rehabilitation versus control, Outcome 7 Barthel Index (by risk of bias).
Figuras y tablas -
Analysis 1.7

Comparison 1 Rehabilitation versus control, Outcome 7 Barthel Index (by risk of bias).

Comparison 1 Rehabilitation versus control, Outcome 8 Barthel Index (by duration of intervention).
Figuras y tablas -
Analysis 1.8

Comparison 1 Rehabilitation versus control, Outcome 8 Barthel Index (by duration of intervention).

Comparison 1 Rehabilitation versus control, Outcome 9 Barthel Index (by mode of delivery).
Figuras y tablas -
Analysis 1.9

Comparison 1 Rehabilitation versus control, Outcome 9 Barthel Index (by mode of delivery).

Comparison 1 Rehabilitation versus control, Outcome 10 Barthel Index (by baseline Barthel Index score).
Figuras y tablas -
Analysis 1.10

Comparison 1 Rehabilitation versus control, Outcome 10 Barthel Index (by baseline Barthel Index score).

Comparison 1 Rehabilitation versus control, Outcome 11 Barthel Index (by age).
Figuras y tablas -
Analysis 1.11

Comparison 1 Rehabilitation versus control, Outcome 11 Barthel Index (by age).

Comparison 1 Rehabilitation versus control, Outcome 12 Barthel Index (by gender).
Figuras y tablas -
Analysis 1.12

Comparison 1 Rehabilitation versus control, Outcome 12 Barthel Index (by gender).

Comparison 1 Rehabilitation versus control, Outcome 13 Functional Independence Measure (by risk of bias).
Figuras y tablas -
Analysis 1.13

Comparison 1 Rehabilitation versus control, Outcome 13 Functional Independence Measure (by risk of bias).

Comparison 1 Rehabilitation versus control, Outcome 14 Functional Independence Measure (by duration of intervention).
Figuras y tablas -
Analysis 1.14

Comparison 1 Rehabilitation versus control, Outcome 14 Functional Independence Measure (by duration of intervention).

Comparison 1 Rehabilitation versus control, Outcome 15 Functional Independence Measure (by mode of delivery).
Figuras y tablas -
Analysis 1.15

Comparison 1 Rehabilitation versus control, Outcome 15 Functional Independence Measure (by mode of delivery).

Comparison 1 Rehabilitation versus control, Outcome 16 Functional Independence Measure (by baseline FIM score).
Figuras y tablas -
Analysis 1.16

Comparison 1 Rehabilitation versus control, Outcome 16 Functional Independence Measure (by baseline FIM score).

Comparison 1 Rehabilitation versus control, Outcome 17 Functional Independence Measure (by age).
Figuras y tablas -
Analysis 1.17

Comparison 1 Rehabilitation versus control, Outcome 17 Functional Independence Measure (by age).

Comparison 1 Rehabilitation versus control, Outcome 18 Functional Independence Measure (by gender).
Figuras y tablas -
Analysis 1.18

Comparison 1 Rehabilitation versus control, Outcome 18 Functional Independence Measure (by gender).

Comparison 1 Rehabilitation versus control, Outcome 19 Rivermead Mobility Index (by risk of bias).
Figuras y tablas -
Analysis 1.19

Comparison 1 Rehabilitation versus control, Outcome 19 Rivermead Mobility Index (by risk of bias).

Comparison 1 Rehabilitation versus control, Outcome 20 Rivermead Mobility Index (by duration of intervention).
Figuras y tablas -
Analysis 1.20

Comparison 1 Rehabilitation versus control, Outcome 20 Rivermead Mobility Index (by duration of intervention).

Comparison 1 Rehabilitation versus control, Outcome 21 Rivermead Mobility Index (by mode of delivery).
Figuras y tablas -
Analysis 1.21

Comparison 1 Rehabilitation versus control, Outcome 21 Rivermead Mobility Index (by mode of delivery).

Comparison 1 Rehabilitation versus control, Outcome 22 Rivermead Mobility Index (by baseline RMI score).
Figuras y tablas -
Analysis 1.22

Comparison 1 Rehabilitation versus control, Outcome 22 Rivermead Mobility Index (by baseline RMI score).

Comparison 1 Rehabilitation versus control, Outcome 23 Rivermead Mobility Index (by age).
Figuras y tablas -
Analysis 1.23

Comparison 1 Rehabilitation versus control, Outcome 23 Rivermead Mobility Index (by age).

Comparison 1 Rehabilitation versus control, Outcome 24 Rivermead Mobility Index (by gender).
Figuras y tablas -
Analysis 1.24

Comparison 1 Rehabilitation versus control, Outcome 24 Rivermead Mobility Index (by gender).

Comparison 1 Rehabilitation versus control, Outcome 25 TUG Test (by risk of bias).
Figuras y tablas -
Analysis 1.25

Comparison 1 Rehabilitation versus control, Outcome 25 TUG Test (by risk of bias).

Comparison 1 Rehabilitation versus control, Outcome 26 TUG Test (by duration of intervention).
Figuras y tablas -
Analysis 1.26

Comparison 1 Rehabilitation versus control, Outcome 26 TUG Test (by duration of intervention).

Comparison 1 Rehabilitation versus control, Outcome 27 TUG Test (by mode of delivery).
Figuras y tablas -
Analysis 1.27

Comparison 1 Rehabilitation versus control, Outcome 27 TUG Test (by mode of delivery).

Comparison 1 Rehabilitation versus control, Outcome 28 TUG Test (by baseline TUG score).
Figuras y tablas -
Analysis 1.28

Comparison 1 Rehabilitation versus control, Outcome 28 TUG Test (by baseline TUG score).

Comparison 1 Rehabilitation versus control, Outcome 29 TUG Test (by age).
Figuras y tablas -
Analysis 1.29

Comparison 1 Rehabilitation versus control, Outcome 29 TUG Test (by age).

Comparison 1 Rehabilitation versus control, Outcome 30 TUG Test (by gender).
Figuras y tablas -
Analysis 1.30

Comparison 1 Rehabilitation versus control, Outcome 30 TUG Test (by gender).

Comparison 1 Rehabilitation versus control, Outcome 31 Walking speed (by risk of bias).
Figuras y tablas -
Analysis 1.31

Comparison 1 Rehabilitation versus control, Outcome 31 Walking speed (by risk of bias).

Comparison 1 Rehabilitation versus control, Outcome 32 Walking speed (by duration of intervention).
Figuras y tablas -
Analysis 1.32

Comparison 1 Rehabilitation versus control, Outcome 32 Walking speed (by duration of intervention).

Comparison 1 Rehabilitation versus control, Outcome 33 Walking speed (by mode of delivery).
Figuras y tablas -
Analysis 1.33

Comparison 1 Rehabilitation versus control, Outcome 33 Walking speed (by mode of delivery).

Comparison 1 Rehabilitation versus control, Outcome 34 Walking speed (by baseline walking speed).
Figuras y tablas -
Analysis 1.34

Comparison 1 Rehabilitation versus control, Outcome 34 Walking speed (by baseline walking speed).

Comparison 1 Rehabilitation versus control, Outcome 35 Walking speed (by age).
Figuras y tablas -
Analysis 1.35

Comparison 1 Rehabilitation versus control, Outcome 35 Walking speed (by age).

Comparison 1 Rehabilitation versus control, Outcome 36 Walking speed (by gender).
Figuras y tablas -
Analysis 1.36

Comparison 1 Rehabilitation versus control, Outcome 36 Walking speed (by gender).

Comparison 1 Rehabilitation versus control, Outcome 37 Walking speed (by distance walked).
Figuras y tablas -
Analysis 1.37

Comparison 1 Rehabilitation versus control, Outcome 37 Walking speed (by distance walked).

Comparison 1 Rehabilitation versus control, Outcome 38 Death (by risk of bias).
Figuras y tablas -
Analysis 1.38

Comparison 1 Rehabilitation versus control, Outcome 38 Death (by risk of bias).

Comparison 1 Rehabilitation versus control, Outcome 39 Death (by duration of intervention).
Figuras y tablas -
Analysis 1.39

Comparison 1 Rehabilitation versus control, Outcome 39 Death (by duration of intervention).

Comparison 1 Rehabilitation versus control, Outcome 40 Death (by mode of delivery).
Figuras y tablas -
Analysis 1.40

Comparison 1 Rehabilitation versus control, Outcome 40 Death (by mode of delivery).

Comparison 1 Rehabilitation versus control, Outcome 41 Death (by age).
Figuras y tablas -
Analysis 1.41

Comparison 1 Rehabilitation versus control, Outcome 41 Death (by age).

Comparison 1 Rehabilitation versus control, Outcome 42 Death (by gender).
Figuras y tablas -
Analysis 1.42

Comparison 1 Rehabilitation versus control, Outcome 42 Death (by gender).

Comparison 1 Rehabilitation versus control, Outcome 43 Sensitivity analysis: Barthel Index (fixed‐effect).
Figuras y tablas -
Analysis 1.43

Comparison 1 Rehabilitation versus control, Outcome 43 Sensitivity analysis: Barthel Index (fixed‐effect).

Comparison 1 Rehabilitation versus control, Outcome 44 Sensitivity analysis: Barthel Index (cluster trials).
Figuras y tablas -
Analysis 1.44

Comparison 1 Rehabilitation versus control, Outcome 44 Sensitivity analysis: Barthel Index (cluster trials).

Comparison 1 Rehabilitation versus control, Outcome 45 Sensitivity analysis: Functional Independence Measure (fixed‐effect).
Figuras y tablas -
Analysis 1.45

Comparison 1 Rehabilitation versus control, Outcome 45 Sensitivity analysis: Functional Independence Measure (fixed‐effect).

Comparison 1 Rehabilitation versus control, Outcome 46 Sensitivity analysis: Rivermead Mobility Index (fixed‐effect).
Figuras y tablas -
Analysis 1.46

Comparison 1 Rehabilitation versus control, Outcome 46 Sensitivity analysis: Rivermead Mobility Index (fixed‐effect).

Comparison 1 Rehabilitation versus control, Outcome 47 Sensitivity analysis: TUG Test (fixed‐effect).
Figuras y tablas -
Analysis 1.47

Comparison 1 Rehabilitation versus control, Outcome 47 Sensitivity analysis: TUG Test (fixed‐effect).

Comparison 1 Rehabilitation versus control, Outcome 48 Sensitivity anlaysis: TUG Test (cluster trials).
Figuras y tablas -
Analysis 1.48

Comparison 1 Rehabilitation versus control, Outcome 48 Sensitivity anlaysis: TUG Test (cluster trials).

Comparison 1 Rehabilitation versus control, Outcome 49 Sensitivity analysis: TUG Test (re‐including Christofoletti 2008).
Figuras y tablas -
Analysis 1.49

Comparison 1 Rehabilitation versus control, Outcome 49 Sensitivity analysis: TUG Test (re‐including Christofoletti 2008).

Comparison 1 Rehabilitation versus control, Outcome 50 Sensitivity analysis: Walking speed (fixed‐effect).
Figuras y tablas -
Analysis 1.50

Comparison 1 Rehabilitation versus control, Outcome 50 Sensitivity analysis: Walking speed (fixed‐effect).

Comparison 1 Rehabilitation versus control, Outcome 51 Sensitivity analysis: Walking speed (cluster trials).
Figuras y tablas -
Analysis 1.51

Comparison 1 Rehabilitation versus control, Outcome 51 Sensitivity analysis: Walking speed (cluster trials).

Comparison 1 Rehabilitation versus control, Outcome 52 Sensitivity analysis: Death (random‐effects: odds ratio).
Figuras y tablas -
Analysis 1.52

Comparison 1 Rehabilitation versus control, Outcome 52 Sensitivity analysis: Death (random‐effects: odds ratio).

Comparison 1 Rehabilitation versus control, Outcome 53 Sensitivity analysis: Death (random‐effects: risk difference).
Figuras y tablas -
Analysis 1.53

Comparison 1 Rehabilitation versus control, Outcome 53 Sensitivity analysis: Death (random‐effects: risk difference).

Comparison 1 Rehabilitation versus control, Outcome 54 Sensitivity analysis: Death (fixed‐effect).
Figuras y tablas -
Analysis 1.54

Comparison 1 Rehabilitation versus control, Outcome 54 Sensitivity analysis: Death (fixed‐effect).

Comparison 1 Rehabilitation versus control, Outcome 55 Sensitivity analysis: Death (fixed‐effect: Peto odds ratio).
Figuras y tablas -
Analysis 1.55

Comparison 1 Rehabilitation versus control, Outcome 55 Sensitivity analysis: Death (fixed‐effect: Peto odds ratio).

Comparison 1 Rehabilitation versus control, Outcome 56 Sensitivity analysis: Death (cluster trials).
Figuras y tablas -
Analysis 1.56

Comparison 1 Rehabilitation versus control, Outcome 56 Sensitivity analysis: Death (cluster trials).

Comparison 1 Rehabilitation versus control, Outcome 57 Sensitivity analysis: Death (including Brittle 2009).
Figuras y tablas -
Analysis 1.57

Comparison 1 Rehabilitation versus control, Outcome 57 Sensitivity analysis: Death (including Brittle 2009).

Comparison 2 Rehabilitation (experimental) versus rehabilitation (control), Outcome 1 TUG Test.
Figuras y tablas -
Analysis 2.1

Comparison 2 Rehabilitation (experimental) versus rehabilitation (control), Outcome 1 TUG Test.

Comparison 2 Rehabilitation (experimental) versus rehabilitation (control), Outcome 2 Death.
Figuras y tablas -
Analysis 2.2

Comparison 2 Rehabilitation (experimental) versus rehabilitation (control), Outcome 2 Death.

Comparison 2 Rehabilitation (experimental) versus rehabilitation (control), Outcome 3 Sensitivity analysis: TUG Test (fixed‐effect).
Figuras y tablas -
Analysis 2.3

Comparison 2 Rehabilitation (experimental) versus rehabilitation (control), Outcome 3 Sensitivity analysis: TUG Test (fixed‐effect).

Comparison 1. Rehabilitation versus control

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Barthel Index Show forest plot

7

857

Mean Difference (Random, 95% CI)

6.38 [1.63, 11.12]

2 Functional Independence Measure (FIM) Show forest plot

4

303

Mean Difference (Random, 95% CI)

4.98 [‐1.55, 11.51]

3 Rivermead Mobility Index (RMI) Show forest plot

3

323

Mean Difference (Random, 95% CI)

0.69 [0.04, 1.33]

4 Timed Up and Go (TUG) Test Show forest plot

7

885

Mean Difference (Random, 95% CI)

‐4.59 [‐9.19, 0.01]

5 Walking speed Show forest plot

9

590

Mean Difference (Random, 95% CI)

0.03 [‐0.01, 0.07]

6 Death Show forest plot

25

3721

Risk Ratio (M‐H, Random, 95% CI)

0.95 [0.80, 1.13]

7 Barthel Index (by risk of bias) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

7.1 lower risk of bias

2

275

Mean Difference (Random, 95% CI)

3.38 [‐2.10, 8.86]

7.2 higher risk of bias

5

582

Mean Difference (Random, 95% CI)

8.25 [1.15, 15.34]

8 Barthel Index (by duration of intervention) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

8.1 shorter (< 3 months intervention)

2

46

Mean Difference (Random, 95% CI)

17.55 [6.97, 28.13]

8.2 longer (3+ months intervention)

5

811

Mean Difference (Random, 95% CI)

3.08 [‐0.03, 6.19]

9 Barthel Index (by mode of delivery) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

9.1 group

4

256

Mean Difference (Random, 95% CI)

10.99 [1.51, 20.48]

9.2 individual

2

275

Mean Difference (Random, 95% CI)

3.38 [‐2.10, 8.86]

9.3 not reported

1

326

Mean Difference (Random, 95% CI)

2.19 [‐4.35, 8.73]

10 Barthel Index (by baseline Barthel Index score) Show forest plot

6

Mean Difference (Random, 95% CI)

Subtotals only

10.1 better (baseline Barthel Index score > median)

3

511

Mean Difference (Random, 95% CI)

7.94 [‐1.77, 17.64]

10.2 worse (baseline Barthel Index score < median)

3

305

Mean Difference (Random, 95% CI)

3.97 [‐0.83, 8.78]

11 Barthel Index (by age) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

11.1 younger (mean age < 85 years)

4

552

Mean Difference (Random, 95% CI)

8.02 [‐0.25, 16.30]

11.2 older (mean age 85+ years)

3

305

Mean Difference (Random, 95% CI)

3.97 [‐0.83, 8.78]

12 Barthel Index (by gender) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

12.1 < 80% female

4

402

Mean Difference (Random, 95% CI)

7.93 [0.18, 15.69]

12.2 80%+ female

3

455

Mean Difference (Random, 95% CI)

4.29 [‐1.25, 9.83]

13 Functional Independence Measure (by risk of bias) Show forest plot

4

Mean Difference (Random, 95% CI)

Subtotals only

13.1 lower risk of bias

0

0

Mean Difference (Random, 95% CI)

0.0 [0.0, 0.0]

13.2 higher risk of bias

4

303

Mean Difference (Random, 95% CI)

4.98 [‐1.55, 11.51]

14 Functional Independence Measure (by duration of intervention) Show forest plot

4

Mean Difference (Random, 95% CI)

Subtotals only

14.1 shorter (< 3 months intervention)

1

30

Mean Difference (Random, 95% CI)

2.0 [‐10.26, 14.26]

14.2 longer (3+ months intervention)

3

273

Mean Difference (Random, 95% CI)

5.85 [‐2.22, 13.93]

15 Functional Independence Measure (by mode of delivery) Show forest plot

4

Mean Difference (Random, 95% CI)

Subtotals only

15.1 group

3

240

Mean Difference (Random, 95% CI)

3.90 [‐3.08, 10.88]

15.2 individual

1

63

Mean Difference (Random, 95% CI)

11.76 [‐2.66, 26.18]

16 Functional Independence Measure (by baseline FIM score) Show forest plot

3

Mean Difference (Random, 95% CI)

Subtotals only

16.1 better (baseline FIM score > median)

2

95

Mean Difference (Random, 95% CI)

7.77 [1.39, 14.14]

16.2 worse (baseline FIM score < median)

1

145

Mean Difference (Random, 95% CI)

0.3 [‐1.73, 2.33]

17 Functional Independence Measure (by age) Show forest plot

4

Mean Difference (Random, 95% CI)

Subtotals only

17.1 younger (mean age < 85 years)

2

128

Mean Difference (Random, 95% CI)

9.91 [4.41, 15.42]

17.2 older (mean age 85+ years)

2

175

Mean Difference (Random, 95% CI)

0.35 [‐1.65, 2.34]

18 Functional Independence Measure (by gender) Show forest plot

4

Mean Difference (Random, 95% CI)

Subtotals only

18.1 < 80% female

2

93

Mean Difference (Random, 95% CI)

6.11 [‐3.33, 15.55]

18.2 80%+ female

2

210

Mean Difference (Random, 95% CI)

4.51 [‐4.56, 13.58]

19 Rivermead Mobility Index (by risk of bias) Show forest plot

3

Mean Difference (Random, 95% CI)

Subtotals only

19.1 lower risk of bias

3

323

Mean Difference (Random, 95% CI)

0.69 [0.04, 1.33]

19.2 higher risk of bias

0

0

Mean Difference (Random, 95% CI)

0.0 [0.0, 0.0]

20 Rivermead Mobility Index (by duration of intervention) Show forest plot

3

Mean Difference (Random, 95% CI)

Subtotals only

20.1 shorter (< 3 months intervention)

1

49

Mean Difference (Random, 95% CI)

0.6 [‐1.48, 2.68]

20.2 longer (3+ months intervention)

2

274

Mean Difference (Random, 95% CI)

0.69 [0.02, 1.37]

21 Rivermead Mobility Index (by mode of delivery) Show forest plot

3

Mean Difference (Random, 95% CI)

Subtotals only

21.1 group

1

49

Mean Difference (Random, 95% CI)

0.6 [‐1.48, 2.68]

21.2 individual

2

274

Mean Difference (Random, 95% CI)

0.69 [0.02, 1.37]

22 Rivermead Mobility Index (by baseline RMI score) Show forest plot

3

Mean Difference (Random, 95% CI)

Subtotals only

22.1 better (baseline RMI score > median)

2

235

Mean Difference (Random, 95% CI)

0.70 [0.01, 1.39]

22.2 worse (baseline RMI score < median)

1

88

Mean Difference (Random, 95% CI)

0.6 [‐1.17, 2.37]

23 Rivermead Mobility Index (by age) Show forest plot

3

Mean Difference (Random, 95% CI)

Subtotals only

23.1 younger (mean age < 85 years)

1

49

Mean Difference (Random, 95% CI)

0.6 [‐1.48, 2.68]

23.2 older (mean age 85+ years)

2

274

Mean Difference (Random, 95% CI)

0.69 [0.02, 1.37]

24 Rivermead Mobility Index (by gender) Show forest plot

3

Mean Difference (Random, 95% CI)

Subtotals only

24.1 < 80% female

2

235

Mean Difference (Random, 95% CI)

0.70 [0.01, 1.39]

24.2 80%+ female

1

88

Mean Difference (Random, 95% CI)

0.6 [‐1.17, 2.37]

25 TUG Test (by risk of bias) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

25.1 lower risk of bias

1

556

Mean Difference (Random, 95% CI)

0.6 [‐5.36, 6.56]

25.2 higher risk of bias

6

329

Mean Difference (Random, 95% CI)

‐5.92 [‐11.29, ‐0.54]

26 TUG Test (by duration of intervention) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

26.1 shorter (< 6 months intervention)

4

185

Mean Difference (Random, 95% CI)

‐7.34 [‐13.93, ‐0.75]

26.2 longer (6+ months intervention)

3

700

Mean Difference (Random, 95% CI)

0.13 [‐4.28, 4.53]

27 TUG Test (by mode of delivery) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

27.1 group

4

154

Mean Difference (Random, 95% CI)

‐4.98 [‐10.74, 0.77]

27.2 individual

3

731

Mean Difference (Random, 95% CI)

‐4.56 [‐14.02, 4.90]

28 TUG Test (by baseline TUG score) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

28.1 better (baseline TUG score < median)

4

185

Mean Difference (Random, 95% CI)

‐7.34 [‐13.93, ‐0.75]

28.2 worse (baseline TUG score > median)

3

700

Mean Difference (Random, 95% CI)

0.13 [‐4.28, 4.53]

29 TUG Test (by age) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

29.1 younger (mean age < 85 years)

5

741

Mean Difference (Random, 95% CI)

‐5.39 [‐10.77, ‐0.00]

29.2 older (mean age 85+ years)

2

144

Mean Difference (Random, 95% CI)

‐5.40 [‐25.75, 14.96]

30 TUG Test (by gender) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

30.1 < 80% female

3

594

Mean Difference (Random, 95% CI)

0.17 [‐3.90, 4.24]

30.2 80%+ female

4

291

Mean Difference (Random, 95% CI)

‐7.55 [‐14.28, ‐0.82]

31 Walking speed (by risk of bias) Show forest plot

9

Mean Difference (Random, 95% CI)

Subtotals only

31.1 lower risk of bias

1

75

Mean Difference (Random, 95% CI)

‐0.10 [‐0.21, 0.01]

31.2 higher risk of bias

8

515

Mean Difference (Random, 95% CI)

0.04 [0.01, 0.07]

32 Walking speed (by duration of intervention) Show forest plot

9

Mean Difference (Random, 95% CI)

Subtotals only

32.1 shorter (< 3 months intervention)

3

59

Mean Difference (Random, 95% CI)

0.24 [‐0.74, 1.22]

32.2 longer (3+ months intervention)

6

531

Mean Difference (Random, 95% CI)

0.02 [‐0.03, 0.08]

33 Walking speed (by mode of delivery) Show forest plot

9

Mean Difference (Random, 95% CI)

Subtotals only

33.1 group

7

475

Mean Difference (Random, 95% CI)

0.03 [‐0.02, 0.07]

33.2 individual

1

48

Mean Difference (Random, 95% CI)

0.26 [‐0.32, 0.83]

33.3 not reported

1

67

Mean Difference (Random, 95% CI)

‐0.03 [‐0.19, 0.13]

34 Walking speed (by baseline walking speed) Show forest plot

9

Mean Difference (Random, 95% CI)

Subtotals only

34.1 better (baseline walking speed > median)

5

198

Mean Difference (Random, 95% CI)

‐0.00 [‐0.15, 0.14]

34.2 worse (baseline walking speed < median)

4

392

Mean Difference (Random, 95% CI)

0.04 [0.01, 0.07]

35 Walking speed (by age) Show forest plot

9

Mean Difference (Random, 95% CI)

Subtotals only

35.1 younger (mean age < 85 years)

9

590

Mean Difference (Random, 95% CI)

0.03 [‐0.01, 0.07]

35.2 older (mean age 85+ years)

0

0

Mean Difference (Random, 95% CI)

0.0 [0.0, 0.0]

36 Walking speed (by gender) Show forest plot

9

Mean Difference (Random, 95% CI)

Subtotals only

36.1 < 80% female

5

437

Mean Difference (Random, 95% CI)

0.01 [‐0.04, 0.07]

36.2 80%+ female

4

153

Mean Difference (Random, 95% CI)

0.13 [‐0.02, 0.28]

37 Walking speed (by distance walked) Show forest plot

9

Mean Difference (Random, 95% CI)

Subtotals only

37.1 less far (< 6 metres)

2

185

Mean Difference (Random, 95% CI)

0.04 [0.01, 0.07]

37.2 further (6+ metres)

7

405

Mean Difference (Random, 95% CI)

0.01 [‐0.06, 0.09]

38 Death (by risk of bias) Show forest plot

25

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

38.1 lower risk of bias

6

1366

Risk Ratio (M‐H, Random, 95% CI)

1.05 [0.76, 1.46]

38.2 higher risk of bias

19

2355

Risk Ratio (M‐H, Random, 95% CI)

0.88 [0.71, 1.10]

39 Death (by duration of intervention) Show forest plot

25

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

39.1 shorter intervention (< 3 months)

10

663

Risk Ratio (M‐H, Random, 95% CI)

0.64 [0.18, 2.29]

39.2 longer intervention (3+ months)

15

3058

Risk Ratio (M‐H, Random, 95% CI)

0.95 [0.80, 1.14]

40 Death (by mode of delivery) Show forest plot

25

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

40.1 group

12

1007

Risk Ratio (M‐H, Random, 95% CI)

0.82 [0.46, 1.49]

40.2 individual

9

2172

Risk Ratio (M‐H, Random, 95% CI)

0.91 [0.70, 1.19]

40.3 group and individual

1

24

Risk Ratio (M‐H, Random, 95% CI)

5.0 [0.27, 94.34]

40.4 not reported

3

518

Risk Ratio (M‐H, Random, 95% CI)

1.00 [0.73, 1.36]

41 Death (by age) Show forest plot

25

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

41.1 younger (mean age < 85 years)

16

3001

Risk Ratio (M‐H, Random, 95% CI)

0.97 [0.81, 1.17]

41.2 older (mean age 85+ years)

9

720

Risk Ratio (M‐H, Random, 95% CI)

0.79 [0.49, 1.27]

42 Death (by gender) Show forest plot

25

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

42.1 < 80% female

12

2366

Risk Ratio (M‐H, Random, 95% CI)

0.98 [0.77, 1.25]

42.2 80%+ female

12

1340

Risk Ratio (M‐H, Random, 95% CI)

0.91 [0.71, 1.18]

42.3 not reported

1

15

Risk Ratio (M‐H, Random, 95% CI)

0.88 [0.16, 4.68]

43 Sensitivity analysis: Barthel Index (fixed‐effect) Show forest plot

7

857

Mean Difference (Fixed, 95% CI)

4.54 [1.59, 7.49]

44 Sensitivity analysis: Barthel Index (cluster trials) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

44.1 cluster (adjusted)

5

811

Mean Difference (Random, 95% CI)

3.08 [‐0.03, 6.19]

44.2 individual

2

46

Mean Difference (Random, 95% CI)

17.55 [6.97, 28.13]

45 Sensitivity analysis: Functional Independence Measure (fixed‐effect) Show forest plot

4

303

Mean Difference (Fixed, 95% CI)

1.46 [‐0.42, 3.34]

46 Sensitivity analysis: Rivermead Mobility Index (fixed‐effect) Show forest plot

3

323

Mean Difference (Fixed, 95% CI)

0.69 [0.04, 1.33]

47 Sensitivity analysis: TUG Test (fixed‐effect) Show forest plot

7

885

Mean Difference (Fixed, 95% CI)

‐3.66 [‐5.86, ‐1.45]

48 Sensitivity anlaysis: TUG Test (cluster trials) Show forest plot

7

Mean Difference (Random, 95% CI)

Subtotals only

48.1 cluster (adjusted)

2

Mean Difference (Random, 95% CI)

0.51 [‐3.93, 4.95]

48.2 individual

5

Mean Difference (Random, 95% CI)

‐7.85 [‐14.34, ‐1.37]

49 Sensitivity analysis: TUG Test (re‐including Christofoletti 2008) Show forest plot

8

914

Mean Difference (Random, 95% CI)

‐8.41 [‐15.53, ‐1.29]

50 Sensitivity analysis: Walking speed (fixed‐effect) Show forest plot

9

590

Mean Difference (Fixed, 95% CI)

0.03 [0.00, 0.06]

51 Sensitivity analysis: Walking speed (cluster trials) Show forest plot

9

Mean Difference (Random, 95% CI)

Subtotals only

51.1 cluster (unadjusted)

1

Mean Difference (Random, 95% CI)

0.04 [0.01, 0.07]

51.2 individual

8

Mean Difference (Random, 95% CI)

0.01 [‐0.05, 0.08]

52 Sensitivity analysis: Death (random‐effects: odds ratio) Show forest plot

25

3721

Odds Ratio (M‐H, Random, 95% CI)

0.93 [0.75, 1.15]

53 Sensitivity analysis: Death (random‐effects: risk difference) Show forest plot

25

3721

Risk Difference (M‐H, Random, 95% CI)

‐0.01 [‐0.02, 0.01]

54 Sensitivity analysis: Death (fixed‐effect) Show forest plot

25

3721

Risk Ratio (M‐H, Random, 95% CI)

0.95 [0.80, 1.13]

55 Sensitivity analysis: Death (fixed‐effect: Peto odds ratio) Show forest plot

25

3721

Peto Odds Ratio (Peto, Fixed, 95% CI)

0.93 [0.75, 1.14]

56 Sensitivity analysis: Death (cluster trials) Show forest plot

25

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

56.1 cluster (unadjusted)

13

2644

Risk Ratio (M‐H, Random, 95% CI)

0.95 [0.79, 1.15]

56.2 individual

12

1077

Risk Ratio (M‐H, Random, 95% CI)

0.93 [0.60, 1.44]

57 Sensitivity analysis: Death (including Brittle 2009) Show forest plot

26

3777

Risk Ratio (M‐H, Random, 95% CI)

0.94 [0.79, 1.11]

Figuras y tablas -
Comparison 1. Rehabilitation versus control
Comparison 2. Rehabilitation (experimental) versus rehabilitation (control)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 TUG Test Show forest plot

2

57

Mean Difference (Random, 95% CI)

‐7.95 [‐19.22, 3.31]

2 Death Show forest plot

4

118

Risk Ratio (M‐H, Random, 95% CI)

2.67 [0.12, 60.93]

3 Sensitivity analysis: TUG Test (fixed‐effect) Show forest plot

2

57

Mean Difference (Fixed, 95% CI)

‐7.19 [‐10.92, ‐3.46]

Figuras y tablas -
Comparison 2. Rehabilitation (experimental) versus rehabilitation (control)