The worldwide population is progressively ageing, with an expected increase in morbidity
and demand for long-term care. Physical rehabilitation is beneficial in older people,
but relatively little is known about effects on long-term care residents. This is
an update of a Cochrane review first published in 2009.
To evaluate the benefits and harms of rehabilitation interventions directed at maintaining,
or improving, physical function for older people in long-term care through the review
of randomised and cluster randomised controlled trials.
We searched the trials registers of the following Cochrane entities: the Stroke Group
(May 2012), the Effective Practice and Organisation of Care Group (April 2012), and
the Rehabilitation and Related Therapies Field (April 2012). In addition, we searched
20 relevant electronic databases, including the Cochrane Central Register of Controlled
Trials (The Cochrane Library, 2009, Issue 4), MEDLINE (1966 to December 2009), EMBASE
(1980 to December 2009), CINAHL (1982 to December 2009), AMED (1985 to December 2009),
and PsycINFO (1967 to December 2009). We also searched trials and research registers
and conference proceedings; checked reference lists; and contacted authors, researchers,
and other relevant Cochrane entities. We updated our searches of electronic databases
in 2011 and listed relevant studies as awaiting assessment.
Randomised studies comparing a rehabilitation intervention designed to maintain or
improve physical function with either no intervention or an alternative intervention
in older people (over 60 years) who have permanent long-term care residency.
Two review authors independently assessed risk of bias and extracted data. We contacted
study authors for additional information. The primary outcome was function in activities
of daily living. Secondary outcomes included exercise tolerance, strength, flexibility,
balance, perceived health status, mood, cognitive status, fear of falling, and economic
analyses. We investigated adverse effects, including death, morbidity, and other events.
We synthesised estimates of the primary outcome with the mean difference; mortality
data, with the risk ratio; and secondary outcomes, using vote-counting.
We included 67 trials, involving 6300 participants. Fifty-one trials reported the
primary outcome, a measure of activities of daily living. The estimated effects of
physical rehabilitation at the end of the intervention were an improvement in Barthel
Index (0 to 100) scores of six points (95% confidence interval (CI) 2 to 11, P = 0.008,
seven studies), Functional Independence Measure (0 to 126) scores of five points (95% CI
-2 to 12, P = 0.1, four studies), Rivermead Mobility Index (0 to 15) scores of 0.7
points (95% CI 0.04 to 1.3, P = 0.04, three studies), Timed Up and Go test of five
seconds (95% CI -9 to 0, P = 0.05, seven studies), and walking speed of 0.03 m/s (95% CI
-0.01 to 0.07, P = 0.1, nine studies). Synthesis of secondary outcomes suggested there
is a beneficial effect on strength, flexibility, and balance, and possibly on mood,
although the size of any such effect is unknown. There was insufficient evidence of
the effect on other secondary outcomes. Based on 25 studies (3721 participants), rehabilitation
does not increase risk of mortality in this population (risk ratio 0.95, 95% CI 0.80
to 1.13). However, it is possible bias has resulted in overestimation of the positive
effects of physical rehabilitation.
Physical rehabilitation for long-term care residents may be effective, reducing disability
with few adverse events, but effects appear quite small and may not be applicable
to all residents. There is insufficient evidence to reach conclusions about improvement
sustainability, cost-effectiveness, or which interventions are most appropriate. Future
large-scale trials are justified.