Figure 1 Prisma Flow diagram
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(Legend): Adapted with permission from the PRISMA Group (29)
After screening 2,304 unique records, of which 236 were examined in full-text, 43 articles met our eligibility criteria and served as the overall data material for the scoping review (illustrated in Figure 1- Prisma Flow Diagram). Among these studies were 12 intervention studies, including five RCTs (30-34), five non-randomized controlled trials (35-39) and two non-controlled pre-post study (40, 41), in addition to one RCT long-term follow up study (42); four studies with mixed design/other (43-46); three studies based on quantitative research (47-49); and 23 qualitative studies, of which 15 focused on HCPs’ perspectives (50-64), six on older adults’ perspectives (65-70) and two on family members perspectives (71, 72).
In most of the included studies, the terms reablement or restorative care were used (n= 39). However, four of the studies that met our inclusion criteria did use other intervention terms including ‘homecare rehabilitation service specially trained in falls identification’ (39), ‘supported discharge team’ (32), ‘everyday rehabilitation’ (63) and ‘rehabilitative eldercare/homecare’ (62). Different groups of HCPs were represented in the interdisciplinary teams including OTs (n=41), PTs (n=36), RNs (n=11) or nurses (n=26), allied health personnel (n=40) and social educators/managers (n=7). All of the included studies served as the collective data material for investigating how PA was described and explored in reablement research. Intervention studies are presented in Table 1, and studies that provided additional information about PA characteristics or provided information about PA experiences or barriers are presented in Table 2. Further information and study details of all included studies is presented in an additional file (see Additional file 2).
Q1 -Extensiveness and characteristics of physical activity strategies in reablement
Characteristics of general PA interventions
Five Australian studies aimed to specifically investigate PA-related inquiries in a reablement setting (30, 42-44, 47). In one of these studies PA/Exercise interventions were described in detail, including intensity of the intervention (30) and two of the studies referred to government recommendations of PA in the background of the studies (43, 44). With the exception of these studies, the term physical activity was rarely mentioned in other studies. Instead, a range of terms that were likely to involve some degree of PA were used, such as training, training in daily activities, practicing ADL-activities, physical training, being active or enhancing active engagement or independence in daily activities. Also, broader terms such as rehabilitation, occupational therapy, physiotherapy or reablement intervention were used in contexts, in which it was likely that some degree of PA was involved.
Encouragement of active engagement and practicing/training ADL- tasks were explicitly reported as part of the reablement intervention in nine of 12 intervention studies (30-36, 38, 41). These activities were related to the older adults’ individual goals for reablement and could include activities such as indoor or outdoor mobility, dressing, bathing, kitchen activities, household activities and social/leisure activities. However, in most studies it was not possible to capture if and to what degree/intensity the activity training involved PA. Only one (American) study mentioned sedentary behavior, and explicitly mentioned that the interventions were (among other aims) aimed at reducing sedentary behavior among participants (46). Terms such as inactivity or passivity were rarely used.
Characteristics of exercise interventions
Exercise interventions were reported to be included in nine of the 12 intervention studies. Of these, six studies reported only overall aims/characteristics of the exercises, such as ‘exercise programs targeting strength, balance or endurance’ (31, 32, 36-39). One Australian intervention study (30), two Norwegian intervention studies including referrals to their study protocols (33, 35, 73, 74), and also one Norwegian field study (including three publications) (53-55) reported additional characteristics of exercise interventions provided through reablement. Two different overall exercise approaches were described in these studies, including i) standardized exercise programs (30, 54) and ii) individually targeted/ adapted exercises (30, 33, 35).
Burton et al. (2013) was the only study that provided detailed descriptions of PA and exercise interventions incorporated in the reablement intervention (30). The aim of that study was to compare a lifestyle exercise program (LiFE) with a standardized structured exercise program in an Australian reablement setting (30, 42). The LiFE program was aimed at improving balance, increasing strength and preventing falls by embedding exercises into everyday activities. The program included 18 different exercises/tasks (e.g. knee bends, walking up stairs, tandem stand or walking, one leg stand; these were further specified in the article) that were incorporated into daily activities. The exercises were to be performed every day and did not require additional time. The control intervention of this study was a structured exercise program, which had been part of the restorative care services for years. The structured exercise program included eight prespecified balance and strength exercises (e.g. sit to stand, stand and reach, toe taps) that the participants were asked to do in five repetitions three times a day (approximately 15-20 minutes per day).
In the two Norwegian intervention studies by Tuntland et al. (2015) and Langeland et al. (2019), it was described that daily training in activities was part of the general features of reablement, while exercise programs were recommended as individual features to improve strength, balance or fine motor skills (33, 35, 73, 74). In the study by Eliassen et al. (2018), they explored different perspectives of physiotherapy practice and supervision in reablement in Norwegian municipalities, and found that exercises were provided in all observed cases and that reablement plans contained elements of both exercises and daily activities (53-55). Though, while some of the teams mainly emphasized standardized exercises, other teams put more emphasis on daily activities in addition to targeted exercise strategies (53).
The intensity for follow-up of exercises by HCPs was different between studies. Burton et al. (2013) described that health professionals provided an average of three visits to participants, and that the participants were instructed to do the exercises unsupervised (30). At the visits in that study, the health professionals described the different exercises, discussed with the participants how they could incorporate the exercises into their daily routines (for the LiFE program) and provided support and encouragement for doing the exercises as well as other areas of their reablement. Tuntland et al. (2015) and Langeland et al. (2019) reported more frequent visits and described that HCPs would be present during daily training to build confidence, relearn skills and stimulate the participant in self-management and self-training (33, 35). They also reported that the participants would be encouraged to perform exercise programs on their own.
The duration of the exercise interventions in Burton et al. (2013) was 8 weeks (with care manager assistance) (30), while Langeland et al. (2019) reported a maximum of 10 weeks duration (average 5.7 weeks) (35) and Tuntland et al. (2015) a maximum of 3 months (with an average of 10 weeks) duration of the reablement intervention (33). Some of the included studies reported that written and/or illustrative manuals of the exercises/training was provided (30, 33, 44, 54). None of the studies reported using equipment for PA/Exercise.
Targeting and progression of PA interventions
In some of the studies, it was reported that exercises were provided to reablement users if they had an individual need for this (30, 33). However, none of the studies provided information about how the individual needs for exercises or PA were assessed. In the LiFE RCT study by Burton et al. (2013), only older adults that had been prescribed an exercise intervention by their care manager (health professionals, including PTs, OTs or RNs) were included in the study (30). Of the entire group receiving reablement, only 5.4 % met the eligibility criteria of the study; one of which included that they had been referred to an exercise program. This could indicate that only a minority of reablement receivers in that setting was considered to benefit from participating in an exercise program. In a questionnaire study undertaken in the same state of Australia as the LiFE RCT, 30% of reablement clients recalled being given an activity program, and a third of them reported having been encouraged to be more physically active (47).
Several of the studies reported that exercises were progressed and adapted during the reablement period according to the older adults’ development of function (30, 32, 44, 53). In the LiFE program and the structured exercise program in the study by Burton et al. (2013), progression of exercises was reported to be included, but it was not described how the need for progression was assessed (30). In the structured exercise program, it was reported that the participants were to progress to level two exercises on the back of the exercise sheet. In the field study by Eliassen et al. (2018), the researchers observed that the characteristics of the targeting processes of the exercises were mainly divided into two groups; i) standardized approaches and ii) individually tailored approaches (53-55). In the standardized approaches, allied health personnel conducted training sessions based on standardized exercise programs. In these cases the reablement plan (including the exercises) was provided by the PTs, and the allied health personnel made minimal adjustments to this. In the second group, Individually tailored approaches targeting quality of movement, the exercises were individually targeted based on extended examinations and assessments by PTs, including functional analysis regarding movement and structure of muscles and joints, in addition to standardized physical performance tests. In these teams, the allied health personnel were instructed about movement quality, however it was described that only a few of them were able to pay attention to the small details of the instructions (54). Similar to this second approach, Moe et al. (2016) reported from another Norwegian field study, that exercises (and other therapeutic activities) were based on a detailed screening that identified activity goals and functional impairments, as well as other factors contributing to functional loss such as pain, malnutrition and medication use (69). Several of the studies described that the role of the health professionals was to be a consultant and/or advisor, including developing and adjusting a rehabilitation plan and supervise allied health personnel. The allied health personnel were then responsible for following up on the training, including e.g. encouraging, supporting and ensuring security when the older adult performed everyday activities and/or exercises (53, 54, 58, 62).
Compliance of PA recommendations
Burton et al. (2013) was the only study that had assessed compliance with exercises during the intervention period, by using an exercise adherence diary (30). They found that participants undertook exercises on average 4.91 times a week (in the LiFE group) and 4.42 times a week (in the structured exercise group). In the six-month follow up study it was reported that the participants in both groups still undertook exercises, though a little less often (average of 3.45 times per week) (42).
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Q2 -Experiences and barriers for PA
Older adults’ perspectives
Six qualitative studies explored older adults’ experiences of participating in reablement (65-70), of which three qualitative studies (two Norwegian and one from the United Kingdom) (67, 69, 70) and also one mixed method study(45) touched upon themes related to PA, which are summarized in the following. Additionally, one Australian mixed-method study investigated motivators and barriers to being physically active for older people (70+) that previously had received either reablement or usual home care services (43), and one Norwegian quantitative study explored which occupations and rehabilitation goals older people prioritizes in a reablement setting (75).
In a field study by Moe et al. (2016), the older adults experienced physical strengthening to be essential for their progress and that physical strengthening also led to increased participation in other activities in their daily life (69). Some older adults reported that they felt insecure when participating in activities, due to fear of injury or overload of body structures (69). However, they experienced that self-confidence to manage exercises and activities was built during the reablement period and was strengthened by doing activities repeatedly (69). Similarly, Hjelle et al. (2017) found that the older adults’ willpower to engage in exercises and everyday activities evolved during their recovery (67). The older adults’ determination and willpower was considered important for their engagement in exercise and performing everyday activities (67).
Encouragement, support, supervision, and a push by reablement staff was considered a motivational factor for increasing PA (67, 69). The support from the reablement staff stimulated some older adults to do exercises/activities on their own and also to continue PA after the reablement period, while others were only motivated when the staff were encouraging them (67). Older adults reported that they preferred to plan their own day themselves, including deciding when to perform training and activities, and that being in their home environment stimulated them to be independent and take part in everyday activities (67). Organizing the home to make it safer and easier to maneuvre inside, as well as reducing barriers for outside activities were also reported as important for activity performance (69).
Some of the older adults expressed that they considered exercising or training to be something different than practicing activities (67). They considered training in reablement as doing physical exercises in order to improve physical strength, balance or range of motion, but they did not consider ADL as training, although the HCPs facilitated training in ADL as well as suggesting various physical exercises. In a study from the UK by Wilde et al. (2012), service users expressed frustration at the limited access to wider sources of professional expertise (social workers and OTs were involved in that setting), particularly with the aim of maintaining or improving their ability to walk outdoors and manage stairs so that they could participate in social activities (70). Likewise, another UK study reported that outdoor mobility goals were difficult to reach due to fluctuations in the users’ health or weather conditions (45).
Tuntland et al. (2019) investigated what types of activities or tasks that older adults that had participated in an Norwegian RCT (33) reported as difficult to perform, and which activities they prioritized as rehabilitation goals (75). They found that fracture and dizziness/balance problems were the most frequent reasons for needing reablement. Functional mobility goals, such as going for a walk, climbing stairs, transferring or outdoor mobility were most frequently prioritized (35% of prioritized sub-areas), followed by personal care activities, such as taking a shower or dress/undress (18% of prioritized sub-areas) and household activities, such as preparing food or cleaning/vacuuming the house (15% of prioritized sub-areas).They also reported that some of the responses remained unclassified (3.5%) because they were mainly impairment-based goals such as improving balance, strength or memory, rather than activity-based goals.
Burton et al. (2013) found in their mixed-method study that health and fitness (reported by 56.3% of reablement receivers) and well-being (55.3%) were the top two reasons participants gave for being active, followed by enjoyment (48.4%), social/family (44.7%) transport (20%), weight loss (18.6%), walking the dog (11.6%) and competition/challenge (7%). The highest ranked barriers were ongoing injury/illness (reported by 45.6% of reablement receivers) and feeling too old (41.4%), followed by temporary injury/illness (17.7%), nobody to be physically active with (12.1%), lack of transport (11.6%), cost (7%), nowhere to be physically active (4.7%), not interested (3.7), do not know how to be physically active (1.9%) and lack of time (3.7%) (43).
HCPs’ perspectives
Fifteen qualitative studies and two mixed method/feasibility/implementation studies investigated inquiries based on HCPs experiences or perspectives on reablement (44, 46, 50, 52-64, 76), but none of these specifically aimed at investigating or exploring HCPs’ experiences related to PA facilitation. However, some of the studies – of which five were Norwegian (53-55, 58, 60), two were Danish (51, 62), one Australian (44) and one from the USA (46), brought up perspectives from HCPs related to activity training or exercises, which are presented in the following.
HCPs considered the organization of tasks between health professionals and allied health personnel to be beneficial for reaching out to a larger population and for giving more intensive training (54, 58). However, it was also reported that the competencies of the allied health personnel and the team collaboration could have impact on the content of the training or exercises (46, 53-55). HCPs in several of the studies noted that it was advantageous to implement simple and recognizable exercises, that could easily be explained to both the allied health personnel and the older adults (44, 46, 54). It was considered beneficial to use written instructions for the exercises/training (44, 46), and in one study they reported lower compliance among users when e.g. giving complicated verbal instructions without leaving written instructions (46).
In some reablement settings, the ability to target the exercises/training to the older adults’ individual needs, including a focus on movement quality, was more emphasized than standardized exercise programs (53). In these teams, a more intense collaboration between health professionals (PTs in this case) and allied health personnel was observed, including both formal and informal meeting-points, as well as on-going supervision and common reflection in the team. It was emphasized that allied health personnel had the required competencies to follow up individually targeted interventions, that they were capable of independent evaluations of the older adults’ function and independence during the period, and also that they had sufficient competence to evaluate the need for additional therapeutic assistance (53). The allied health personnel in these teams expressed that it was difficult to point out what to look for, but that they learned along the way. Thus, this approach relied more on building the competencies of allied health personnel, which was reported as a limitation in other settings (46, 54).
The roles of the allied health personnel were found to be transformed from being carers to become trainers and implied a change of mindset of what it means to be a good carer (76). However, this transformation of mindset could also lead to discrepancies regarding different disciplinary views and norms related to caring and rehabilitation (76). Phrases such as keeping your hands behind your back and don’t take over for the citizen were reported to be commonly repeated in a Danish reablement setting, and HCPs were reported to increasingly assume a physically passive position, including a more distanced, observational and instructing practice (62).
One study investigated HCPs perspectives regarding family members of older adults in a reablement setting (60). They found that family members were sometimes considered a resource, that could facilitate the older adult to participate in additional activities. However, the family members could also be a barrier to (physical) activity, by taking over the older adults daily activities. Several studies reported that the knowledge and values related to the benefits of PA and active aging sometimes were met with skepticism or resistance from older adults themselves, family members, HCPs or by habitual traditions of running healthcare services (46, 60, 64, 76).
Family members’ perspectives
Three Norwegian studies had investigated family members’ perspectives (including relatives, adult children and caregivers/spouses) and experiences with reablement (69, 71, 72), and two of them touched upon some themes related to PA (71, 72). Family members expressed that they wanted information about how to support and motivate the older adult to engage in PA (71, 72). However, some of them expressed that taking this responsibility was problematic (72). Some of the family members perceived that it was difficult for them, in the role as a family member, to facilitate PA, and that the older adult (their mother/father etc) were more likely to listen to PA advice from the reablement staff (72). Some of the family members missed follow-ups, including motivation to train and practice to ensure that the older adults’ achieved function was maintained after the reablement was finished (71).
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Q3 -Assessment of physical fitness and PA levels
Physical fitness
Five of the 11 intervention studies that were included (three Australian studies and two Norwegian studies) reported using at least one standardized clinical measure of physical fitness (30, 31, 33, 35, 36). Timed up and Go (TUG) was most frequently used (n=4) with the aim of measuring functional mobility (30, 31, 33, 36). One study used the Short Physical Performance battery (SPPB) to measure lower extremity strength, walking speed and static balance (35). Specific strength assessments included Sit-to-stand one repetition and five repetitions (30) and Grip Strength/Dynamometer (33), while specific balance assessments included Functional reach/static balance (30) and Tandem walk/dynamic balance (30). Follow-up measures of physical fitness in the intervention studies were made at 8 weeks (30), 10 weeks (35) three months (31, 33, 36), six months (35, 42), nine months (33) and 12 months (31, 35, 36). Eliassen et al. (2018) reported in their field study that SPPB was used as a standard assessment method in all of the seven included Norwegian municipalities, and that some of the municipalities also used additional tests (no further details provided) related to movement quality (54).
Among the included RCT-studies, the two studies that reported mobility outcomes (TUG) did not have comparable comparison interventions (one compared two different exercise interventions in reablement and the other compared reablement with standard homecare services) (30, 33). Thus, a synthesis of this evidence would not be considered adequate. Among the non-RCTs, more positive results for physical fitness outcomes were reported (for TUG and SPPB), however the design of these studies meant that the risk of bias was too high to be included in a synthesis of outcomes. No other outcome measures related to physical fitness were comparable in the RCTs. Overall, the only significant differences related to physical fitness in an RCT study was reported by Burton et al. (2013), that reported significantly better outcomes in balance (tandem walk) in the reablement + LiFE program compared to reablement + structured exercise program (30).
Physical activity
None of the intervention studies assessed levels of PA or sedentary behavior. However, one Australian RCT reported using an exercise diary to assess adherence (30). One feasibility study (44) used the physical activity scale for the elderly (PASE) to assess habitual PA among older adults receiving reablement in an Australian setting. They also used an accelerometer to assess energy expended over seven days. It was however, decided not to include accelerometer assessments in the following RCT because of poor compliance and potential for causing discomfort to some participants (44).
The only study that reported PA levels among older adults (that previously had received either reablement or usual care), was an Australian questionnaire study (n=506) that used the self-reported PASE questionnaire to assess and compare PA levels between participants receiving reablement and usual care (47). They found that 77.7% of all respondents reported that they were physically active for the recommended minimum 30 min of moderate exercise each day, and that there were insignificant differences between groups (47).