Saad Shakeel, MPH1, Ian Newhouse, PhD2, Ali Malik, MSc3, George Heckman, MD, MSc, FRCPC4
1Department of Surgery, Saint Joseph’s Healthcare, Hamilton, ON;
2School of Kinesiology, Lakehead University, Thunder Bay, ON;
3Research Institute for Aging and School of Public Health and Health Systems, University of Waterloo, Waterloo, ON;
4Schlegel-UW Research Institute for Aging and School of Public Health and Health Systems, University of Waterloo, Waterloo, ONDOI: http://dx.doi.org/10.5770/cgj.18.158
Background
Structured exercise programs for frail institutionalized seniors have shown improvement in physical, functional, and psychological health of this population. However, the ‘feasibility’ of implementation of such programs in real settings is seldom discussed. The purpose of this systematic review was to gauge feasibility of exercise and falls prevention programs from the perspective of long-term care homes in Ontario, given the recent changes in funding for publically funded physiotherapy services.
Method
Six electronic databases were searched by two independent researchers for randomized controlled trials that targeted long-term care residents and included exercise as an independent component of the intervention.
Results
A total of 39 studies were included in this review. A majority of these interventions were led by physiotherapist(s), carried out three times per week for 30–45 minutes per session. However, a few group-based interventions that were led by long-term care staff, volunteers, or trained non-exercise specialists were identified that also required minimal equipment.
Conclusion
This systematic review has identified ‘feasible’ physical activity and falls prevention programs that required minimal investment in staff and equipment, and demonstrated positive outcomes. Implementation of such programs represents cost-effective means of providing long-term care residents with meaningful gains in physical, psychological, and social health.
Key words: exercise, long-term care homes, physical activity, falls prevention, feasibility
Many Canadian seniors ultimately experience difficulty living independently. Long-term care homes (LTCH) are designed to provide 24-hour nursing care for individuals unable to independently undertake activities of daily living.(1) Most LTCH residents in Canada are elderly. In 2002, 34% of Canadians aged 85 years or older resided in LTCH.(2) Long-term care residents are generally frail, de-conditioned, have multiple co-morbidities, and are at risk of poorer physical function and a higher risk of falls.(3,4,5)
Compelling evidence suggests that engagement in physical activity can be effective in preventing or slowing health decline and maintaining functionamong this population. Studies have shown that physical activity interventions can not only restore and/or maintain functional independence in older population,(6) they may also prevent or delay the frailty process as well.(7) A systematic review conducted by Theou et al.(8) demonstrated that the benefits of physical activity in frail seniors include improved body composition, improved dietary intake, improved muscle function, improved upper and lower body flexibility, and reduced depression. A recent Cochrane review concluded that the physical rehabilitation treatments can be effective in improving the functional levels of people in LTCH.(9) Overall, the accumulated evidence shows that the beneficial effects of physical activity programs tailored specifically towards LTCH residents include: falls prevention,(10,11) improved muscular strength and function,(12,13,14) better sleep and awake patterns,(15,16) and reduced periods of agitation.(17) Additional benefits of such programs may extend to lower costs related to hospitalization and pharmaceuticals, and costs associated with extended staff time due to assistance required with activities of daily living.(8)
Health-care in Canada is a provincial responsibility. Therefore, there are multiple provincial and territorial jurisdictions within Canada, each constituting a different health-care funding system. In Ontario, LTCH are required to have falls prevention and management programs in accordance with section 49 of O.Reg 79/10 under the Long-Term Care Homes Act, 2007.(18) The individual Licensees are required to optimally utilize resources and to meet residents’ care needs, including organization of falls prevention and management program(s). However, the Ontario government recently changed the funding system for physiotherapy services for seniors.(19) Physiotherapy services will be restricted to one-on-one treatment prescribed according to the treatment plan based on need. These services will not include exercise and falls prevention exercise programs led by physiotherapists. Under this new agreement, $10 million will be allocated each year for exercise and falls prevention classes three times a week for all long-term care residents.
Under this new funding system, there is an increased need to identify effective and efficient exercise programs for LTCH in Ontario. The following criteria for feasibility of implementation of an exercise and falls prevention program in LTCH were established based on a thorough review of the literature: a) demonstrated positive outcomes, b) minimal investment in equipment and staff, c) implementable within existing LTCH infrastructure, d) carried out three times per week, for 30–45 minutes per session, and e) group-based exercise regimen.(8,12,20–24,25,26–28) The programs carried out three times per week are not only favoured by the new legislation, but are also deemed more effective in improving outcomes in LTCH population by previous literature reviews.(8,12) In addition, Theou and colleagues(8) suggested that shorter duration sessions, lasting 30–40 minutes, might be more suitable for LTCH population to gain optimal benefits while minimizing the risk of adverse consequences. While high-intensity, one-on-one strength training interventions using sophisticated equipment have been shown to be effective, group-based programs using low-cost equipment and facility staff are considered more feasible and cost-effective for LTCH.(20,21) Relatively low-cost equipment includes cuff weights, elastic resistance bands (Therabands®), soft weights, and sand balls. In addition to being relatively inexpensive and portable, such equipment also requires less supervision and assistance, and has been shown to have beneficial impacts on LTCH population.(20,22–24) The purpose of this systematic review is to critically evaluate published exercise and falls prevention programs for LTCH with respect to the feasibility of their implementation according to the above criteria specified.
The search criteria for this review were adopted from Theou et al.(8) Medline (OVID; 1990-), Embase (OVID; 1990-), Psycinfo (Scholars Portal; 1990-), Cinahl (OVID & EBSCO; 1990-), Ageline (AARP; 1990-), and Allied and Complementary Medicine (OVID; 1990-) were searched up to March 31st, 2014 to select relevant publications. The Medline (OVID) search criterion is available upon request.
The articles found through database search were assessed by two independent reviewers based on the following considerations: 1) acknowledged as a randomized controlled trial, 2) full-text published in English, after year 1990, 3) study participants residing in LTCH identified in title, abstract and/or text, and 4) exercise program specified in text as an independent component of the intervention.
The search results were uploaded into citation management software. Two reviewers independently screened the titles and abstracts of articles that were identified from the literature search based on identified inclusion/exclusion criteria. The following information was extracted from the selected studies: participant characteristics (age, sex), recruitment process, program description, length, duration, frequency, staff and equipment required, outcomes, and inclusion criteria used to recruit participants. The reviewers paid particular attention to reporting of cost or any economic analysis (i.e., cost-effectiveness or cost-benefit analysis) in selected studies. Any discrepancies at any stage were resolved by the third reviewer.
Quality assessment was performed using Physiotherapy Evidence database (PEDro) scale designed to assess the quality of randomized control trials focusing on exercise programs. The validity and reliability of this scale is published in the literature.(29) It measures internal validity and interpretability of the trials by assigning 1 point for each of the following criterion met: random allocation; concealment of allocation; comparability of groups at baseline; blinding of patients, therapists and assessors; analysis by intention to treat and adequacy of follow-up; between-group statistical comparisons and reports of both point estimates and measures of variability; and whether or not the trial contains sufficient statistical information to make it interpretable.(30) The scale does not measure external validity of the trial or the size of the treatment effect. The PEDro score is determined by counting the number of checklist criteria that are satisfied in the trial.
Figure 1 depicts the process of screening of identified publications. A total of 1751 studies were identified after removal of duplicates, of which 269 abstracts were screened before full-text assessment. Thirty-nine studies were included after full-text assessment of 69 randomized control trials. All studies were published after 1993 and, except for six,(13,20,22,25,31,32) the majority were published after 2000. Ten of the selected studies were from the United States,(22,31,32,33,34,35,36,37,38,39) 18 from the European countries,(7,17, 21,40,41,42,43–45,46,47–50,51,52,53,54) two each from Japan,(55,56) United Kingdom,(13,25) Turkey,(57,58) and Canada.(20,59) There was one intervention each from Taiwan,(60) Norway,(61) and Brazil.(62) The number of participants who completed the study or were included in the analysis varied from 14(32) to 98,(47) with a total of 4470 participants included in this review. Studies with the same participants but different outcome measures for similar interventions were included.(17,40,44) If an updated version of the intervention was available, the latest version was included.
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FIGURE 1. Flow diagram depicting literature screening process |
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Participants of the majority of studies were older than 60 years, with mean age ranging from 67 years(62) to 92 years.(45) The majority of participants were female. Three studies included only female,(50,55,62) while only one study included only male participants.(32) Most of the studies were designed for long term care sub-population with specific conditions — i.e., those with Alzheimer’s disease,(31,39) dementia,(44) frailty,(13,33,46,49,55,59) mild to substantial cognitive impairment,(46,49) incontinence,(38) de-conditioning,(43,52) at-risk of falls,(58) gait and balance difficulties,(32) or impairment in one or more basic, physical, or personal activity of daily living (ADL).(7,17,22,35,37,40,44,53,54,61,60,)
The pre-determined quality scores from PEDro database were used. The total scores ranged from four to eight (out of ten). Two studies scored eight,(17,33) eight scored seven,(7,13,40,43–45,48,54) 12 scored six,(21,22,31,32,35,38,41,47,51,52,53,58) nine scored five,(20,39,46,49,50,55,57,60,62) and seven scored four.(25,34,36,37,42,59,61) The PEDro rating for one study was not found in the database, hence, the reviewers assigned a consensus rating of six to the study.(56) The studies were not excluded based on their quality score.
A majority of studies included multi-component exercise regimens, usually focusing on a combination of resistance/strength, endurance, range-of-motion, balance, aerobics, walking, flexibility, and jumping. Some interventions focused specifically on resistance,(13,42,45) balance,(50,56) stretching,(62) low-intensity task oriented exercise program,(60) Tai Chi,(43) whole body vibration exercise,(7,51,52,56) or exercise therapy using the Takizawa Program.(55) Two training programs included a variety of multifaceted, non-pharmaceutical components (e.g., staff and resident education on falls prevention, environmental modification, adaptation, balance and resistance training, and use of hip protectors.(47,48) A nutritional component was part of three interventions.(13,17,54) 11 studies compared outcomes of two different exercise interventions with each other, with a control group, or combined both interventions to compare effects with the control group.(20,21,34,37,39,41,42,43,49,57,58) The control groups mostly received usual care, social visits, or non-exercise recreational activities. They comprised of an exercise regimen in five interventions.(7,20,42,51,57) No description of the intervention was provided in one study.(25)
Nine programs were reported as being group bas ed,(20,21,25,32,33,35,46,47,57) while other nine constituted an individualized regimen tailored to the needs or functional deficit of the participants but were performed in a group environment.(17,36,40,41,43,44,48,61,54) Only the supervised program was group-based in one study, while the unsupervised regimen was carried out by individuals in their rooms.(58) Twelve of the interventions were either individually tailored or constituted one-on-one training sessions.(7,13,22,38,39,45,49,50,52,53,56,60) Eight studies had unclear description of whether the programs constituted group-based or an individualized regimen.
The majority of interventions were carried out three times per week.(7,13,20,22,31,32,33,36,42,45,46,48–50,51,52,55,57,58,59,60,61,62) Six interventions took place once to twice a week,(21,25,41,43,47,56) while four interventions occurred five times per week.(35,37,38,39) Four programs constituted of 29 sessions over a three-month period (five sessions per two weeks).(17,40,44,54) The number of sessions varied for three programs based on an individualized plan,(53,61) or because the two intervention groups had different frequencies.(43)
The duration of interventions ranged from four weeks(50,60) to two years.(34) The majority of programs lasted for either 30–45 minutes per session, (13,17,20,22,25,31,37,40,43,44,49,54,57,60) or less than 30 minutes per session.(36,39,50,51,52,56,62) Seven interventions lasted between 45–75 minutes per session.(21,32,33,45,46,47,58) Two interventions in one study lasted for 90 minutes per session, including a 30-minute social component.(41) One intervention started with 20 minutes per session but was extended to an hour by the end of 10 week intervention.(59) Duration was not reported for four interventions,(7,38,42,48) while it varied for the other five.(34,35,53,55,61)
The most commonly studied patient based outcomes in the selected studies included functional fitness, strength, endurance, balance, flexibility, ability to perform activities of daily living (ADL), falls prevention, and alleviation of depression and incontinence symptoms. Exercise interventions, in general, improved a variety of functional, performance, and psychological outcomes in this population (see Appendix Table A.1 for list of major outcomes). Only six interventions showed negative, or non-significant outcomes as compared to the control group.(22,34,39,40,52,54) The studies comparing two different exercise regimes showed positive outcomes in at least one outcome measure for both regimens, except for one study that showed non-significant effects of strength training regimen.(21)
TABLE A.1 Description of interventions
Summarized in Appendix Table A.2.
TABLE A.2 Staff, equipment, and participant-related factors
The staff requirements varied based on the type of exercise program. Sixteen programs were conducted by licensed physiotherapists.(7,17,21,22,25,32,35,44,51,52,53,54,55,56,57,58) Six interventions combined the services of trained exercise specialists (physiotherapists, exercise instructors, occupational therapist) and the facility staff members.(33,34,48,49,53,61) Eleven studies did not identify credentials of (at least one of) the exercise intervention instructors.(32,41,42,43,45,47,49,50,51,59,62) The rest of the interventions were conducted by either a certified therapeutic recreation therapist,(13) a sport scientist/teacher,(46,57) a Tai-Chi instructor,(34,43) long-term care nursing staff,(20,31,38) trained research staff (including nurses),(37) unspecified graduate and undergraduate students,(36) or graduate nurses and physiotherapy students trained by the investigators.(39)
Overall, exercise interventions that were conducted by in situ LTCH staff or non-exercise specialists and showed positive patient-based outcomes were found in the literature.(20,31,33,37,38,55) In one of the interventions conducted by trained non-exercise facility staff and volunteers, a 16-hour training workshop was provided by the study researchers.(20) The trained volunteers were used to conduct balance, flexibility, and walking exercises for both low- and high-mobility residents. A physiotherapist was initially used three hours per week in one program while the staff was being trained.(33) However, the physiotherapist was needed only for periodic consultation when the staff was adequately trained after one to two months. A multi-centre study reported that the physical therapist provided training to the participants in one centre, while nurses and care-workers served as physical exercise instructors in the other centre.(55) The physical therapist only visited the nursing homes once a month to ensure that proper exercise regimen was being followed. No differences in outcomes between the two centres were reported. While the supervised program was carried out by a physiotherapist, the unsupervised program was completed by the residents in their rooms without any supervisions, and showed comparable results.(58) One study used an exercise instructor and trained nurses to train the facility nurses through a 60-minute session on incidence and consequences of falls.(47) The staff, however, participated in the educational component of the intervention only.
Overall, interventions that used inexpensive and simple-to-use equipment and showed gains of comparable magnitude to interventions using relatively expensive and custom designed equipments were identified in the literature. None of these programs required additional infrastructure. Eight studies did not require any additional equipment as they used body weight, or consisted of walking, stretching, and balance exercises.(31,34,36,39,41,43,49,58) Nine studies utilized in-home, inexpensive, and simple-to-use equipment — i.e., cuff weights, elastic bands (Therabands®), non-elastic bands, soft weights, weight belts, exercise balls, sand balls, balance discs.(20,22,33,42,44,46,57,59,62) Relatively inexpensive equipment (e.g., free weights, hand-held weights, ankle weights, dumbbells) was used in three interventions.(38,47,48) Easily transportable and inexpensive equipment was reported to be used by one intervention for functional skills training group, while the equipment for resistance training group (i.e., gym machines) was reported to be expensive.(21) A Japanese study reported use of simple equipment including movable pulley, parallel or stall bars, and specially modified walker.(55) Hip protectors were worn by the participants in three interventions to reduce the risk of injury from falls.(47,48,56) Relatively expensive equipment involved weight machines (hip extension/leg press, seated chest press), treadmill, stationary air dyne or cycle ergometers, upper extremity ergometer, stationary cycle, weight and puller system, UNEX II chair, and recumbent stepper.(13,32,34,35,37,45,60) In addition, vibration platform (power-plate),(7) sinusoidal vibration platform and locometric system,(52) sinusoidal vertical vibration platform,(51) wobble board,(56) and computerized force platform with visual feedback,(50) were examples of more sophisticated equipment.
Overall, even though there were examples of interventions that were designed to be cost-effective or that used simple, inexpensive equipment, and used in-home staff, formal economic evaluations were not identified in the literature. Apart from one study,(22) the operating costs associated with the programs were not reported. Mulrow et al.(22) reported that the cost of a four-month physiotherapy program carried out by six physiotherapists was $1220 US per subject (95% CI: $402–$1832 US) and $189 US per subject ($80–$298 US) for the control group — a friendly visit program. There was no difference in total health-care charges (mean $11398 (US) per person during the four-month intervention) between the nursing home residents in the intervention and the control group. The intervention was reported to be substantially more expensive than the control with only modest improvements in the mobility of the participants. One individualized intervention was reported to require high resources,(50) while another reported to require a drastic change in staff levels to meet the resources required to successfully implement the intervention (i.e., 60 minutes per hour to care for 2–3 residents).(38) A formal cost-benefit analysis was recommended for one intervention given a large investment in staff personnel and equipment required.(35) A study comparing two different exercise programs with a control group concluded that the interventions would not be cost-effective in the institutionalized population with fixed costs for nursing.(43) It was reported that the “cognitive-action” intervention carried out twice per week would be less expensive (total expense less than 200 Euros/year) than the “adapted tai-chi” intervention carried out four times per week, given the comparable benefits.
There were some interventions that were designed to be cost effective and feasible in real-life situations by utilizing a low-frequency exercise regimen, using in-home and inexpensive equipment.(21,33,36,59) The use of inexpensive equipment (Therabands®) in a low-cost program was shown to have gains comparable to those seen in similar studies that used more costly and sophisticated training equipment.(59) Only one of the interventions was designed specifically to make the program less resource intensive by using facility staff and trained volunteers, in addition to using the low-cost equipment.(20)
This systematic review reinforces previous work showing that physical activity interventions have a positive impact on frail older adults residing in LTCH. A full assessment of outcomes and their relative significance in improving the health and quality of life of the residents of LTCH is beyond the scope of this study. The focus of this study was to discuss relative resource utilization of selected interventions to determine their feasibility of implementation in LTCH across Ontario, Canada. A majority of participants were female, aged 65 and over, and suffered from multiple co-morbid conditions. Improved effects on most physical, functional, and psychological outcomes were reported, with high compliance rates, and low risk of adverse events (see Appendix Table A.2). This supports the premise that physical activity is a safe and effective intervention for LTCH population.
The most common exercise interventions for frail older adults included in this systematic review were multi-component exercise programs performed three times per week, with each session lasting 30–45 minutes. The interventions varied based on frequency, duration, type (e.g., balance, strength, endurance), and intensity of exercise(s) performed. Previous studies have reported that this variability in interventions and participant characteristics, the selection criteria, and the assessment and measurement of outcomes limits the ability to conduct meta-analyses.(8,12,63–65) Weening-Dijksterhuis et al.(12) conducted a systematic review to identify criteria for exercise protocols to improve physical fitness, activity of daily living performance, and quality-of-life of frail institutionalized older people. Only interventions showing strong or very strong effect sizes were examined for setting the criteria. They proposed that physical training should comprise of a combination of progressive resistance training, balance training, and functional training, carried out three times per week, for at least 10 weeks.
Most of the studies failed to report cost associated with the interventions. Some programs required special or extra equipment and hence are deemed less feasible than the programs using simple and cheap equipment. Moreover, most of the interventions used trained physiotherapists. This presents with a challenge, since only the prescribed physiotherapy services will be publically funded under the new funding system. Examples of successful interventions run by LTCH staff or non-exercise specialists were identified in this systematic review. Four studies are noteworthy, as they were conducted by LTCH staff (or non-exercise specialists) and met most other criteria for feasibility.(20,31,36,39) Programs meeting three or more of our feasibility criteria are listed in Table 1. The table also includes programs that were conducted by licensed exercise professionals, but were designed in a way that they could easily be conducted by LTCH staff after some training.(33,36) Comparable effects were demonstrated for a program run by physiotherapists in one centre as compared to nursing home staff in the other centre.(55) One program conducted by LTCH nursing staff was excluded, given the high staff levels required to run it.(38) The staff required to lead the sessions was not specified in two interventions, but met most of other feasibility criteria.(41,59) Two programs designed for residents with Alzheimer’s disease were conducted by non-exercise specialists but constituted individualized regimen.(31,39) These programs met most of the specified criteria for feasibility, except they were not conducted in a group-based setting.
TABLE 1. Summary table of potentially feasible interventions
Lazowski et al.(20) specifically designed a low-cost, group-based program in the Ontario context, run by trained in situ staff and volunteers, using simple and inexpensive equipment. The ‘Functional Fitness (FFLTC) program was compared with the status quo (seated Range of Motion (ROM)) program. The FFLTC program consisted of progressive strength, balance, flexibility, and walking exercises. The participants were divided into high- and low-mobility groups, depending on their scores in ‘Timed Up and Go’ test. On average, 10 minutes were spent on stretching exercise for warm up and cool down, 15 minutes on walking, and 10 minutes each on strength and balance exercises for high-mobility residents. The balance exercises were cut short five minutes for low-mobility residents and that time was spent on lower body strengthening exercises. The attendance rate averaged 86% for the FFLTC and 79% for the range of motion classes. Overall, significant improvements in balance, mobility, flexibility, and knee and hip strength were reported for FFLTC in both high- and low-mobility residents. Only shoulder strength improved in ROM group, while hip strength, mobility, and functional ability deteriorated. The study did not exclude participants with mobility challenges, dementia, or incontinence, but emphasized tailoring the intensity levels of exercises based on mobility status of the participants.(20)
Group-based exercise programs have been recommended for LTCH population as they are likely to further enhance the broader effectiveness of such interventions, as compared to the individualized interventions. Participants in these programs stand to gain from not only the physical activity component, but also from the social aspects of the intervention.(66) The feasibility of group-based exercise programs for LTCH population has been increasingly documented in the literature.(20,23,25,26–28) The decision to adopt a group-based exercise regimen is also dependent on the cognitive and ambulatory status of the residents. A class size of up to 10 individuals has been suggested for residents that are non-cognitively impaired, and have retained higher mobility, while smaller class sizes (three to five individuals) are suggested for lower mobility residents.(20) Those with cognitive impairments require close supervision, and a four-to-one participant to instructor ratio is proposed for group-based programs for these residents.(27) Individualized exercise regimens are only recommended for severely de-conditioned and bed-bound residents.(67)
The differences in intervention and patient characteristics, patient selection, measurement of outcomes, and assessment tools make it difficult to compare the outcomes of physical activity programs in LTCH population. A majority of residents were excluded from the interventions given strict inclusion/exclusion criteria, which could bias the study results and reduce generalizability of the findings to overall LTCH population. Moreover, the studies deemed feasible for our purpose had lower methodological quality scores (i.e., lower internal validity and interpretability). Therefore, there is a need for studies with better methodological quality in order to improve validity of study results to assist with evidence-based decision practices.
Overall, this systematic review provides evidence that effective exercise programs for frail LTCH residents can be implemented in jurisdictions with resource constraints, such as Ontario, Canada. With this paper we intended to provide LTCH administrators and program planners with a list of exercise programs that can be adopted to accomplish selected improvements in the health and functional status of the residents. Effective group-based exercise programs can be implemented in LTCH with the use of trained staff members (e.g., nurses, volunteers), using simple and inexpensive equipment and carried out three times per week for 30–45 minutes per session. An exercise specialist could be used to train non-specialized LTCH staff initially, with exercise specialist only needed occasionally to ensure proper techniques were being followed. Further research should focus on assessing the validity of outcomes of interventions identified to be feasible.
The authors declare that no conflicts of interest exist.
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Canadian Geriatrics Journal, Vol. 18, No. 2, June 2015