Stepping impairments are associated with physical and cognitive decline in older adults and increased fall risk. Exercise interventions can reduce fall risk, but adherence is often low. A new ...exergame involving step training may provide an enjoyable exercise alternative for preventing falls in older people.
To assess the feasibility and safety of unsupervised, home-based step pad training and determine the effectiveness of this intervention on stepping performance and associated fall risk in older people.
Single-blinded two-arm randomized controlled trial comparing step pad training with control (no-intervention).
Thirty-seven older adults residing in independent-living units of a retirement village in Sydney, Australia.
Intervention group (IG) participants were provided with a computerized step pad system connected to their TVs and played a step game as often as they liked (with a recommended dose of 2-3 sessions per week for 15-20 minutes each) for eight weeks. In addition, IG participants were asked to complete a choice stepping reaction time (CSRT) task once each week.
CSRT, the Physiological Profile Assessment (PPA), neuropsychological and functional mobility measures were assessed at baseline and eight week follow-up.
Thirty-two participants completed the study (86.5%). IG participants played a median 2.75 sessions/week and no adverse events were reported. Compared to the control group, the IG significantly improved their CSRT (F31,1 = 18.203, p<.001), PPA composite scores (F31,1 = 12.706, p = 0.001), as well as the postural sway (F31,1 = 4.226, p = 0.049) and contrast sensitivity (F31,1 = 4.415, p = 0.044) PPA sub-component scores. In addition, the IG improved significantly in their dual-task ability as assessed by a timed up and go test/verbal fluency task (F31,1 = 4.226, p = 0.049).
Step pad training can be safely undertaken at home to improve physical and cognitive parameters of fall risk in older people without major cognitive and physical impairments.
Australian New Zealand Clinical Trials Registry ACTRN12611001081909.
Exercise for osteoarthritis of the knee Fransen, Marlene; McConnell, Sara; Harmer, Alison R ...
Cochrane database of systematic reviews,
01/2015, Letnik:
2015, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Background
Knee osteoarthritis (OA) is a major public health issue because it causes chronic pain, reduces physical function and diminishes quality of life. Ageing of the population and increased ...global prevalence of obesity are anticipated to dramatically increase the prevalence of knee OA and its associated impairments. No cure for knee OA is known, but exercise therapy is among the dominant non‐pharmacological interventions recommended by international guidelines.
Objectives
To determine whether land‐based therapeutic exercise is beneficial for people with knee OA in terms of reduced joint pain or improved physical function and quality of life.
Search methods
Five electronic databases were searched, up until May 2013.
Selection criteria
All randomised controlled trials (RCTs) randomly assigning individuals and comparing groups treated with some form of land‐based therapeutic exercise (as opposed to exercise conducted in the water) with a non‐exercise group or a non‐treatment control group.
Data collection and analysis
Three teams of two review authors independently extracted data, assessed risk of bias for each study and assessed the quality of the body of evidence for each outcome using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. We conducted analyses on continuous outcomes (pain, physical function and quality of life) immediately after treatment and on dichotomous outcomes (proportion of study withdrawals) at the end of the study; we also conducted analyses on the sustained effects of exercise on pain and function (two to six months, and longer than six months).
Main results
In total, we extracted data from 54 studies. Overall, 19 (20%) studies reported adequate random sequence generation and allocation concealment and adequately accounted for incomplete outcome data; we considered these studies to have an overall low risk of bias. Studies were largely free from selection bias, but research results may be vulnerable to performance and detection bias, as only four of the RCTs reported blinding of participants to treatment allocation, and, although most RCTs reported blinded outcome assessment, pain, physical function and quality of life were participant self‐reported.
High‐quality evidence from 44 trials (3537 participants) indicates that exercise reduced pain (standardised mean difference (SMD) ‐0.49, 95% confidence interval (CI) ‐0.39 to ‐0.59) immediately after treatment. Pain was estimated at 44 points on a 0 to 100‐point scale (0 indicated no pain) in the control group; exercise reduced pain by an equivalent of 12 points (95% CI 10 to 15 points). Moderate‐quality evidence from 44 trials (3913 participants) showed that exercise improved physical function (SMD ‐0.52, 95% CI ‐0.39 to ‐0.64) immediately after treatment. Physical function was estimated at 38 points on a 0 to 100‐point scale (0 indicated no loss of physical function) in the control group; exercise improved physical function by an equivalent of 10 points (95% CI 8 to 13 points). High‐quality evidence from 13 studies (1073 participants) revealed that exercise improved quality of life (SMD 0.28, 95% CI 0.15 to 0.40) immediately after treatment. Quality of life was estimated at 43 points on a 0 to 100‐point scale (100 indicated best quality of life) in the control group; exercise improved quality of life by an equivalent of 4 points (95% CI 2 to 5 points).
High‐quality evidence from 45 studies (4607 participants) showed a comparable likelihood of withdrawal from exercise allocation (event rate 14%) compared with the control group (event rate 15%), and this difference was not significant: odds ratio (OR) 0.93 (95% CI 0.75 to 1.15). Eight studies reported adverse events, all of which were related to increased knee or low back pain attributed to the exercise intervention provided. No study reported a serious adverse event.
In addition, 12 included studies provided two to six‐month post‐treatment sustainability data on 1468 participants for knee pain and on 1279 (10 studies) participants for physical function. These studies indicated sustainability of treatment effect for pain (SMD ‐0.24, 95% CI ‐0.35 to ‐0.14), with an equivalent reduction of 6 (3 to 9) points on 0 to 100‐point scale, and of physical function (SMD ‐0.15 95% CI ‐0.26 to ‐0.04), with an equivalent improvement of 3 (1 to 5) points on 0 to 100‐point scale.
Marked variability was noted across included studies among participants recruited, symptom duration, exercise interventions assessed and important aspects of study methodology. Individually delivered programmes tended to result in greater reductions in pain and improvements in physical function, compared to class‐based exercise programmes or home‐based programmes; however between‐study heterogeneity was marked within the individually provided treatment delivery subgroup.
Authors' conclusions
High‐quality evidence indicates that land‐based therapeutic exercise provides short‐term benefit that is sustained for at least two to six months after cessation of formal treatment in terms of reduced knee pain, and moderate‐quality evidence shows improvement in physical function among people with knee OA. The magnitude of the treatment effect would be considered moderate (immediate) to small (two to six months) but comparable with estimates reported for non‐steroidal anti‐inflammatory drugs. Confidence intervals around demonstrated pooled results for pain reduction and improvement in physical function do not exclude a minimal clinically important treatment effect. Since the participants in most trials were aware of their treatment, this may have contributed to their improvement. Despite the lack of blinding we did not downgrade the quality of evidence for risk of performance or detection bias. This reflects our belief that further research in this area is unlikely to change the findings of our review.
Therapeutic exercise is a recommended first‐line treatment for patients with knee and hip osteoarthritis (OA); however, there is little specific advice or practical resources to guide clinicians in ...its implementation. As the first in a series of projects by the Osteoarthritis Research Society International Rehabilitation Discussion Group to address this gap, we aim in this narrative review to synthesize current literature informing the implementation of therapeutic exercise for patients with knee and hip OA, focusing on evidence from systematic reviews and randomized controlled trials. Therapeutic exercise is safe for patients with knee and hip OA. Numerous types of therapeutic exercise (including aerobic, strengthening, neuromuscular, mind‐body exercise) may be utilized at varying doses and in different settings to improve pain and function. Benefits from therapeutic exercise appear greater when dosage recommendations from general exercise guidelines for healthy adults are met. However, interim therapeutic exercise goals may also be useful, given that many barriers to achieving these dosages exist among this patient group. Theoretically‐informed strategies to improve adherence to therapeutic exercise, such as patient education, goal‐setting, monitoring, and feedback, may help maintain participation and optimize clinical benefits over the longer term. Sedentary behavior is also a risk factor for disability and lower quality of life in patients with knee and hip OA, although limited evidence exists regarding how best to reduce this behavior. Current evidence can be used to inform how to implement best practice therapeutic exercise at a sufficient and appropriate dose for patients with knee and hip OA.
Virtual reality (VR) has recently been explored as a tool for neurorehabilitation to enable individuals with Parkinson's disease (PD) to practice challenging skills in a safe environment. Current ...technological advances have enabled the use of affordable, fully immersive head-mounted displays (HMDs) for potential therapeutic applications. However, while previous studies have used HMDs in individuals with PD, these were only used for short bouts of walking. Clinical applications of VR for gait training would likely involve an extended exposure to the virtual environment, which has the potential to cause individuals with PD to experience simulator-related adverse effects due to their age or pathology. Thus, our objective was to evaluate the safety of using an HMD for longer bouts of walking in fully immersive VR for older adults and individuals with PD.
Thirty-three participants (11 healthy young, 11 healthy older adults, and 11 individuals with PD) were recruited for this study. Participants walked for 20 min while viewing a virtual city scene through an HMD (Oculus Rift DK2). Safety was evaluated using the mini-BESTest, measures of center of pressure (CoP) excursion, and questionnaires addressing symptoms of simulator sickness (SSQ) and measures of stress and arousal.
Most participants successfully completed all trials without any discomfort. There were no significant changes for any of our groups in symptoms of simulator sickness or measures of static and dynamic balance after exposure to the virtual environment. Surprisingly, measures of stress decreased in all groups while the PD group also increased the level of arousal after exposure.
Older adults and individuals with PD were able to successfully use immersive VR during walking without adverse effects. This provides systematic evidence supporting the safety of immersive VR for gait training in these populations.
Background
Treadmill training is used in rehabilitation and is described as improving gait parameters of patients with Parkinson's disease.
Objectives
To assess the effectiveness of treadmill ...training in improving the gait of patients with Parkinson's disease and the acceptability and safety of this type of therapy.
Search methods
We searched the Cochrane Movement Disorders Group Specialised Register (see Review Group details for more information) (last searched September 2014), Cochrane Central Register of Controlled Trials (The Cochrane Library 2014, Issue 10), MEDLINE (1950 to September 2014), and EMBASE (1980 to September 2014). We also handsearched relevant conference proceedings, searched trials and research registers, and checked reference lists (last searched September 2014). We contacted trialists, experts and researchers in the field and manufacturers of commercial devices.
Selection criteria
We included randomised controlled trials comparing treadmill training with no treadmill training in patients with Parkinson's disease.
Data collection and analysis
Two review authors independently selected trials for inclusion, assessed trial quality and extracted data. We contacted the trialists for additional information. We analysed the results as mean differences (MDs) for continuous variables and relative risk differences (RD) for dichotomous variables.
Main results
We included 18 trials (633 participants) in this update of this review. Treadmill training improved gait speed (MD = 0.09 m/s; 95% confidence interval (CI) 0.03 to 0.14; P = 0.001; I2 = 24%; moderate quality of evidence), stride length (MD = 0.05 metres; 95% CI 0.01 to 0.09; P = 0.01; I2 = 0%; low quality of evidence), but walking distance (MD = 48.9 metres; 95% CI ‐1.32 to 99.14; P = 0.06; I2 = 91%; very low quality of evidence) and cadence did not improve (MD = 2.16 steps/minute; 95% CI ‐0.13 to 4.46; P = 0.07; I2 = 28%; low quality of evidence) at the end of study. Treadmill training did not increase the risk of patients dropping out from intervention (RD = ‐0.02; 95% CI ‐0.06 to 0.02; P = 0.32; I2 = 13%; moderate quality of evidence). Adverse events were not reported in included studies.
Authors' conclusions
This update of our systematic review provides evidence from eighteen trials with moderate to low risk of bias that the use of treadmill training in patients with PD may improve clinically relevant gait parameters such as gait speed and stride length (moderate and low quality of evidence, respectively). This apparent benefit for patients is, however, not supported by all secondary variables (e.g. cadence and walking distance). Comparing physiotherapy and treadmill training against other alternatives in the treatment of gait hypokinesia such as physiotherapy without treadmill training this type of therapy seems to be more beneficial in practice without increased risk. The gain seems small to moderate clinically relevant. However, the results must be interpreted with caution because it is not known how long these improvements may last and some studies used no intervention in the control group and underlie some risk of bias. Additionally the results were heterogenous and we found variations between the trials in patient characteristics, the duration and amount of training, and types of treadmill training applied.
Manual therapy (MT) and exercise have been extensively used to treat people with musculoskeletal conditions such as temporomandibular disorders (TMD). The evidence regarding their effectiveness ...provided by early systematic reviews is outdated.
The aim of this study was to summarize evidence from and evaluate the methodological quality of randomized controlled trials that examined the effectiveness of MT and therapeutic exercise interventions compared with other active interventions or standard care for treatment of TMD.
Electronic data searches of 6 databases were performed, in addition to a manual search.
Randomized controlled trials involving adults with TMD that compared any type of MT intervention (eg, mobilization, manipulation) or exercise therapy with a placebo intervention, controlled comparison intervention, or standard care were included. The main outcomes of this systematic review were pain, range of motion, and oral function. Forty-eight studies met the inclusion criteria and were analyzed.
Data were extracted in duplicate on specific study characteristics.
The overall evidence for this systematic review was considered low. The trials included in this review had unclear or high risk of bias. Thus, the evidence was generally downgraded based on assessments of risk of bias. Most of the effect sizes were low to moderate, with no clear indication of superiority of exercises versus other conservative treatments for TMD. However, MT alone or in combination with exercises at the jaw or cervical level showed promising effects.
Quality of the evidence and heterogeneity of the studies were limitations of the study.
No high-quality evidence was found, indicating that there is great uncertainty about the effectiveness of exercise and MT for treatment of TMD.
Purpose
The purpose of this study was to explore breast cancer survivors’ interest in and preferences for technology-supported exercise interventions.
Methods
Post-treatment survivors
n
= 279;
M
...age
= 60.7 (SD = 9.7) completed a battery of online questionnaires in August 2015. Descriptive statistics were calculated for all data. Logistic regression analyses were conducted to examine relationships between survivors’ interest in a technology-supported exercise interventions and demographic, disease, and behavioral factors. These same factors were examined in relation to perceived effectiveness of such interventions using multiple regression analyses.
Results
About half (53.4%) of survivors self-reported meeting public health recommendations for physical activity. Fewer than half reported using an exercise or diet mobile app (41.2%) or owning an activity tracker (40.5%). The majority were interested in receiving remotely delivered exercise counseling (84.6%), participating in a remotely delivered exercise intervention (79.5%), and using an exercise app or website (68%). Survivors reported that the most helpful technology-supported intervention components would be an activity tracker (89.5%), personalized feedback (81.2%), and feedback on how exercise is influencing mood, fatigue, etc. (73.6%). Components rated as least helpful were social networking integration (31.2%), group competitions (33.9%), and ability to see others’ progress (35.1%).
Conclusions
Preferences for technology-supported exercise interventions varied among breast cancer survivors. Nonetheless, data indicate that technology-supported interventions may be feasible and acceptable. Engaging stakeholders may be important in developing and testing potential intervention components.
Background
Exercise‐based cardiac rehabilitation may benefit adults with atrial fibrillation or those who had been treated for atrial fibrillation. Atrial fibrillation is caused by multiple micro ...re‐entry circuits within the atrial tissue, which result in chaotic rapid activity in the atria.
Objectives
To assess the benefits and harms of exercise‐based rehabilitation programmes, alone or with another intervention, compared with no‐exercise training controls in adults who currently have AF, or have been treated for AF.
Search methods
We searched the following electronic databases; CENTRAL and the Database of s of Reviews of Effectiveness (DARE) in the Cochrane Library, MEDLINE Ovid, Embase Ovid, PsycINFO Ovid, Web of Science Core Collection Thomson Reuters, CINAHL EBSCO, LILACS Bireme, and three clinical trial registers on 14 July 2016. We also checked the bibliographies of relevant systematic reviews identified by the searches. We imposed no language restrictions.
Selection criteria
We included randomised controlled trials (RCT) that investigated exercise‐based interventions compared with any type of no‐exercise control. We included trials that included adults aged 18 years or older with atrial fibrillation, or post‐treatment for atrial fibrillation.
Data collection and analysis
Two authors independently extracted data. We assessed the risk of bias using the domains outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We assessed clinical and statistical heterogeneity by visual inspection of the forest plots, and by using standard Chi² and I² statistics. We performed meta‐analyses using fixed‐effect and random‐effects models; we used standardised mean differences where different scales were used for the same outcome. We assessed the risk of random errors with trial sequential analysis (TSA) and used the GRADE methodology to rate the quality of evidence, reporting it in the 'Summary of findings' table.
Main results
We included six RCTs with a total of 421 patients with various types of atrial fibrillation. All trials were conducted between 2006 and 2016, and had short follow‐up (eight weeks to six months). Risks of bias ranged from high risk to low risk.The exercise‐based programmes in four trials consisted of both aerobic exercise and resistance training, in one trial consisted of Qi‐gong (slow and graceful movements), and in another trial, consisted of inspiratory muscle training.
For mortality, very low‐quality evidence from six trials suggested no clear difference in deaths between the exercise and no‐exercise groups (relative risk (RR) 1.00, 95% confidence interval (CI) 0.06 to 15.78; participants = 421; I² = 0%; deaths = 2). Very low‐quality evidence from five trials suggested no clear difference between groups for serious adverse events (RR 1.01, 95% CI 0.98 to 1.05; participants = 381; I² = 0%; events = 8). Low‐quality evidence from two trials suggested no clear difference in health‐related quality of life for the Short Form‐36 (SF‐36) physical component summary measure (mean difference (MD) 1.96, 95% CI ‐2.50 to 6.42; participants = 224; I² = 69%), or the SF‐36 mental component summary measure (MD 1.99, 95% CI ‐0.48 to 4.46; participants = 224; I² = 0%). Exercise capacity was assessed by cumulated work, or maximal power (Watt), obtained by cycle ergometer, or by six minute walking test, or ergospirometry testing measuring VO2 peak. We found moderate‐quality evidence from two studies that exercise‐based rehabilitation increased exercise capacity, measured by VO2 peak, more than no exercise (MD 3.76, 95% CI 1.37 to 6.15; participants = 208; I² = 0%); and very low‐quality evidence from four studies that exercise‐based rehabilitation increased exercise capacity more than no exercise, measured by the six‐minute walking test (MD 75.76, 95% CI 14.00 to 137.53; participants = 272; I² = 85%). When we combined the different assessment tools for exercise capacity, we found very low‐quality evidence from six trials that exercise‐based rehabilitation increased exercise capacity more than no exercise (standardised mean difference (SMD) 0.86, 95% CI 0.46 to 1.26; participants = 359; I² = 65%). Overall, the quality of the evidence for the outcomes ranged from moderate to very‐low.
Authors' conclusions
Due to few randomised patients and outcomes, we could not evaluate the real impact of exercise‐based cardiac rehabilitation on mortality or serious adverse events. The evidence showed no clinically relevant effect on health‐related quality of life. Pooled data showed a positive effect on the surrogate outcome of physical exercise capacity, but due to the low number of patients and the moderate to very low‐quality of the underpinning evidence, we could not be certain of the magnitude of the effect. Future high‐quality randomised trials are needed to assess the benefits and harms of exercise‐based cardiac rehabilitation for adults with atrial fibrillation on patient‐relevant outcomes.
Cardiac rehabilitation (CR) is an evidence-based intervention that uses patient education, health behavior modification, and exercise training to improve secondary prevention outcomes in patients ...with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, heart failure, or cardiac surgery but are significantly underused, with only a minority of eligible patients participating in CR in the United States. New delivery strategies are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). In contrast to center-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision and is provided mostly or entirely outside of the traditional center-based setting. Although HBCR has been successfully deployed in the United Kingdom, Canada, and other countries, most US healthcare organizations have little to no experience with such programs. The purpose of this scientific statement is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR in the United States. Previous randomized trials have generated low- to moderate-strength evidence that HBCR and center-based CR can achieve similar improvements in 3- to 12-month clinical outcomes. Although HBCR appears to hold promise in expanding the use of CR to eligible patients, additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and other higher-risk and understudied groups. In the interim, we conclude that HBCR may be a reasonable option for selected clinically stable low- to moderate-risk patients who are eligible for CR but cannot attend a traditional center-based CR program.
Patients may be offered cardiac rehabilitation (CR), a supervised programme often including exercises, education and psychological care, following a cardiac event, with the aim of reducing morbidity ...and mortality. Cost-constrained healthcare systems require information about the best use of budget and resources to maximise patient benefit. We aimed to systematically review and critically appraise economic studies of CR and its components. In January 2016, validated electronic searches of the National Health Service Economic Evaluation Database (NHS EED), Health Technology Assessment, PsycINFO, MEDLINE and Embase databases were run to identify full economic evaluations published since 2001. Two levels of screening were used and explicit inclusion criteria were applied. Prespecified data extraction and critical appraisal were performed using the NHS EED handbook and Drummond checklist. The majority of studies concluded that CR was cost-effective versus no CR (incremental cost-effectiveness ratios (ICERs) ranged from $1065 to $71 755 per quality-adjusted life-year (QALY)). Evidence for specific interventions within CR was varied; psychological intervention ranged from dominant (cost saving and more effective) to $226 128 per QALY, telehealth ranged from dominant to $588 734 per QALY and while exercise was cost-effective across all relevant studies, results were subject to uncertainty. Key drivers of cost-effectiveness were risk of subsequent events and hospitalisation, hospitalisation and intervention costs, and utilities. This systematic review of studies evaluates the cost-effectiveness of CR in the modern era, providing a fresh evidence base for policy-makers. Evidence suggests that CR is cost-effective, especially with exercise as a component. However, research is needed to determine the most cost-effective design of CR.
PDF
