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School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy


CRITICALLY APPRAISED TOPIC (CAT) WORKSHEET
Focused Question:
Do long-term physical exercise programs help improve community mobility among older adults?
Prepared By:
Ayessa Escandar, OTS (OT16.Ayessa.Escandar@nv.touro.edu) &
Davis Legaspi-David, OTS (OT16.Davis.Legaspi-David@nv.touro.edu)
Department of Occupational Therapy
Touro University, Nevada
874 American Pacific Dr.
Henderson, NV 89014
Supervised by Donna Costa, MS, OTR/L, PhD (Donna.Costa@tun.touro.edu)

Date Review Completed:


October 8, 2015
Clinical Scenario:
An important aspect towards living a satisfying life for older adults is being able to
interact with their external environment so that they can continue to perform meaningful
activities, complete daily errands, and engage in social participation (Rantanen, 2013). A key
component that allows an older adult to stay functionally independent in interacting with their
external environment is being able to sustain their ability to maneuver in their community,
particularly for our case it is focusing on older adults with the ability to transport themselves
from one location to another. However, a common trend with older adults is a decline in their
physical ability, which slowly inhibits them from performing functional mobility. The physical
decline in older adults is not because of old age, but often due to a lack of exercise,
environmental factors such as smoking, and a poor diet (Robnett, 2008). As a result, client
factors that are often affected amongst older adults are their joint mobility, muscle power, and
muscle endurance (Robnett, 2008). With that said, the significant growth of the older adult

population in the near future will have many individuals experiencing a decline in these and
possibly additional client factors. Therefore, in order for older adults to age healthier and
maintain a quality of life, additional research studies must be conducted. By understanding the
factors affecting community mobility in older adults it will help develop evidence-base
interventions that will promote older adults to safely interact with their outdoor environment.
Ultimately, the preservation of an older adults community mobility will greatly prevent their
chances of developing disabilities, diseases, and injuries (Peterson, 2011).
There are multiple interventions that occupational therapists (OT) subscribe to that help
older adults maintain their community mobility. For example, older adults who are at risk or
those who already have had a fall incident when performing functional mobility, an OT may
recommend that these individuals join a fall prevention program such as the Otago Exercise
Program or Tai Chi: Moving for Better Balance (Peterson, 2011). The Otago is a home-based,
individualized exercise program that was designed to improve balance and increase lower limb
strength. A meta-analysis of the Otago has shown it to reduce falls and fall related injuries by
35% (Peterson, 2011). Tai Chi: Moving for Better Balance is an alternative exercise program that
emphasizes weight shifting, postural alignment, and coordinated movements with synchronized
breathing. Studies have been conducted and have demonstrated the Tai Chi program to improve
functional balance, strength, flexibility, and the reduction of fall risks (Peterson, 2011). Solely,
based off of the two programs intervention approach, they seem to differ greatly with one
another. However, the two programs underlying philosophy of using exercise as a means of
preventing the decline of community mobility amongst older adults is similar. Therefore, the
implementation of long-term physical exercise programs can be beneficial to improve older
adults community mobility.

Summary of Key Findings:


Summary of Levels I, II and III:
Level I:
Research indicates that long-term physical exercise programs can be effective at
improving physical health amongst the older adult population. The physical
improvements that are made through physical exercise programs are all positive factors
that contribute to the ability of older adults maintaining community mobility
independence. One study found that a community-based exercise program consisting of
both balance and resistance training, significantly reduced knee joint pain, improved
muscle strength, and functional ability among community-dwelling older adults
(Hasegawa et al., 2010). In a similar study, a 16 week exercise program designed to
increase aerobic capacity, muscular strength, and muscular endurance in older adults

who reported limited functional mobility, found to improve isokinetic strength,


functional ability, and aerobic exercise capacity. (Falman, Topp, McNevin, Morgan, &
Boardley, 2007). An additional community-based exercise program named Fitness and
Mobility Exercise program focused on improvements in cardiorespiratory fitness,
mobility, paretic leg muscle strength, balance, and activity participation. The study
resulted in improvements in all outcome measures by the end of the 19 week program
among older individuals with chronic stroke (Pang, Eng, Dawson, McKay, & Harris,
2005). An intensive 9 month exercise training program for older community-dwelling
adults with physical frailty indicated at the end of the study significant improvements in
balance, muscular strength, and a decrease in difficulty performing activities of daily
living (Binder et al., 2002). Four research articles also included falls as an outcome
measure to determine the benefits of long term exercise programs. Specifically, one
study was conducted to determine the safety and efficacy of a home-based exercise
intervention on older adults with multiple sclerosis. The results of the study indicated a
decrease in fall risk and postural sway, with an increase in walking distance, balance,
and confidence (Sosnoff, Finlayson, Morrison, & Motl, 2014). A study that focused on a
multicomponent exercise program targeted at decreasing fractured related falls
concluded a decrease in the fear of falls and fall related fracture, and an increase in
walking time (Yamada, Nishiguischi, Yoshimra, Kajiwara, & Aoyama, 2013). In
another study, a 6 month Tai Chi: Moving for Better Balance intervention was utilized
to decrease the number of falls and risk for falling in older adults. The study found that
Tai Chi was beneficial in lowering portions of fallers, fewer injurious falls, reduce fear
of falling, and improvements in all measure of functional balance and physical
performance (Li et al., 2005). One last study that looked at falls as an outcome measure,
aimed to investigate the effects of a home-based exercise program on falls and mobility
among older adults recently discharged from a hospital. The results concluded that
although improvements in performance base mobility, balance, and grip occurred, an
increase in falls were reported for the intervention group in comparison to the control
group (Sherrington et al., 2014). A Green Prescription physical activity intervention was
utilized in a 12 month study on non-depressed, low active community-dwelling older
adults and determined an increase in leisure physical activities and an increase in
mental health (Patel, Keogh, Kolt, & Schofield, 2013). One last study, found that a 12
week physical and cognitive exercise program can improve memory, executive
functioning, walking distance, and functional activities (Nishiguichi et al., 2015).
No level II & III studies were appraised

Summary of Level IV and V:

No level IV and V studies were appraised


Contributions of Qualitative Studies:
No qualitative studies were appraised

Bottom Line for Occupational Therapy Practice:


The clinical and community-based practice of OT:
Physical exercise programs have found to improve various factors of physical health in
older adults. Although each study presented different exercise programs, various similarities in
improvement of physical health were concluded. Specific improvement were found in the areas
of balance, fall risks, endurance, speed and distance of walking, muscle strength, and functional
abilities. In addition, other studies resulted in an improvement in mental health and cognitive
skills. Therefore, an improvement in physical, cognitive, and mental health are all factors that
contribute to improving community mobility among older adults. However, while the use of
physical exercise programs has been shown to provide positive results, occupational therapist
cannot solely rely on a physical exercise program as an intervention to improve community
mobility. Additional research needs to be conducted to determine the positive effects of longterm physical exercise programs on community mobility among older adults.
Program development:
The use of physical exercise programs should be used alongside traditional occupational
therapy interventions for improving community mobility among older adults. Although physical
exercise programs have proven to show substantial improvement in overall physical health, it
should not solely be the only intervention given to older adults for improving community
mobility. Occupational therapist can consider developing an intervention that implements the use
of an exercise program in conjunction with occupation-based activities that relates to specific
community mobility needs. It is also important that if a home exercise program is utilized, proper
training and execution should be highly focused on during the intervention to ensure safety. In
addition, because community mobility may differ for each client, the program should be tailored
to each individuals needs.
Societal Needs:
With an increase in community-dwelling older adults, access to physical exercise
programs focused on maintaining community mobility should be expanded so that older adults
may continue to maintain independence, safety, and health. As many individuals age, an increase
in debility or disabilities could occur and interfere with the ability to perform community

mobility. However, many older adults may not have insurance coverage that extends to long
periods of occupational therapy rehabilitative services. Therefore, home and community exercise
programs could be recommended to individuals who want to continue maintaining a long-term
physical exercise program that could enhance community mobility. A long-term physical
exercise program that improves community mobility in older adults will provide clients with
accessibility to the community and improve engagement in community activities.
Healthcare delivery and policy:
Results from these studies should be used to inform policy makers that there is a great
need for an increase in occupational therapy services to help improve community mobility
among older adults. With additional training, occupational therapist can implement a physical
exercise program in conjunction with occupation-based activities to enhance community
mobility and help maintain the independence of community-dwelling older adults. In addition,
benefits proven from the physical exercise programs, such as improving physical health, can
serve as a viable option for lowering health care costs. Specifically, several of the studies show
strong evidence that the interventions work to decrease risk for falls and injurious falls which
possibly could lead to hospitalization and an increase in health care costs. Therefore, the results
can be used to advocate funding for physical exercise programs that enhances community
mobility to help older adults maintain independence and continue aging in place.
Education and training of OT students:
Student entry-level knowledge includes only basic understanding of different physical
exercise programs utilized by occupational therapy. However, students have pertinent knowledge
on proper body mechanics and the bodys mechanisms needed to participate in physical exercise
programs. In addition, the use of outcome measures such as, Time Up and Go Test, Berg Balance
Scale, Portable dynamometer, and Chair Stand test is education that is also obtained at entrylevel. Lastly, students have also learned biomechanical interventions, such as simple physical
exercises used as physical modalities that could be implemented in a physical exercise program.
Refinement, revision, and advancement of factual knowledge or theory:
Further research is needed to determine if community mobility will improve due to the
benefits associated with long-term physical exercise programs. Although, the selected research
articles indicates improvements in various client factors and increased participation in daily
activities, it does not directly correlate to improvements in community mobility. In addition,
continuous follow up should be implemented in the research to determine long-term effects of
the interventions.

Review Process:

Selected a special issue topic from AOTA that dealt with a particular population,
intervention, and outcomes
Articulated and developed focused question in PIO format
Focused question with rationale was submitted and approved by instructor
Developed inclusion and exclusion criteria for comprehensive literature search
Received instructor feedback on inclusion/exclusion criteria for evidence table
Developed a key term and database table to organize comprehensive literature searches
Key terms and database table completed and submitted for instructor review
Online search for ten peer reviewed articles that correlated to the focused question
Each of the ten literature studies that were selected underwent a McMaster critical review
and were then submitted to the instructor for approval
The instructors feedbacks of the McMaster critical reviews were discussed in weekly
meetings
Evidence table completed and submitted for instructor review
Instructor provided feedback for evidence table
All peer-reviewed articles were summarized and put into CAT format
CAT was completed and submitted for instructor to review
Procedures for the Selection and appraisal of articles:
Inclusion Criteria:

Articles for year 2000-current


Exercise intervention program
Older adults
Full Articles
Inclusion of abstract
Written in English
Articles that meet any of the following search categories: patient population, intervention,
and outcomes

Exclusion Criteria:

Systematic reviews
Level III-V articles
Adolescent or young adult population
Duplicate publications
Articles 15 years or older
Articles that did not meet any of the search categories: patient population, intervention,
and outcomes

Search Strategies:

Categories
Patient/Client Population
Intervention

Outcomes

Key Search Terms


Community mobility for older adults, Older adults exercise
program
Long term exercise program, Tai Chi, Fall prevention program,
Home base exercise program, Community base exercise
program
Fall risk, functional balance, functional mobility, community
mobility, muscular strength, endurance, walking distance
Databases and Sites Searched

CINAHL, Google Scholar

Quality Control/Peer Review Process:

Instructor review and feedback was provided on:


o Formulation of PICO question
o Comprehensive literature search
o Inclusion/exclusion criteria
o McMaster Critical Review Form for each article
o Evidence table
o CAT
o Systematic review poster
Peer review and feedback from team member was provided on:
o Formulation of PICO question
o Comprehensive literature search
o Inclusion/exclusion criteria
o McMaster Critical Review Forms for each research article
o Evidence table
o CAT
o Systematic review poster

Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:
Level of
Evidence

Study Design/Methodology of Selected Articles

Number of Articles
Selected

I
II
III
IV
V
Other

Systematic reviews, meta-analysis, randomized


controlled trials
Two groups, nonrandomized studies (e.g., cohort,
case-control)
One group, nonrandomized (e.g., before and after,
pretest, and posttest)
Descriptive studies that include analysis of outcomes
(single subject design, case series)
Case reports and expert opinion, which include
narrative literature reviews and consensus statements
Qualitative Studies
TOTAL:

10
0
0
0
0
0
10

Limitations of the Studies Appraised:


Levels I, II, and III
Level I:
Small sample sizes (Sosnoff, Finlayson, Morrison, & Motl, 2014; Sherrington et
al., 2014; Hasegawa et al., 2010).
Not double blinded (Nishiguichi et al., 2015; Yamada, Nishiguischi, Yoshimra,
Kajiwara, & Aoyama, 2013).
No follow up after intervention to determine long term effects (Nishiguichi et al.,
2015; Yamada, Nishiguischi, Yoshimra, Kajiwara, & Aoyama, 2013; Pang, Eng,
Dawson, McKay, & Harris, 2005).
Examiners did not enforce subjects from not sharing their performance with
anyone involved with the study (Nishiguichi et al., 2015; Sosnoff, Finlayson,
Morrison, & Motl, 2014; Binder et al., 2002; Li et al., 2005).
Subjects self-reported their data (Sherrington et al., 2014; Yamada, Nishiguischi,
Yoshimra, Kajiwara, & Aoyama, 2013; Li et al., 2005).
Subject inclusion criteria was not generalizable (Pang, Eng, Dawson, McKay, &
Harris, 2005; Li et al., 2005; Falman, Topp, McNevin, Morgan, & Boardley,
2007; Patel, Keogh, Kolt, & Schofield, 2013; Sosnoff, Finlayson, Morrison, &
Motl, 2014).
No level II and III studies were appraised

Levels IV and V
No Level IV and V studies were appraised
Other
No other additional studies were appraised
Articles Selected for Appraisal:
Binder, E. F., Schenchtman, K. B., Ehsani, A. A., Steger-May, K., Brown, M., Sinacore, D. R., &
Holloszy, J. O. (2002). Effects of exercise training on frailty in community-dwelling older
adults: results of a randomized, controlled trial. Journal of The American Geriatrics
Society, 50(12), 1921-1928. doi:10.1046/j. 1532-5415.2002.50601.x
Fahlman, M., Topp, R., McNevin, N., Morgan, A., & Boardley, D. (2007). Structured exercise in
older adults with limited functional ability. Journal of Gerontological Nursing, 33(6), 3239.
Hasegawa, R., Islam, M., Nasu, E., Tomiyama, N., Lee, S., Koizumi, D., & Takeshima, N.
(2010). Effects of combined balance and resistance exercise on reducing knee pain in
community-dwelling older adults. Physical & Occupational Therapy in Geriatrics, 28(1),
44-65. doi:10.3109/02703180903381086
Li, F., Harmer, P., Fisher, J., McAuley, E., Chaumeton, N., Eckstrom, E., & Wilson, N. L. (2005).
Tai chi and fall reductions in older adults: a randomized controlled trial. Journal of
Gerontology, 60(2), 187-194. doi:10.3109/02703180903381086
Nishiguichi, S., Yamada, M., Tanigawa, T., Sekiyama, K., Kawagoe, T., Suzaki, M., Yoshikawa,
S., Abe, N., Otsuka, Y., Nakai, R., Aoyama, T., & Tsuboyama, T. (2015). A 12-week
physical and cognitive exercise program can improve cognitive function and neural
efficiency in community-dwelling older adults: a randomized controlled trial. Journal of
the American Geriatrics Society, 63(7), 1355-1363. doi:10.1111/jgs.13481
Pang, M., Eng, J., Dawson, A., McKay, H., & Harris, J. (2005). A community-based fitness and
mobility exercise program for older adults with chronic stroke: a randomized, controlled
trial. Journal Of The American Geriatrics Society, 53(10), 1667-1674.
doi:10.1111/j.1532-5415.2005.53521.x
Patel, A., Keogh, J. W., Kolt, G. S., & Schofield, G. M. (2013). The long-term effects of a
primary care physical activity intervention on mental health in low-active, communitydwelling older adults. Aging & Mental Health, 17(6), 766-772.
doi:10.1080/13607863.2013.781118
Sherrington, C., Lord, R. S., Vogler, M. C., Close C. J., Howard, K., Dean, L. (2014). A post-

hospital home exercise program improved mobility but increased falls in older people: a
randomized controlled trial. Plos One, 9(9): e104412. doi:10.1371/journal/pone.0104412
Sosnoff, J. J., Finlayson, M., McAuley, E., Morrison, S., & Motl, R. W. (2014). Home-base
exercise program and fall risk reduction in older adults with multiple sclerosis: phase 1
randomized controlled trial. Clinical Rehabilitation, 28(3), 254-263.
doi:10.1177/026921551350192
Yamada, M., Higuchi, T., Nishiguschi, S., Yoshimura, K., Kajiwara, Y., & Aoyama, T. (2013).
Multitarget stepping program in combination with a standardize multicomponent exercise
program can prevent falls in community-dwelling older adults: a randomized, controlled
trial. Journal of The American Geriatrics Society, 61(10), 1669-1675.
doi:10.1111/jgs.1253

Other References:
Peterson, E.W. (2011). Reducing fall risk: A guide to community-based programs. OT Practice,
16(18), 15-20.
Rantanen, T. (2013). Promoting mobility in older people. Journal of Preventive Medicine and
Public Health, 46(Suppl 1), S50S54. http://doi.org/10.3961/jpmph.2013.46.S.S50
Robnett H. R. (2008). Client factors and their effect on occupational performance in late life. In
S. Coppola, S. J. Elliott, & P. E. Toto (Eds.), Strategies to Advance Gerontology
Excellence: Promoting Best Practice in Occupational Therapy Self-Paced Clinical
Course (1st ed., pp.163-191). Bethesda: AOTA Press.