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衰弱老年人的活动能力训练可提高其活动能力和功能。

Mobility training for increasing mobility and functioning in older people with frailty.

机构信息

Physiotherapy Department, Prince of Wales Hospital, South Eastern Sydney Local Health District, Randwick, Australia.

Discipline of Physiotherapy, Faculty of Health Sciences and Musculoskeletal Health Sydney, School of Public Health, The University of Sydney, Sydney, Australia.

出版信息

Cochrane Database Syst Rev. 2022 Jun 30;6(6):CD010494. doi: 10.1002/14651858.CD010494.pub2.


DOI:10.1002/14651858.CD010494.pub2
PMID:35771806
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC9245897/
Abstract

BACKGROUND: Frailty is common in older people and is characterised by decline across multiple body systems, causing decreased physiological reserve and increased vulnerability to adverse health outcomes. It is estimated that 21% of the community-dwelling population over 65 years are frail. Frailty is independently predictive of falls, worsening mobility, deteriorating functioning, impaired activities of daily living, and death. The World Health Organization's International Classification of Functioning, Disability and Health (ICF) defines mobility as: changing and maintaining a body position, walking, and moving. Common interventions used to increase mobility include functional exercises, such as sit-to-stand, walking, or stepping practice. OBJECTIVES: To summarise the evidence for the benefits and safety of mobility training on overall functioning and mobility in frail older people living in the community. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, AMED, PEDro, US National Institutes of Health Ongoing Trials Register, and the World Health Organization International Clinical Trials Registry Platform (June 2021). SELECTION CRITERIA: We included randomised controlled trials (RCTs) evaluating the effects of mobility training on mobility and function in frail people aged 65+ years living in the community. We defined community as those residing either at home or in places that do not provide rehabilitative services or residential health-related care, for example, retirement villages, sheltered housing, or hostels.  DATA COLLECTION AND ANALYSIS: We undertook an 'umbrella' comparison of all types of mobility training versus control. MAIN RESULTS: This review included 12 RCTs, with 1317 participants, carried out in 9 countries. The median number of participants in the trials was 97. The mean age of the included participants was 82 years. The majority of trials had unclear or high risk of bias for one or more items. All trials compared mobility training with a control intervention (defined as one that is not thought to improve mobility, such as general health education, social visits, very gentle exercise, or "sham" exercise not expected to impact on mobility). High-certainty evidence showed that mobility training improves the level of mobility upon completion of the intervention period. The mean mobility score was 4.69 in the control group, and with mobility training, this score improved by 1.00 point (95% confidence interval (CI) 0.51 to 1.51) on the Short Physical Performance Battery (on a scale of 0 to 12; higher scores indicate better mobility levels) (12 studies, 1151 participants). This is a clinically significant change (minimum clinically important difference: 0.5 points; absolute improvement of 8% (4% higher to 13% higher); number needed to treat for an additional beneficial outcome (NNTB) 5 (95% CI 3.00 to 9.00)). This benefit was maintained at six months post-intervention. Moderate-certainty evidence (downgraded for inconsistency) showed that mobility training likely improves the level of functioning upon completion of the intervention. The mean function score was 86.1 in the control group, and with mobility training, this score improved by 8.58 points (95% CI 3.00 to 14.30) on the Barthel Index (on a scale of 0 to 100; higher scores indicate better functioning levels) (9 studies, 916 participants) (absolute improvement of 9% (3% higher to 14% higher)). This result did not reach clinical significance (9.8 points). This benefit did not appear to be maintained six months after the intervention. We are uncertain of the effect of mobility training on adverse events as we assessed the certainty of the evidence as very low (downgraded one level for imprecision and two levels for bias). The number of events was 771 per 1000 in the control group and 562 per 1000 in the group with mobility training (risk ratio (RR) 0.74, 95% CI 0.63 to 0.88; 2 studies, 225 participants) (absolute difference of 19% fewer (9% fewer to 26% fewer)). Mobility training may result in little to no difference in the number of people who are admitted to nursing care facilities at the end of the intervention period as the 95% confidence interval includes the possibility of both a reduced and increased number of admissions to nursing care facilities (low-certainty evidence, downgraded for imprecision and bias). The number of events was 248 per 1000 in the control group and 208 per 1000 in the group with mobility training (RR 0.84, 95% CI 0.53 to 1.34; 1 study, 241 participants) (absolute difference of 4% fewer (8% more to 12% fewer)). Mobility training may result in little to no difference in the number of people who fall as the 95% confidence interval includes the possibility of both a reduced and increased number of fallers (low-certainty evidence, downgraded for imprecision and study design limitations). The number of events was 573 per 1000 in the control group and 584 per 1000 in the group with mobility training (RR 1.02, 95% CI 0.87 to 1.20; 2 studies, 425 participants) (absolute improvement of 1% (12% more to 7% fewer)). Mobility training probably results in little to no difference in the death rate at the end of the intervention period as the 95% confidence interval includes the possibility of both a reduced and increased death rate (moderate-certainty evidence, downgraded for bias). The number of events was 51 per 1000 in the control group and 59 per 1000 in the group with mobility training (RR 1.16, 95% CI 0.64 to 2.10; 6 studies, 747 participants) (absolute improvement of 1% (6% more to 2% fewer)). AUTHORS' CONCLUSIONS: The data in the review supports the use of mobility training for improving mobility in a frail community-dwelling older population. High-certainty evidence shows that compared to control, mobility training improves the level of mobility, and moderate-certainty evidence shows it may improve the level of functioning in frail community-dwelling older people. There is moderate-certainty evidence that the improvement in mobility continues six months post-intervention. Mobility training may make little to no difference to the number of people who fall or are admitted to nursing care facilities, or to the death rate. We are unsure of the effect on adverse events as the certainty of evidence was very low.

摘要

背景:衰弱在老年人中很常见,其特征是身体多个系统功能下降,导致生理储备减少,对不良健康结果的脆弱性增加。据估计,65 岁以上的社区居民中有 21%是虚弱的。衰弱与跌倒、移动能力恶化、功能下降、日常生活活动受损和死亡独立相关。世界卫生组织的《国际功能、残疾和健康分类》(ICF)将移动能力定义为:改变和维持身体姿势、行走和移动。常用于增加移动能力的常见干预措施包括功能性锻炼,如坐站、行走或踏步练习。 目的:总结在社区居住的虚弱老年人中进行移动训练对整体功能和移动能力的益处和安全性的证据。 检索方法:我们检索了 CENTRAL、MEDLINE、Embase、AMED、PEDro、美国国立卫生研究院正在进行的试验登记处和世界卫生组织国际临床试验注册平台(2021 年 6 月)。 选择标准:我们纳入了随机对照试验(RCT),评估了针对 65 岁以上社区居住的虚弱人群的移动训练对移动和功能的影响。我们将社区定义为那些居住在家庭或不提供康复服务或与健康相关的居住护理的地方的人,例如退休村、庇护性住房或宿舍。数据收集和分析:我们对所有类型的移动训练与对照组进行了“伞式”比较。 主要结果:本综述纳入了 12 项 RCT,涉及 1317 名参与者,在 9 个国家进行。试验的中位数参与者人数为 97 人。纳入参与者的平均年龄为 82 岁。大多数试验对一个或多个项目存在不确定或高偏倚风险。所有试验均将移动训练与对照组进行了比较(定义为不被认为可以改善移动能力的干预措施,例如一般健康教育、社交访问、非常温和的运动或不期望对移动能力产生影响的“假”运动)。高确定性证据表明,移动训练可提高干预结束时的移动水平。对照组的移动能力评分平均为 4.69,而接受移动训练的组的评分提高了 1.00 分(95%置信区间(CI)为 0.51 至 1.51))在短期身体表现电池(范围为 0 至 12;分数越高表示移动水平越高)(12 项研究,1151 名参与者)。这是一个具有临床意义的变化(最小临床重要差异:0.5 分;绝对改善 8%(4%更高至 13%更高);额外获益的治疗需要数(NNTB)为 5(95%CI 为 3.00 至 9.00))。这种益处在干预结束后 6 个月时仍然存在。中等确定性证据(因不一致而降级)表明,移动训练可能会提高干预结束时的功能水平。对照组的功能评分平均为 86.1,而接受移动训练的组的评分提高了 8.58 分(95%CI 为 3.00 至 14.30))在巴氏量表上(范围为 0 至 100;分数越高表示功能水平越高)(9 项研究,916 名参与者)(绝对改善 9%(3%更高至 14%更高))。结果没有达到临床意义(9.8 分)。这种益处似乎在干预结束后 6 个月内没有维持。我们对移动训练对不良事件的影响不确定,因为我们将证据的确定性评估为非常低(因不精确和偏倚降低一个级别)。对照组的事件数为每 1000 人 771 人,而接受移动训练的组为每 1000 人 562 人(风险比(RR)0.74,95%CI 为 0.63 至 0.88;2 项研究,225 名参与者)(绝对差异为 19%的事件更少(9%更少至 26%更少))。移动训练可能对干预结束时进入护理设施的人数没有差异或差异很小,因为 95%置信区间包括进入护理设施的人数减少和增加的可能性(低确定性证据,因不精确和偏倚降级)。对照组的事件数为每 1000 人 248 人,而接受移动训练的组为每 1000 人 208 人(RR 0.84,95%CI 为 0.53 至 1.34;1 项研究,241 名参与者)(绝对差异为 4%的事件更少(8%更多至 12%更少))。移动训练可能对跌倒人数没有差异或差异很小,因为 95%置信区间包括跌倒人数减少和增加的可能性(低确定性证据,因不精确和研究设计限制降级)。对照组的事件数为每 1000 人 573 人,而接受移动训练的组为每 1000 人 584 人(RR 1.02,95%CI 为 0.87 至 1.20;2 项研究,425 名参与者)(绝对改善 1%(12%更多至 7%更少))。移动训练可能对干预结束时的死亡率没有差异或差异很小,因为 95%置信区间包括死亡率降低和增加的可能性(中等确定性证据,因偏倚降级)。对照组的事件数为每 1000 人 51 人,而接受移动训练的组为每 1000 人 59 人(RR 1.16,95%CI 为 0.64 至 2.10;6 项研究,747 名参与者)(绝对改善 1%(6%更多至 2%更少))。 作者结论:综述中的数据支持使用移动训练来提高虚弱的社区居住老年人的移动能力。高确定性证据表明,与对照组相比,移动训练可提高移动能力,中等确定性证据表明,它可能提高虚弱的社区居住老年人的功能水平。有中等确定性证据表明,移动能力的改善在干预结束后 6 个月内持续。移动训练可能对跌倒或入住护理设施的人数或死亡率没有影响。我们对不良事件的影响不确定,因为证据的确定性非常低。

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