title: Physical rehabilitation for older people in long-term care.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors: Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Trust,Bradford, UK.
authors: Tom
authors: T
authors: Crocker
authors: Anne
authors: A
authors: Forster
authors: John
authors: J
authors: Young
authors: Lesley
authors: L
authors: Brown
authors: Seline
authors: S
authors: Ozer
authors: Jane
authors: J
authors: Smith
authors: John
authors: J
authors: Green
authors: Jo
authors: J
authors: Hardy
authors: Eileen
authors: E
authors: Burns
authors: Elizabeth
authors: E
authors: Glidewell
authors: Darren C
authors: DC
authors: Greenwood
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D000369:Aged, 80 and over; D003072:Cognition Disorders / Q000534:rehabilitation; D005081:Exercise Therapy; D005260:Female; D006707:Homes for the Aged; D006801:Humans; D008134:Long-Term Care; D008297:Male; D009735:Nursing Homes; D016032:Randomized Controlled Trials as Topic; D012046:Rehabilitation