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Abstract

To review the effects of Otago exercise program (performed individually or in group) on several physical and psychosocial outcomes for community-dwelling and institutionalized older adults. Fourteen articles met the inclusion criteria. Three electronic databases and reference lists of identified studies were searched. Eligibility criteria included clinical trials of the Otago exercise program conducted among older adults. Two studies were conducted in institutions, 2 in groups. None of the studies reviewed reported the post-intervention result of the Otago exercise program on depression or any other psychological construct. Otago exercise program was effective in reducing falls, improving balance, strength, mobility, and health-related quality of life within the community and in institutions. Available evidence suggests group performance may be better than individual programs. The Otago exercise program is an important and effective exercise strategy which can be administered in groups or individualized to both community-dwelling and institution-resident older adults. Future reviews, especially, systematic reviews with meta-analysis should be performed.

Keywords

community-dwelling institutionalized Otago exercise program older adults

What do we already know about this topic?

The effectiveness of the Otago Exercise Program on fall intervention

How does your research contribute to the field?

This review would provide evidence based data on the effectiveness of the Otago Exercise Program on physical and psychosocial functions among older adults in the community and institutions.

What are your research’s implications toward theory, practice, or policy?

Health care professionals and researchers would have available to them information on variables that have been explored using the Otago Exercise Program. It would also help policy makers in formulating policies for older adults to ensure healthy/active aging.

Introduction

Globally, falls and their consequences continue to be significant public health challenges for the older adult population, caregivers and health care providers.^1-3 Approximately one-third of older adults fall at least once every year as a result of intrinsic and extrinsic risk factors.⁴ The risk of falls can increase due to an interaction of multiple factors related to aging such as depression, reduced muscle strength, balance, and gait changes.^5,6 Fall is a common cause of injury, morbidity and mortality that affects all older adults whether resident in institutions or in the community.^7-10 It can lead to increased dependency, institutionalization, fear of falling, high economic cost, prolonged activity restriction and associated problems such as fear of falling with its negative impact on quality of life.^11-13 Fear of falling (FOF) is a common consequence of falls and has been associated with limitation and/or reduction in the performance of activities of daily living, mobility, physical capability, mental health, balancing activities, quality of life, and also with increased institutionalization among older adults.^14,15 Approximately half of those who fall develop fear of falling.¹⁶ According to Cox and Williams,¹⁷ fear of falling may occur in older adults, regardless of their history of falls. Over the years, FOF has been identified as a substantial health issue for older adults both physically as well as psychologically.¹⁸

Previous studies have reported varying prevalence rates of falls among older adults: 60.3% in Egypt,¹⁹ 50.8% in United Arab Emirates,¹³ 34.7% in Ecuador,²⁰ 27.8% in Nigeria,¹⁴ 27.6% in Brazil,²¹ 24.98% in India.²² Recurring falls in the older adult population may result in serious health problems. Depression, fear of falling and other psychological problems are common consequences of recurrent falls.²³ Reports from recent Nigerian studies showed that there is a high prevalence of fear of falling among assisted-living and community-dwelling older adults respectively.^15,24

Since falls pose a great concern for the older adults, the need to address it and provide an intervention becomes imperative. Exercise is considered an obvious preference as a fall prevention intervention.^25,26 Over time, individually tailored fall prevention exercise programmes have become more common than general programmes. One example of an individually tailored exercise programme is the Otago Exercise Programme.²⁷

The Otago exercise program (OEP) is a well designed and tested falls prevention program that targets strength and balance deficits and can lead to a reduction in falls by about one-third.²⁸ This comprises 30 min of leg muscle strengthening and balance retraining exercises, progressing in difficulty, to be performed at home at least 3 times per week, and a walking plan for up to 30 min at a moderate pace to be undertaken at least 2 times per week. Otago exercise program has been shown to be effective in reducing fear of falling, falls and fall-related injuries. The Otago exercise program has been shown to be effective in improving balance, functional mobility, physical performance, functional capacity, lower limbs muscle strength, functional independence, health-related quality of life and reduced risk of falling in older adults.^29-32 Otago exercise program reduced risk of falling, improved physical performance, functional capacity, and health-related quality of life in older adults receiving home care. Two previously published reviews,^33,34 revealed the effectiveness of the OEP on the outcomes studied but none of the reviews included any article from Africa or low income populations. There has also not been any comprehensive review that studied the effect of OEP on both physical (falls, physical activity, physical function, balance, strength, mobility) and psychosocial (quality of life, depression, fear of falling) outcomes together either among community-dwelling or institutionalized older adults. Research interest on falls prevention intervention began in the 1970s in developed countries. The available studies were also among community-dwelling older adults with apparently few studies published in this area among institutionalized older adults, a group that has been reported to be more adversely affected by falls and fear of falling than their community-dwelling counterparts.³⁵ This study was therefore aimed at determining what is known about the effects of OEP on physical and psychosocial functions among community-dwelling and institutionalized older adults, in literature.

Methods

Search Strategy

According to Arksey and O’Malley,³⁶ scoping reviews “aim to map rapidly the key concepts underpinning a research area and the main sources and types of evidence available.” Arksey and O’Malley³⁶ developed a 5-stage framework for conducting a scoping review, expanded by Levac et al³⁷ which maintains a methodical course of transparency, in order to ensure reproduction of the search strategy and increasing the reliability of the study findings.³⁸ Consistent with this framework, we (1) identified the research questions, (2) identified the relevant studies, (3) selected the studies, (4) charted the data, and (5) collated, summarized, and reported the results obtained.

Step 1: Posing the initial research question

A considerable number of literatures that related to the outcomes of interest were extensively covered, through mapping the following initial research questions which guided the search: What is known from available literature about the effects of OEP on physical and psychosocial functions among community-dwelling and institutionalized older adults?

Step 2: Identifying the relevant research studies

For electronic searching, articles were identified by searching abstracts, titles and key words using appropriate MeSH terms or key words related to “Otago Exercise Program” (otago exercise), “older adults” (older, elderly, elder, senior), “effects” (impact, influence), “physical” (fall, balance, strength, physical activity, physical function, mobility), “psychosocial” (anxiety, depression, quality of life, fear of falling), “community” (community-dwelling), “institution” (long-term care, assisted living facility, nursing home, institutionalized). In order to broaden our search and ensure that we did not miss any relevant article, we did not restrict our searches to any publication date. The search was however, restricted to peer-reviewed English-language articles available online in order to avoid the cost of language translations. PEDro, PubMed, and Cochrane databases were used for the search. Furthermore, a manual search of the reference lists of identified articles was conducted and Google Scholar was searched to identify additional relevant articles within grey literature. The literature search was concluded in 6 months, ending in November 2020.

Step 3: Selecting the Studies

Using the title, abstract, keyword search, we identified 1069 articles (Cochrane = 352; PubMed = 574; PEDro = 143). Google Scholar yielded no additional relevant article. Six articles were also identified by a manual search of the reference lists of relevant studies. All the searches yielded a total of 1075 articles. Several articles were removed from the search as they were duplicated in all the databases. We manually removed 776 duplicates, resulting in 299 articles remaining. A critical re-evaluation of the available identified articles (titles and abstracts) revealed substantial numbers of articles that were not relevant. The relevance of papers without abstracts was ascertained from the title and key words. Full-texts of the remaining articles (number = 45) were obtained and further screened for eligibility. Keeping in mind the eligibility criteria, 14 articles considered relevant to this study topic were included. Figure 1 below is a PRISMA flowchart illustrating the process of selection of articles for this study.

Figure 1.

PRISMA diagram of the search strategy and study selection processes.

The following eligibility criteria were chosen in order to ensure that the selected articles studied only the variables under review.

Inclusion criteria: Original research articles; published in English language in a peer review journal; OEP was the central topic of the paper; the research was concerned with older adults. We also included studies where OEP was compared with no intervention or a placebo control intervention.

Exclusion criteria: We excluded articles that did not discuss OEP and/or older adults. Studies that included people who were not solely older adults were excluded.^39-42We also excluded studies in which OEP was part of a multifactorial program or not solely the intervention such that participants received other interventions^41,43-45; or studies in which OEP was in comparison with another exercise intervention.⁴⁶ We excluded feasibility/protocol/pilot studies; non-experimental studies; case report studies, follow-up studies. Two studies^47,48 were 12- and 24-month follow-up studies of another randomized controlled trial,⁴⁹ and so were excluded while retaining the initial study. Systematic reviews; non-English language studies; duplicates, other scoping reviews, translational studies of implementation, dissertations, theses and conference papers were also excluded.

Restricting our searches to only English language and scientific articles is a limitation of our search, which may have diminished the scope of this review. However, the strength of this search is the fact that we did not restrict our searches to any publication year in order to ensure that we did not miss relevant article. We did not also restrict this review to studies that must have a comparison with a control group performing the original OEP (Table 1).

Table 1.

The Inclusion and Exclusion Criteria in a PICOS Format.

Component	Inclusion criteria	Exclusion criteria
Population	Studies that were concerned with older adults	Studies that included people who were not solely older adults
Intervention	Otago Exercise Program	Not solely OEP or OEP in conjunction with another exercise protocol
Comparison	Studies where OEP was compared with no intervention or a placebo control intervention. Studies that have a comparison with a control group performing the original OEP	Studies comparing the OEP with another exercise regimen; OEP was part of a multifactorial program
Outcomes	Health-related quality of life, fall, fall efficacy, functional mobility, fear of falling, balance, lower limb muscle strength	Outcomes that are not physical or psychosocial
Study design	Randomized control trial, pretest-posttest design, Quasi-experimental study- pre- and post-test design using a control group, Non randomized experimental study using a control group	Feasibility/protocol/pilot studies, non-experimental studies; translational studies of implementation, systematic reviews, case report studies, follow-up studies, and scoping reviews

Step 4: Charting the data and collation

Summaries of each article were developed as it relates to the author, study location, year of publication, intervention type/study design, study population, sample size, aims of the study, overview of methods, outcome measures, and results (Table 2).

Table 2.

Meta-data of Included Studies.

Authors/ Study location	Study design	Study population	Aims/Objectives/Purposes of the study	Methods/study duration	Outcome measures/Outcomes of interest	Results	Strengths/limitations
Bjerk et al²⁹/Norway	RCT	155 older adults, Mean age = 82.7 years, 79.3% women, Able to walk with or without a walking aid	To determine the effects of a falls prevention exercise program on health-related quality of life (HRQOL), physical function and falls self-efficacy in older fallers receiving home care.	Otago exercise program for 12 weeks. Three times weekly for 30 min, and walk up to 30 min at least 2 times weekly	Health-related quality of life, BBS, Sit-To-Stand test, FES-1	Otago exercise program improved physical HRQOL and balance in older adults receiving home care. There was no effect on falls self-efficacy.	Well-known assessment instruments were employed, but some were self-reported introducing additional uncertainty. Recruitment was active and outreaching, and drop-outs were few, which could have limited selection bias and increased the representativeness by providing a clinical relevant sample. Participants were more heterogeneous and medically unstable.
Kyrdalen et al⁵¹/Norway	RCT	125 people, Mean age = 82.5 ± 5.7 years, 73% Women; Able to walk without support from another person	The study aimed to compare the Otago exercise program, originally designed as supervised home training, with the same program performed as group program, on functional balance and muscle strength, mobility, fall efficacy and self-reported health.	Otago exercise program for 12 weeks; as group training twice weekly or as home program 3 times a week	Balance by Berg Balance Scale, strength by 30-second sit-to-stand test, self-reported health measured by the Short Form-36. Change in mobility measured by the Timed Up and Go test, and fall efficacy by the Fall Efficacy Scale International	Otago exercise program performed as group training is more effective for improving functional balance, muscle strength and physical health, but not fall efficacy and mental health than when performed as home program.	A high dropout rate which may have introduced some level of bias. The time window from randomization to start of the group program was set to 30 days. A change in functional or health status may have occurred among those with the longest waiting time which also may have influenced the results.
Dadgari et al⁵²/Iran	RCT	317 community-dwelling older, Mean age = 70.3 ± 5.5, Able to walk independently for 10 m	To examine the effectiveness of Otago exercise program to reduce falls among older adults.	Otago exercise program for 6 months; 3 times a week	The functional capacity included the Berg balance scale (BBS) and the timed up and go test (TUGT). Chair stand test (CST) and arm curl test (ACT) assessed physical performance for each subject.	Otago exercise program improved physical performance and functional capacity. In addition, Otago exercise program significantly reduced the incidence of falls.	Limitation includes application of falls self-report profiles. The health condition of most of the participants played a deterrent role for participation in the program. This study supports the effectiveness of OEP to improve balance and prevent falls among elderly people.
Liu-Ambrose et al⁵³/Canada	RCT	74 older adults Mean age = 82.5 ± 6.4, 69.4% women, Able to walk at least 3 m	To determine the effects of the Otago exercise program on physiological falls risk, functional mobility, and executive functioning after 6 months in older adults with a recent history of falls; and also ascertained the effect of the OEP on falls during a 1 year follow-up period	Otago exercise program for 6 months; 3 times per week (approximately 30 min); and to walk at least twice per week	Physiological falls risk was measured using the Physiological Profile Assessment. Functional mobility was assessed using the Timed Up and Go Test. Three central executive functions were assessed	At 6 months, there was no significant between-group difference in physiological falls risk or functional mobility. There was a significant between-group difference in response inhibition. The novelty of the current study was the indication that the Otago exercise program may reduce falls by improving cognitive performance.	The groups were balanced for sex, so there is little risk of the result being confounded, although the effect of group exercise on executive function in older women may have been underestimated. The rate of recruitment was high for an exercise intervention. A pitfall is the inclusion of fewer than 50% of patients who were seen in the falls clinic. There was no adequate sample size.
Liew et al³²/Malaysia	RCT	67 Patients Mean age = 75.6 ± 7.1, 79.2% women, able to walk at least 3 m	To evaluate the effect of Otago exercise program on hand grip strength, mobility and balance outcomes	Modified Otago exercise program for 3 months with 6 months follow up; at least 3 times a week	Mobility (TUG), balance (BBS, Functional Reach test), and grip strength (This measurement was performed using a Jamar hydraulic hand dynamometer)	Significant improvements were observed in grip strength, mobility and balance in the Otago exercise program group. The Otago exercise program also prevents deterioration in upper limb strength.	Limitation includes lack of power to detect smaller changes due to the relatively small number of participants, and shorter duration. The study serves as a pilot study to inform future larger studies to evaluate exercise programs for the prevention of frailty and sarcopenia among older individuals presenting with falls
Arkkukangas et al⁴⁹/Sweden	RCT	175 older adults Mean age = 83 ± 4.7 years; 70% women have the ability to walk Independently	This study aimed to explore the short-term effect of a home-based exercise program with or without motivational interviewing (MI) compared with standard care on physical performance, fall self-efficacy, balance, activity level, handgrip strength, adherence to the exercise, and fall frequency.	Otago exercise program for 12 weeks; 3 times weekly	Measurements of physical performance, fall self-efficacy, balance, activity level, handgrip strength, adherence to the exercise, and fall frequency were done before and 12 weeks after randomization.	No significant differences were observed between groups after 12 weeks of regular exercise. Within the Otago exercise programme + MI group, physical performance, fall self-efficacy, physical activity level, and handgrip strength improved significantly; likewise, improved physical performance and fall self-efficacy were found in the control group. A corresponding difference did not occur in the Otago exercise program group. Adherence to the exercise was generally high in both exercise groups.	Limitations include Short duration of follow-up; the similarities of the exercise programs and the unexpected improvement in the control group. The control group did not keep exercise diaries. The strength of this study is the control of treatment ﬁdelity, the thoroughly followed protocols including proper randomization and blinding
Kocic et al³¹/Serbia	RCT	77 older adults Mean age = 78.4 ± 7.6 years, 66.4% women independently walking, cognitively unimpaired residents	To examine whether the 6-months group-based OEP is more effective than usual care on physical function and functional independence in nursing home residents older than 65 years.	Group Otago exercise program for 6 months; 3 times a week, walk 2 times weekly	Physical function was assessed at baseline, after 3 and 6 months of the Otago exercise program by 3 performance tests: Berg Balance Scale (BBS), Timed Up and Go (TUG) and Chair Rising Test (CRT), and functional independence by the motor Functional Independence Measure (mFIM)	The Otago exercise program was shown as effective in improving balance, functional mobility, lower limbs muscle strength and functional independence, indicating that it could help in slowing of disability progression.	The strength of the study was that physical performance tests were assessed by 2 investigators who had been a board certified rehabilitation medicine specialists ensuring uniform criteria of data collection. Also, exercises were performed under supervision of 2 physiotherapists who encouraged the participants’ progression. Again, the overall exercise sessions attendance rate was very high. Furthermore, there were no major adverse events. Drop-out rate was slightly higher
Liu-Ambrose et al⁵⁴/Canada	RCT	344 participants Mean age = 81.6 ± 6.1. 67% women	To assess the effect of a home-based exercise program as a fall prevention strategy in older adults who were referred to a fall prevention clinic after an index fall.	Otago exercise program for 12 months; 3 times per week and walk at least twice per week	Rate of falls, changes in fall risk (Physiological Profile Assessment), general balance, and mobility (Timed Up and Go Test). Short Physical Performance Battery score	Otago exercise program significantly reduced the rate of subsequent falls compared with usual care.	It was a single-center study and may not represent other non-urban centers. Again, a single geriatrician provided care for 70% of the patients and may not be representative of all geriatricians. There were multiple secondary outcome measures, and no adjustment for multiple comparisons was made.
Binns and Taylor⁵⁷/West Auckland	A clinical trial	37 community dwelling women Age ≥80 years, independently mobile	To explore the effect of participation in the Otago exercise program on clinical measures of lower limb strength and balance in community dwelling older women	Otago exercise program for 6 months	Strength—30 s chair stand test, balance—step test, mobility—TUG, and falls self-efficacy–MFES.	There were no statistically significant differences between the groups for any of the outcome measures. It is of interest that the control group did not deteriorate significantly on any of the outcome measures although they received no formal input. This may be due to 6 months being an insufficient period of time in which to observe the manifestation of physiological changes associated with the aging process	Small sample size was recruited. The relationship between improvements in strength and balance and falls reduction is unclear. Participants were reassessed on all outcomes after 6 months participation in the OEP instead of after the full 12 months of the program.
Park & Chang⁵⁵/Korea	Pre- and post-test design	Eight stroke participants Age ≥65 years 62.5% women	To determine the effects of the Otago exercise program on fall efficacy, activities of daily living, and quality of life in elderly stroke patients	Otago exercise program for 8 weeks; 3 times per week	The Fall Efficacy Scale score for fall efficacy, modified Barthel index for activities of daily living, and EQ-5D for quality of life	The Otago exercise program improved fall efficacy significantly as well as the score for activities of daily living and quality of life, though not significantly	The results could not be generalized to elderly stroke patients because of the small number of participants. Also, there was no follow-up testing. It is the only study in this review that studied a specific disease condition.
Phu et al⁵⁶/Australia	Pre- and post-test design	195 participants (median age 78 years, IQR 73-84; 67% women	To compare the effects of virtual reality training using the Balance Rehabilitation Unit (BRU) versus exercise using a modified Otago Exercise Program (EX) on improving balance and physical performance in the short-term restorative care setting of the Gait and Balance Gym (Gabagym)	Otago exercise program for 6 weeks; twice a week	Balance and physical performance were assessed at initial and final attendance and included the 5 Times Sit to Stand (5STS) test, Timed Up and Go (TUG), gait speed and posturography assessment using the BRU. Fear of falling was assessed using the Falls Efficacy Scale. Handgrip strength and adherence were also monitored.	Both intervention groups improved in balance and physical performance measures. Both interventions showed significantly better improvement than the non-intervention group in TUG, gait speed, limits of stability in posturography assessment, FES-I score and handgrip strength	Testing a new technology specifically designed to measure and treat balance in a population of participants at high risk of falls and fractures is a strength of this study. Groups were well balanced on demographic, physical performance and clinical characteristics. There was no significant differences between groups at baseline for the majority of measures. Limitations include: activities performed in addition to the supervised sessions were not controlled. There was also no randomization which could lead to the introduction of bias to the results.
Patel and Pachpute²³/India	Pre- and post-test experimental design	30 community dwelling older adults Age ≥60 years	To find the effects of Otago exercise program for fall prevention in community dwelling elderly people.	Otago exercise program for 6 weeks; walking for 2 times a week.	Tinetti Performance Oriented Mobility Assessment, 10RM and Chair stand test	The Otago exercise program is significantly effective in increasing strength of lower limb and improving in balance, gait and prevention of fall in elderly people in India.	Otago exercise program can be used in day to day clinical practice. Limitation includes small sample size.
Kiik et al³⁰/Indonesia	Quasi-experimental study- pre- and post-test design using a control group.	42 older adults living in a social elderly institution Mean age = 74 ± 8.53 55% women	This study aimed to investigate the effect of a 12-week Otago Exercise intended to reduce the risk of falls and health status among the elderly with chronic illness in the social elderly institution.	Otago exercise program for 12 weeks; twice a week	The short form 12 health survey (SF-12) was used to measure the health status of the elderly. The risk of falling was measured using the observation sheet of Timed Up and Go Test (TUGT)	Otago exercise significantly reduced the respondents’ risk of falling and enhanced their health status. Significant differences were observed between the 2 groups in terms of the risk of fall and health status.	There was no blinding process.
Martins et al⁵⁸/Portugal	Non randomized experimental study using a control group	34 participants Mean age = 83.24 ± 6.89 years 76.7% women	To evaluate the effect of a “modified” Otago, incorporated within a technological system, on functional abilities, social participation, and self-efficacy for exercise in older adults.	Modified Otago exercise program for 8 weeks; 3 times a week	Handgrip Strength, 30 Seconds Sit-to-Stand (30 s STS), Timed Up and Go (TUG), Step Test, Stage Balance Test Modified (4StageBTM), Self-efficacy for Exercise (SEE), Activities and Participation Profile related to Mobility (PAPM)	The intervention group showed positive results in the self-efficacy for exercise, PAPM and all functional tests, except for timed up and go. It improves functional abilities, social participation, and self-efficacy, reducing the risk of falling.	The study provides an additional scientific contribution to the potential usefulness of exercise programs incorporated in technological tools. There was no randomization nor blinding in this study.

Step 5: Collating, summarizing, and reporting the results

The final stage collates, summarizes and reports findings.

Results

The critical appraisal of included articles was utilized in this review to assess the methodological quality using the mixed methods appraisal tool (MMAT).⁵⁰ All the studies had low risk of bias. Seven studies utilized an appropriately performed randomization,^{29,31,49,51-54} while 2 of the studies did not perform an appropriate randomization.^30,32 They simply mentioned “using simple randomization.” The remaining 5 studies did not employ randomization. Twelve studies had their participants’ characteristics comparable at baseline; Park and Chang⁵⁵ and Patel and Pachpute²³ had only one group and so could not make comparisons. Eleven studies had a complete data, while the remaining 3 had attrition rates exceeding the recommended accepted rate or had less than 70% of participants completing the study.^51,54,56 Eight studies blinded the administrators to the intervention.^{29,31,32,49,51,53,54,57} The remaining 6 studies made no mention of the blinding process. There was clear representativeness of adherence to intervention protocol in 6 studies.^{23,29,31,49,51,58}

Table 2 below summarizes the meta-data of all the included studies concerning study design, population, aims/objectives, methodology, outcome measures, results, strengths/limitations.

Location of the Studies

This scoping review yielded 14 articles that were published in 12 countries: Canada (2 studies), Norway (2 studies), Australia (1 study), India (1 study), Indonesia (1 study), Iran (1 study), Korea (1 study), Malaysia (1 study), Portugal (1 study), Serbia (1 study), Sweden (1 study), West Auckland (1 study). Approximately 71.4% of the reviewed articles were from Asia and Europe. There was a significant absence of literature from Africa.

Study Design

The study designs utilized by the 14 reviewed articles were: randomized controlled trials (8 studies), pre and post- test design (3 studies), clinical trials (1 study), quasi-experimental study- pre- and post- test design using a control group (1 study) and non-randomized experimental study using a control group (1 study).

Population

Participants were aged 65 years and above. The mean age of the total participants was 79.38 ± 5.85 years. While one trial recruited females only,⁵⁷ the remaining 13 studies recruited a total of 1643 older adults with about 69.6% female (2 studies did not specify the percentage of gender), with a sample size range of 8 to 344. Majority of the trials included ambulant participants (with or without aid), who were not receiving any other form of physiotherapy. Participants needed to be able to walk independently with or without support at least 3 m, because the OEP has a walking component. Only 2 studies recruited only individuals who lived in an institutional setting.^30,31 One study assessed the effect of OEP on specific conditions.⁵⁵

Types of Outcome Measures

Outcomes of interest were physical and psychosocial functions which include: Health-related Quality of life, measurements of physical performance, fall self-efficacy, activity level, handgrip strength, adherence to the exercise, functional independence, gait, strength, rate of falls, fall risk, balance, and functional mobility. Majority (60%) of the articles reviewed aimed at determining balance (71.4%), lower extremity strength (57.1%), and mobility (71.4%). All the studies that assessed mobility utilized Timed-Up-and Go test, while 50% of the studies that assessed balance utilized the Berg Balance Scale (BBS).

Duration of Intervention

The duration of intervention in the articles reviewed was 6 weeks to 12 months: 6 weeks (n = 2); 8 weeks (n = 2); 12 weeks (n = 5); 6 months (n = 4); 12 months (n = 1).

Aims

The studies reviewed explored the effectiveness of the OEP on outcome measures such as balance, strength, gait, functional mobility, health-related quality of life, falls efficacy, falls, fear of falling, etc. among older adults. A study estimated the cost-effectiveness of the OEP from a healthcare system perspective.⁵⁹

Methodology/Intervention Adopted

The interventions adopted by the studies included in this review were OEP in its original and modified forms. Previous reviews used the OEP either in its original form only³³ or modified form only.³⁴

Main Findings of Most of the Included Studies

Most of the included studies reported that: (1) The OEP is significantly effective in increasing strength of lower limb and improving in balance, physical performance measures, functional mobility, gait, reduced the rate of subsequent falls and functional independence, indicating that it could help in slowing of disability progression. (2) The OEP improves functional abilities, social participation, and self-efficacy, reducing the risk of falling and enhancing health. (3) The OEP improved functional capacity as well as the score for activities of daily living and quality of life. (4) The OEP also prevents deterioration in upper limb strength and improves grip strength. (5) OEP performed as group training is more effective for improving functional balance, muscle strength and physical health, but not fall efficacy and mental health than when performed as home training. (6) The OEP improved fall efficacy but some studies found no effect on falls self-efficacy. (7) Majority (12) of the 14 reviewed studies were conducted in the community, while only 2 were conducted in an institution. (8) Only 2 of the reviewed studies were performed in groups; one in each of community and institution.

Table 3 below illustrates the themes from the findings of the reviewed studies

Table 3.

Summary of the Result-Themes and Number of Studies.

Themes	Number of studies
Otago exercise program and fall	2
Otago exercise program and Fear of falling	3
Otago exercise program and quality of life	4
Otago exercise program and balance	6
Otago exercise program and strength	5
Otago exercise program in institutions	2
Otago exercise program in the community	12
Otago exercise program in groups	2
Otago exercise program and functional mobility	4
Modified Otago exercise program	4

Otago exercise program and falls

Falls and fall-related injuries are a leading cause of morbidity and mortality among older adults. The OEP is the most widespread fall prevention program,³⁴ and has been proven to reduce falls by 35%.²⁸

Dadgari et al⁵² reported that in the experimental group, the mean of fall incidence declined from 1.58 to 1.26 from pre to post intervention assessment, showing that the Otago exercise program significantly reduced the incidence of falls.

Findings from Kiik et al³⁰ showed that the Otago training significantly reduced the risk of falling among the studied older adults (P = .041). The risk of falls in the intervention group decreased from 14.26 to 12.05 s and increased from 12.94 to 13.26 s in the control group.

Otago exercise program and fear of falling

Self efficacy is the self-belief or capability to create a plan and implement it.⁴⁶ In studies by Bjerk et al²⁹ and Kyrdalen et al,⁵¹ fear of falling was assessed by Falls Efficacy Scale International (FES-I) which measures fear when performing 16 daily activities. The participants had a mean FES-I score of 30.7. These studies found no effect on falls self-efficacy. This may be due to the shorter duration of the intervention being an insufficient period of time to make any observable psychological changes. However, Park and Chang⁵⁵ revealed that the OEP improved fall efficacy of stroke patients significantly.

Otago exercise program and quality of life

Falls and fall-related injuries have consequent impacts on the quality of life of both fallers and their families. Health-related quality of life in several studies was measured using the Short-Form 36 Health Survey (SF-36). The SF-36 summary score is comprised of a physical component summary and a mental component summary. The scores range from 0 to 100. Bjerk et al²⁹ and Kyrdalen et al ⁵¹ reported that the OEP improved physical health-related quality of life in all physical subscales of SF-36 in the intervention group compared with the control group. However, there was a significant decline in the mental health subscale of SF-36. OEP seems effective in improving physical health; but, may not significantly increase the mental health status. Recent study by Kiik et al³⁰ among older adults with chronic disease however revealed that the mental health status scores in the intervention group increased from 43.24 to 49.42 (P = .002), whereas the physical health status showed no significant increase (P = .556). Park and Chang⁵⁵ utilized the EQ-5D to measure quality of life, and their result showed that the OEP improved quality of life though not significantly. It seems therefore that the presence of chronic diseases or use of varying instruments may determine how quality of life was rated by older adults on OEP.

Otago exercise program and balance

The OEP is a falls prevention program which addresses the risk factors of poor balance and lower limb weakness with an individually prescribed, home-based strength and balance exercise program.²⁷ The BBS was utilized by a greater number of studies to measure balance. The berg balance scale evaluates 14 tasks that are related to stability in sitting, standing, turning around, walking on an even surface, walking on steps and balance while changing body position. It has been found to be excellent, internally consistent and to have a high degree relative inter-rater reliability in a population of nursing home residents.⁶⁰

- Bjerk et al²⁹: Per-protocol analyses showed significant improvements in BBS scores in the intervention group compared with the control group.

- Liew et al³²: Significant improvements were observed in balance in the OEP group. BBS score increased from 48.0 (7.0) at baseline to 49.6 (6.4) at 3 months to 51.5 (5.1) at 6 months

- Kocic et al³¹: The BBS scores increased from 42.7 ± 8.4 (45.0) at baseline, to 47.0 ± 6.7 (48.0) at 3 months to 48.0 ± 6.6 (49.0) at 6 months

- Dadgari et al⁵²: BBS results present significant differences between control and experimental groups when comparing the post-intervention results (x² = 21.31, df = 2, P-value = .025).

- Kyrdalen et al⁵¹: Following the intervention, BBS improved significantly more for the group training group than for the home training group (P = .014). The OEP performed as group training is more effective for improving functional balance than when performed as home training.

- Patel and Pachpute²³ measured balance using Tinetti Performance Oriented Mobility Assessment, and reported a significant difference pre- and post- intervention with mean and standard deviation of 20.42 ± 3.28 versus 21.54 ± 3.44 (P-value = .000).

Otago exercise program and strength

For muscle strength assessment, the sit-to-stand test was used in most of the studies. This involves a standard chair with no arms and a seat height of approximately 43 cm. The participants were asked to fold their arms across their chest and to stand up and from the chair. If successful, participants were asked to stand up and sit down 5 times as quickly as possible. They were timed from the initial sitting position to the final standing position at the end of the fifth stand.

- Bjerk et al²⁹: Per-protocol analyses showed significant improvements in the sit-to-stand scores in the intervention group compared with the control group.

- Kyrdalen et al⁵¹: the OEP performed as group training is more effective for improving muscle strength than when performed as home training.

- Kocic et al³¹: the lower limb strength improved from 12.0 ± 2.6 (12.0) at baseline, to 10.7 ± 2.5 (11.0) at 3 months, to 9.5 ± 2.1 (10.0) at 6 months (P < .001). The OEP was shown as effective in improving lower limbs muscle strength indicating that it could help in slowing of disability progression.

- Liew et al³²: Significant improvements were observed in grip strength in the OEP group. The OEP also prevents deterioration in upper limb strength. Left-hand grip strength increased from 14.0 (7.9) at baseline to 14.7 (6.5) at 3 months, to 13.7 (6.9) at 6 months. Right-hand grip strength improved from 15.8 (6.9) at baseline, to 17.0 (7.0) at 3 months, to 15.8 (6.9) at 6 months. Five Times Sit to Stand test scored 17.4 (10.6) at baseline, 16.4 (9.8) at 3 months, and 15.0 (11.8) at 6 months.

- Patel and Pachpute²³: the Chair Stand Test shows pre and post intervention significant difference in mean and standard deviation of 1.133 ± 0.345 versus 1.346 ± 0.485 (P-value = .01).

Otago exercise program in institutions

The OEP has been shown to be an effective strategy in prevention of functional decline of community-dwelling older people, while there is dearth of evidence to ascertain which exercise program is most appropriate for institutionalized older adults.⁶¹

- Kocic et al³¹: Significant improvement has been observed in the 30 s sit to stand test, BBS, timed up and go test. This could suggest that the OEP might be effective in improving balance, functional mobility, lower limbs muscle strength as well as level of functional independence in nursing home residents older than 65 years.

- Kiik et al³⁰: OEP significantly improves the health status and reduces the risk of falling among older adults with chronic illness (P = .041). The risk of falls after the OEP intervention group decreased from 14.26 to 12.05 s. OEP improved the health status (P = .011) from 42.40 into 47.10, with the mental health status scores increasing from 43.24 to 49.42 (P = .002), though the physical health status showed no significant increase (P = .556). The exercise can be recommended for older adults with chronic illness in social elderly institutions and communities.

Otago exercise program in the community

Substantial evidence on falls prevention among community dwelling older adults abounds.⁶² The OEP has been shown to be an effective strategy in prevention of functional decline of community-dwelling older adults. Majority (85.7%) of the reviewed studies were conducted in the community.

Otago exercise program in group

OEP has been reported to be effective in community dwelling older adults, but in only few studies it was assessed as group-based OEP.^31,51

- Kyrdalen et al⁵¹: The OEP performed as group training is more effective for improving functional balance, muscle strength and physical health, but not fall efficacy and mental health than when performed as home training. The results were significantly better for both Berg Balance Scale and timed up and go test in group-based than in home-based OEP.

- Kocic et al³¹: Significant improvement has been observed in the 30 s sit to stand test, Berg Balance Scale, timed up and go test. This could suggest that the OEP might be effective in improving balance, functional mobility, lower limbs muscle strength as well as level of functional independence in nursing home residents older than 65 years.

Otago exercise program and functional mobility

Majority of the included studies utilized the time-up-and-go-test to measure functional mobility. The timed up and go test involves rising from a chair, walking 3 m, turning around, walking back to the chair and sitting down. The participants are instructed to complete the task at their usual pace. The time is taken when the participants rise from an armchair until they sit down again. The participants are allowed to use their usual walking aids. Each participant is given 3 trials and the average result of 3 trials was used. Scores ≥12 indicate high risk of falls, whereas scores <12 denote a low risk of falling.⁶³ Longer completion times are associated with impaired mobility and fall risk; completion times of 13.5 sor longer indicate high fall risk.⁵⁴

- Kocic et al³¹: The OEP was shown as effective in improving functional mobility indicating that it could help in slowing of disability progression. The timed up and go test improved from 18.9 ± 6.9 (17.1) at baseline, to 17.2 ± 7.1 (15.4) at 3 months, to 16.2 ± 7.5 (13.9) at 6 months (P < .001).

- Liew et al³²: Timed Up and Go test improved from 16.5 (12.2) at baseline, to 14.8 (7.5) at 3 months, to 14.1 (8.7) at 6 months

- Liu-Ambrose et al⁵³: Timed Up and Go Test improved from 14.2 ± 4.6 at baseline, to 13.6 ± 4.3 at 6 months.

- Dadgari et al⁵²: The timed up and go test results present significant differences between control and experimental groups when comparing the post-intervention results of timed up and go test (x² = 36.99, df = 2, P-value = .017).

Modified Otago exercise program

Otago exercise program has been utilized in various modified formats such as exclusion of the walking component of the original Otago exercises,³² exercise in group, kyrdalen, kocic^31,51 a “modified” Otago incorporated in a technological system using pressure and inertial sensors, feedback, and Exergames.⁵⁸ In a systematic review conducted by Martins et al,³⁴ all researches utilizing OEP modified formats revealed improvements on balance and functional ability.

Discussion

Scoping review was chosen in this study because our objective was to identify the important physical and psychosocial outcomes existing in literature as it relates to the Otago exercise program among community-dwelling and institutionalized older adults, which is evidently what scoping reviews were mapped out to do.³⁶

The significant absence of literature from Africa is an issue that warrants attention. According to the World Health Organization, 70% of the aging population live in developing countries where prevalence and incidence of fall are increasing at an alarming rate and injury due to fall is considered as inevitable and high in number. In Africa, a population-based survey from Tanzania revealed that falls accounted for about 35% of reported injuries among older adults.⁶⁴

Our review shows the OEP as an effective exercise prevention intervention among specific older adult population—female-only participants⁵⁷ and condition—stroke.⁵⁵ Previous studies reported that females were associated with a greater prevalence of falls.^20,21 Bekibele and Gureje⁶⁵ had opined that a fall intervention program must have a particular focus on females and those with chronic pain conditions.

Furthermore, this review revealed that only 2 articles studied institutionalized older adults,^30,31 highlighting the limited body of research on this topic, thus suggesting that this population has not been prioritized for research. This calls for serious attention as it has been reported that older adults living in institutions have higher fall prevalence. Evidence reveals that falls are 3 times more frequent in institutionalized older adults than in community-dwellers.⁶⁶ Declines in physical functions associated with age are more prevalent among institutionalized older adults than in community-dwelling older people.⁶⁷ However, the reason for more emphasis on community-dwelling older adults than their institution resident counterparts could be because of its cost-effectiveness, as also revealed in recent studies.⁶⁸ Another reason could be the feasibility of such studies in institutions.

Studies show that exercise can improve balance and reduce fall rates among older adults.⁶⁹ This review corroborates these findings as majority of the included studies reported a significant improvement on all the functional outcomes among older adults; improving physical and psychosocial functioning.^{30,31,51-53,55,57,70-72} However, contradictory results exist on whether the OEP is more effective in improving physical or mental health. While Bjerk et al²⁹ and Kyrdalen et al ⁵¹ reported that the OEP improved physical health-related quality of life in all physical subscales of SF-36 with a significant decline in the mental health subscale; Kiik et al³⁰ revealed improvement in the mental health status scores in the intervention group with no significant increase in the physical health status. Park and Chang⁵⁵ utilized the EQ-5D to measure quality of life, and their result showed that the OEP improved quality of life though not significantly. It seems therefore that the presence of chronic diseases or use of varying instruments may determine how quality of life was rated by older adults on OEP. The Short Form 36 Health Survey (SF-36) is a widely used generic health status questionnaire consisting of 8 domains (physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional and mental health), which measures the quality of life of a population. Higher scores in the domains indicated lower levels of limitation while lower scores indicated high levels of limitation. The EuroQol-5 Dimension (EQ-5D) is a well-established generic tool used for measuring health-related quality of life, consisting of 5 dimensions: mobility, self-care, usual activities, pain/discomfort, anxiety/depression). These 2 instruments are generic. However, there are validated tools with acceptable psychometric properties, specific to older adults, for measuring quality of life among this population, such as the Older People’s Quality of Life Questionnaire (OPQOL-35)^73-75

Conflicting results exist from previous studies on whether group training is more effective than individual training among older adults at higher risk of falling.^76,77 Findings from this review however reveal that group-based Otago exercise program is more effective. This review found that OEP can be successfully and effectively implemented in groups and in institutions, even though there are just very few studies. Only one article studied the effectiveness of the OEP performed in groups among institutionalized older adults.³¹ This buttresses the findings in gerontological literature, that the effects of the OEP performed in groups on falls and fall risks among older adults resident in institutions are sparsely researched.⁷⁸ Performing the OEP in groups is beneficial to the older adults in both settings as it encourages adherence to the program, cost-effectiveness, and enhances social support/participation/networks. Older adults tend to be more secluded, and engaging in group activities can promote social activities and independence.⁷⁹ Leijon et al⁸⁰ had opined that group training motivates participants to perform exercise more effectively and has better adherence rates than individual training. Findings from this review could suggest that the OEP might be effective in improving balance, functional mobility and independence, lower limbs muscle strength, quality of life among older adults. It is therefore important for policy makers and governments to see older adults as a resource in order to help shape decisions concerning them; formulating aging policies especially fall intervention policies.

The theoretical and clinical implications of this study is that health care professionals and researchers would have available to them information on variables that have been explored using the Otago Exercise Program. This would further influence their treatment and rehabilitation plans as it regards older adults while ensuring healthy/active aging.

Gaps in the Research/Key Points

This review found no single study of the OEP from Africa. Further studies on the comparative effects of the OEP on physical and psychosocial functions among community and institution older adult residents are needed. Future studies should compare the effects of the OEP between community and institution older adult residents; and between the OEP applied in groups and individualized.

Most studies had their intervention on a shorter duration than the original OEP protocol. Only one study administered the OEP in its original form duration of 12 months.⁵⁴ Only 2 studies in this review investigated the effects of the OEP among institutionalized older adult residents.^30,31 Some studies also excluded the walking component of the OEP.³²

The studies reviewed explored a good number of the physical and psychosocial function outcomes. From our findings, it is evident that there is no single study on the effects of OEP on depression among older adults, either in the community or in institutions. However, only 2 studies reviewed assessed depression, but only at baseline.^52,54 They failed to report the difference in the pre- and post-intervention results/effects. Adherence to the intervention was not assessed in most of the studies. Evidence from literature shows that adherence and success of an exercise strategy mainly depends on the program characteristics and personal factors.

Limitations

The quality of this survey may have been affected by non-inclusion of studies not published in the English language. There was difficulty getting articles that discussed all the outcome measures, and only a few numbers of studies were included, hence making it difficult to discuss the findings and draw definite conclusions adequately. The older adult sampled in the various studies were quite heterogeneous and may limit the generalizability of the results. However, this study is the first scoping review, to the best of the researchers’ knowledge, performed on the effects of the OEP on physical and psychosocial functions among community and institutionalized older adults. Also, the strength of this review lies in the identification of knowledge gap on the effects of the OEP on physical and psychosocial functions among community and institutionalized older adults through an in-depth literature search and the review of the included studies which had a low risk of bias. Future reviews should widen the eligibility criteria to allow for more inclusion of studies. Further larger clinical studies are needed to evaluate the effectiveness of the group-based OEP among older adults especially in institutions. Adherence issues were also observed in some of the studies; it is possible that greater influence on health outcomes could be achieved if the intervention protocol was adhered to. Future studies should also evaluate the effect of the OEP on depression, pre- and post- intervention, especially from the African context, as no single OEP study was found from Africa. Previous studies in Nigeria, Africa’s most populous nation, have reported a high prevalence rate of depression among older adults,⁸¹ and also provided a validated culture-specific tool for measuring depression.⁸²

Conclusions

The findings from this review support the premise that OEP is an effective fall prevention intervention/strategy. The Otago exercise program performed as group program is more effective in improving lower limb muscle strength, functional balance and mobility than when performed individually. However, the mode of the program should be decided with consideration of the primary aims of the training and the individual’s preferences. This study provides a basis for future research by highlighting the possibilities of different modes of the OEP in improving physical and psychosocial functions among older adults. Further studies should be done to explore the comparative effects of group and individualized OEP in the community and institution on physical and psychosocial functions among older adults. Future and prospective reviews, especially, systematic reviews and meta-analysis should be performed on the variables studied, especially depression.

Footnotes

Acknowledgements

None.

Author Contributions

Ukamaka Gloria Mgbeojedo: conceived and designed the study, screened abstracts for relevancy, determined eligibility and extracted data, involved in the manuscript writing, reviewed the final version of the manuscript. Christopher Olusanjo Akosile: designed the study, involved in the manuscript writing, reviewed the final version of the manuscript. Emmanuel Chiebuka Okoye: screened abstracts for relevancy, involved in the manuscript writing. Kenneth Umezulike Ani: screened abstracts for relevancy, reviewed the final version of the manuscript. Echezona Nelson Ekechukwu: determined eligibility, reviewed the final version of the manuscript. Obinna Chinedu Okezue: determined eligibility, involved in the manuscript writing: Jeneviv Nene John: extracted data, involved in the manuscript writing. Nwobodo Nnaemeka: determined eligibility, reviewed the final version of the manuscript. All authors have read and approved the manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declarations

Our study did not require Ethical board approval and informed consent because it was a review of previous studies. It did not involve any human participants directly.

ORCID iDs

Ukamaka Gloria Mgbeojedo

Emmanuel Chiebuka Okoye

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Effects of Otago Exercise Program on Physical and Psychosocial Functions Among Community-Dwelling and Institutionalized Older Adults: A Scoping Review

Abstract

Keywords

Introduction

Methods

Search Strategy

Step 1: Posing the initial research question

Step 2: Identifying the relevant research studies

Step 3: Selecting the Studies

Step 4: Charting the data and collation

Step 5: Collating, summarizing, and reporting the results

Results

Location of the Studies

Study Design

Population

Types of Outcome Measures

Duration of Intervention

Aims

Methodology/Intervention Adopted

Main Findings of Most of the Included Studies

Otago exercise program and falls

Otago exercise program and fear of falling

Otago exercise program and quality of life

Otago exercise program and balance

Otago exercise program and strength

Otago exercise program in institutions

Otago exercise program in the community

Otago exercise program in group

Otago exercise program and functional mobility

Modified Otago exercise program

Discussion

Gaps in the Research/Key Points

Limitations

Conclusions

Footnotes

Acknowledgements

Author Contributions

Declaration of Conflicting Interests

Funding

Declarations

ORCID iDs

References