Identifying Feasible Physical Activity Programs for Long-Term Care Homes in the Ontario Context

Identifying Feasible Physical Activity Programs for Long-Term Care Homes in the Ontario Context

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, ON

DOI: 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

INTRODUCTION

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.(8,12,2024,25,2628) 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.(20,2224) 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.

METHODS

Literature Search

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.

Inclusion/Exclusion Criteria

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.

Data Collection and Assortment

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

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.

RESULTS

Description of Studies

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, 21,40,41,42,4345,46,4750,51,52,53,54) 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.

 


 

FIGURE 1. Flow diagram depicting literature screening process

Patient Characteristics

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,)

Methodological Quality

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,(7,13,40,4345,48,54) 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.

Intervention Characteristics

Type

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)

Group vs. Individual Sessions

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.

Frequency

The majority of interventions were carried out three times per week.(7,13,20,22,31,32,33,36,42,45,46,4850,51,52,55,57,58,59,60,61,62) 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)

Duration

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)

Outcomes Measures

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












 

Resource Utilization

Summarized in Appendix Table A.2.

TABLE A.2 Staff, equipment, and participant-related factors










 

Staff Requirement

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.

Equipment

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.

Cost

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)

DISCUSSION

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.(8,12,6365) 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.(20,23,25,2628) 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)

Limitations

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.

CONCLUSION

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.

CONFLICT OF INTEREST DISCLOSURES

The authors declare that no conflicts of interest exist.

REFERENCES

1. Ribbe MW, Ljunggren G, Steel K, et al. Nursing homes in 10 nations: a comparison between countries and settings. Age Ageing. 1997;26 Suppl 2:3–12.
cross-ref  

2. Pitters S. Long-term care facilities. In: Stephenson M, Sawyer E, editors. Continuing the care: the issues and challenges for long-term care. Ottawa: CHA Press; 2002. p.163–201.

3. Dybicz SB, Thompson S, Molotsky S, et al. Prevalence of diabetes and the burden of comorbid conditions among elderly nursing home residents. Am J Geriatr Pharmacother. 2011;9(4):212–23.
cross-ref  pubmed  

4. Becker C, Loy S, Sander S, et al. An algorithm to screen long-term care residents at risk for accidental falls. Aging Clin Exp Res. 2005;17(3):186–92.
cross-ref  pubmed  

5. Thapa PB, Brockman KG, Gideon P, et al. Injurious falls in nonambulatory nursing home residents: a comparative study of circumstances, incidence, and risk factors. J Am Geriatr Soc. 1996;44(3):273–78.
cross-ref  pubmed  

6. Bruunsgaard H, Bjerregaard E, Schroll M, et al. Muscle strength after resistance training is inversely correlated with baseline levels of soluble tumor necrosis factor receptors in the oldest old. J Am Geriatr Soc. 2004;52(2):237–41.
cross-ref  pubmed  

7. Bautmans I, Van Hees E, Lemper JC, et al. The feasibility of Whole Body Vibration in institutionalised elderly persons and its influence on muscle performance, balance and mobility: a randomised controlled trial. BMC Geriatr. 2005;5:17.
cross-ref  

8. Theou O, Stathokostas L, Roland KP, et al. The effectiveness of exercise interventions for the management of frailty: a systematic review. J Aging Res. 2011;2011:569194.
cross-ref  pubmed  pmc  

9. Crocker T, Forster A, Young J, et al. Physical rehabilitation for older people in long-term care. Cochrane Database Syst Rev. 2013;2:CD004294.
pubmed  

10. Cameron ID, Murray GR, Gillespie LD, et al. Interventions for preventing falls in older people in nursing care facilities and hospitals. Cochrane Database Syst Rev. 2010;(1):CD005465.
pubmed  

11. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012;9:CD007146.
pubmed  

12. Weening-Dijksterhuis E, de Greef MH, Scherder EJ, et al. Frail institutionalized older persons: A comprehensive review on physical exercise, physical fitness, activities of daily living, and quality-of-life. Am J Phys Med Rehabil. 2011;90(2):156–68.
cross-ref  

13. Fiatarone MA, O’Neill EF, Ryan ND, et al. Exercise training and nutritional supplementation for physical frailty in very elderly people. N Engl J Med. 1994;330(25):1769–75.
cross-ref  pubmed  

14. Ouslander JG, Griffiths PC, McConnell E, et al. Functional incidental training: a randomized, controlled, crossover trial in Veterans Affairs nursing homes. J Am Geriatr Soc. 2005;53(7):1091–100.
cross-ref  pubmed  

15. Alessi CA, Martin JL, Webber AP, et al. Randomized, controlled trial of a nonpharmacological intervention to improve abnormal sleep/wake patterns in nursing home residents. J Am Geriatr Soc. 2005;53(5):803–10.
cross-ref  pubmed  

16. Alessi CA, Yoon EJ, Schnelle JF, et al. A randomized trial of a combined physical activity and environmental intervention in nursing home residents: do sleep and agitation improve? J Am Geriatr Soc. 1999;47(7):784–91.
cross-ref  pubmed  

17. Rosendahl E, Lindelöf N, Littbrand H, 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. Aust J Physiother. 2006;52(2):105–13.
cross-ref  pubmed  

18. Long Term Care Homes Act (2010, c.15, s.2 33) [Internet]. Accessed 2011 May; 2014 June. Available from: http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_07l08_e.htm

19. “More Seniors to Benefit from Physiotherapy and Exercise” [News Release] [Internet]. Ontario Ministry of Health and Long-Term Care, 18 Apr. 2013. Accessed 23 Jan. 2014.

20. Lazowski DA, Ecclestone NA, Myers AM, et al. A randomized outcome evaluation of group exercise programs in long-term care institutions. J Gerontol A Biol Sci Med Sci. 1999;54(12):M621–M628.
cross-ref  

21. Chin A Paw MJ, van Poppel MN, Twisk JW, et al. Once a week not enough, twice a week not feasible? A randomised controlled exercise trial in long-term care facilities. Patient Educ Couns. 2006 Oct;63(1–2):205–14.

22. Mulrow CD, Gerety MB, Kanten D, et al. A randomized trial of physical rehabilitation for very frail nursing home residents. JAMA. 1994;271(7):519–24.
cross-ref  pubmed  

23. Binder EF. Implementing a structured exercise program for frail nursing home residents with dementia: issues and challenges. JAPA. 1995 Oct;3:383–95.

24. Connelly DM, Vandervoort AA. Improvement in knee extensor strength of institutionalized elderly women after exercise with ankle weights. Physiother Can. 1995;47(1):15–23.

25. McMurdo ME, Rennie L. A controlled trial of exercise by residents of old people’s homes. Age Ageing. 1993;22(1):11–15.
cross-ref  pubmed  

26. Brill PA, Drimmer AM, Morgan LA, et al. The feasibility of conducting strength and flexibility programs for elderly nursing home residents with dementia. Gerontologist. 1995;35(2):263–66.
cross-ref  pubmed  

27. Cape E. Activity and independence: issues in the implementation of activity programs for institutionalized elders. Can J Aging. 1983;2:(4):85–95.
cross-ref  

28. O’Hagan CM, Smith DM, Pileggi KL. Exercise classes in rest homes: effect on physical function. N Z Med J. 1994;107(971):39–40.

29. Maher CG, Sherrington C, Herbert RD, et al. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83(8):713–21.
pubmed  

30. de Morton NA. The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Aust J Physiother. 2009;55(2):129–33.
cross-ref  pubmed  

31. Tappen RM, Roach KE, Applegate EB, et al. Effect of a combined walking and conversation intervention on functional mobility of nursing home residents with Alzheimer disease. Alzheimer Dis Assoc Disord. 2000;14(4):196–201.
cross-ref  

32. Sauvage LR, Myklebust BM, Crow-pan J, et al. A clinical trial of strengthening and aerobic exercise to improve gait and balance in elderly male nursing home residents. Am J Phys Med Rehabil. 1992;71(6):333–42.
cross-ref  pubmed  

33. Baum EE, Jarjoura D, Polen AE, et al. Effectiveness of a group exercise program in a long-term care facility: a randomized pilot trial. J Am Med Dir Assoc. 2003;4(2):74–80.
cross-ref  pubmed  

34. Nowalk MP, Prendergast JM, Bayles CM, et al. A randomized trial of exercise programs among older individuals living in two long-term care facilities: the FallsFREE program. J Am Geriatr Soc. 2001;49(7):859–65.
cross-ref  pubmed  

35. Meuleman JR, Brechue WF, Kubilis PS, et al. Exercise training in the debilitated aged: strength and functional outcomes. Arch Phys Med Rehabil. 2000;81(3):312–18.
cross-ref  pubmed  

36. Schoenfelder DP, Rubenstein LM. An exercise program to improve fall-related outcomes in elderly nursing home residents. Appl Nurs Res. 2004;17(1):21–31.
cross-ref  pubmed  

37. Lorenz RA, Gooneratne N, Cole CS, et al. Exercise and social activity improve everyday function in long-term care residents. Am J Geriatr Psychiatry. 2012;20(6):468–76.
cross-ref  pubmed  pmc  

38. Schnelle JF, Alessi CA, Simmons SF, et al. Translating clinical research into practice: a randomized controlled trial of exercise and incontinence care with nursing home residents. J Am Geriatr Soc. 2002;50(9):1476–83.
cross-ref  pubmed  

39. Roach KE, Tappen RM, Kirk-Sanchez N, et al. A randomized controlled trial of an activity specific exercise program for individuals with Alzheimer disease in long-term care settings. J Geriatr Phys Ther. 2011;34(2):50–56.
cross-ref  pubmed  pmc  

40. Rosendahl E, Gustafson Y, Nordin E, et al. A randomized controlled trial of fall prevention by a high-intensity functional exercise program for older people living in residential care facilities. Aging Clin Exp Res. 2008;20(1):67–75.
cross-ref  pubmed  

41. Faber MJ, Bosscher RJ, Chin A Paw MJ, et al. Effects of exercise programs on falls and mobility in frail and pre-frail older adults: a multicenter randomized controlled trial. Arch Phys Med Rehabil. 2006;87(7):885–96.
cross-ref  

42. Seynnes O, Fiatarone Singh MA, Hue O, Pras P, et al. Physiological and functional responses to low-moderate versus high-intensity progressive resistance training in frail elders. J Gerontol A Biol Sci Med Sci. 2004;59(5):503–09.
cross-ref  pubmed  

43. Dechamps A, Diolez P, Thiaudière E, et al. Effects of exercise programs to prevent decline in health-related quality of life in highly deconditioned institutionalized elderly persons: a randomized controlled trial. Arch Intern Med. 2010;170(2):162–69.
cross-ref  pubmed  

44. Littbrand H, Lundin-olsson L, Gustafson Y, et al. The effect of a high-intensity functional exercise program on activities of daily living: a randomized controlled trial in residential care facilities. J Am Geriatr Soc. 2009;57(10):1741–49.
cross-ref  pubmed  

45. Serra-Rexach JA, Bustamante-Ara N, Hierro Villarán M, et al. Short-term, light- to moderate-intensity exercise training improves leg muscle strength in the oldest old: a randomized controlled trial. J Am Geriatr Soc. 2011;59(4):594–602.
cross-ref  pubmed  

46. Dorner T, Kranz A, Zettl-Wiedner K, et al. The effect of structured strength and balance training on cognitive function in frail, cognitive impaired elderly long-term care residents. Aging Clin Exp Res. 2007;19(5):400–05.
cross-ref  pubmed  

47. Becker C, Kron M, Lindemann U, et al. Effectiveness of a multifaceted intervention on falls in nursing home residents. J Am Geriatr Soc. 2003;51(3):306–13.
cross-ref  pubmed  

48. Jensen J, Nyberg L, Rosendahl E, et al. Effects of a fall prevention program including exercise on mobility and falls in frail older people living in residential care facilities. Aging Clin Exp Res. 2004;16(4):283–92.
cross-ref  pubmed  

49. Scherder EJ, Van Paasschen J, Deijen JB, et al. Physical activity and executive functions in the elderly with mild cognitive impairment. Aging Ment Health. 2005;9(3):272–80.
cross-ref  pubmed  

50. Sihvonen S, Sipilä S, Taskinen S, et al. Fall incidence in frail older women after individualized visual feedback-based balance training. Gerontology. 2004;50(6):411–16.
cross-ref  pubmed  

51. Bruyere O, Wuidart MA, Di Palma E, et al. Controlled whole body vibration to decrease fall risk and improve health-related quality of life of nursing home residents. Arch Phys Med Rehabil. 2005;86(2):303–07.
cross-ref  pubmed  

52. Beaudart C, Maquet D, Mannarino M, et al. Effects of 3 months of short sessions of controlled whole body vibrations on the risk of falls among nursing home residents. BMC Geriatr. 2013;13:42.
cross-ref  pubmed  pmc  

53. Grönstedt H, Frändin K, Bergland A, et al. Effects of individually tailored physical and daily activities in nursing home residents on activities of daily living, physical performance and physical activity level: a randomized controlled trial. Gerontology. 2013;59(3):220–29.
cross-ref  

54. Carlsson M, Littbrand H, Gustafson Y, 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. J Nutr Health Aging. 2011;15(7):554–60.
cross-ref  pubmed  

55. Makita M, Nakadaira H, Yamamoto M. Randomized controlled trial to evaluate effectiveness of exercise therapy (Takizawa Program) for frail elderly. Environ Health Prev Med. 2006;11(5):221–27.
cross-ref  pubmed  pmc  

56. Ogaya S, Ikezoe T, Soda N, et al. Effects of balance training using wobble boards in the elderly. J Strength Cond Res. 2011;25(9):2616–22.
cross-ref  pubmed  

57. Cakar E, Dincer U, Kiralp MZ, 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. Eur J Phys Rehabil Med. 2010;46(1):59–67.
pubmed  

58. 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. Clin Rehabil. 2007;21(3):273–83.
cross-ref  pubmed  

59. Hruda KV, Hicks AL, Mccartney N. Training for muscle power in older adults: effects on functional abilities. Can J Appl Physiol. 2003;28(2):178–89.
cross-ref  pubmed  

60. Tsaih PL, Shih YL, Hu MH. Low-intensity task-oriented exercise for ambulation-challenged residents in long-term care facilities: a randomized, controlled trial. Am J Phys Med Rehabil. 2012;91(7):616–24.
cross-ref  pubmed  

61. Vinsnes AG, Helbostad JL, Nyrønning S, et al. Effect of physical training on urinary incontinence: a randomized parallel group trial in nursing homes. Clin Interv Aging. 2012;7:45–50.
cross-ref  pubmed  pmc  

62. Gallon D, Rodacki AL, Hernandez SG, et al. The effects of stretching on the flexibility, muscle performance and functionality of institutionalized older women. Braz J Med Biol Res. 2011;44(3):229–35.
cross-ref  pubmed  

63. Chin A Paw MJ, van Uffelen JG, Riphagen I, et al. The functional effects of physical exercise training in frail older people: a systematic review. Sports Med. 2008;38(9):781–93.
cross-ref  

64. Daniels R, van Rossum E, de Witte L, et al. Interventions to prevent disability in frail community-dwelling elderly: a systematic review. BMC Health Serv Res. 2008;8:278.
cross-ref  

65. Freedman VA, Martin LG, Schoeni RF. Recent trends in disability and functioning among older adults in the United States: a systematic review. JAMA. 2002;288(24):3137–46.
cross-ref  pubmed  

66. Burke SM, Carron AV, Shapcott KM. Cohesion in exercise groups: An overview. Int Rev Sport Exerc Psychol. 2008;1(2):107–23.
cross-ref  

67. Blocker WP. Maintaining functional independence by mobilizing the aged. Geriatrics. 1992;47(1):42–56.
pubmed  



Correspondence to: George Heckman, md, msc, frcpc, Research Institute for Aging and School of Public Health and Health Systems, 3734 BMH, University of Waterloo, 200 University Ave. West, Waterloo, ON N2L 3G1, Canada, E-mail: ggheckma@uwaterloo.ca

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Canadian Geriatrics Journal, Vol. 18, No. 2, June 2015

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ISSN: 1925-8348 (Online)