Geriatric Nursing 49 (2023) 30 43

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Geriatric Nursing
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Featured Article

The effectiveness of a group-based Otago exercise program on physical

function, frailty and health status in older nursing home residents:
A systematic review and meta-analysis
Yu Peng, MSNa,1, Jing Yi, MSNa,1, Yuhan Zhang, PhDb,*, Liyan Sha, PhDa,*,2, Shixiao Jin, PhDc,
Yang Liu, MSNa
a
Department of Nursing, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
b
Department of Nursing, School of Nursing, Shanxi Medical University, Taiyuan, Shanxi, China
c
Department of Nursing, School of Nursing, China Medical University, Shenyang, Liaoning, China

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: To explore the effects of a group-based Otago exercise program (OEP) on physical function (mobil-
Received 13 August 2022 ity, balance, lower limb strength), frailty and health status in older nursing home residents to determine the
Received in revised form 19 October 2022 optimal scheme and format.
Accepted 21 October 2022
Methods: This systematic review and meta-analysis was conducted to estimate group-based OEP effects. Sub-
Available online 19 November 2022
group analysis was performed to identify the influences of the participant and intervention characteristics on
the effects.
Keywords:
Results: Twelve studies met the eligibility criteria and were included in this meta-analysis, and the overall
Older adults
Otago exercise program
quality was relatively high. The results showed that the group-based OEP significantly improved physical
Physical function function, including mobility [SMD=-0.64, 95% CI (-0.83,-0.45), Z=6.55, p<0.001], balance [MD=4.72, 95% CI
Frailty (3.54, 5.90), Z=7.84, p<0.001], lower limb strength [SMD=-1.09, 95% CI (-1.40, -0.79), Z=7.01, p<0.001]; frailty
Nursing home [SMD=-0.73, 95% CI (-1.01, -0.45), Z=5.13, p<0.001] and health status [SMD=0.47, 95% CI (0.20, 0.74), Z=3.44,
Systematic review p=0.0006]. Subgroup analysis revealed that 30-minute sessions were more beneficial for improving balance
Meta-analysis than >30-minute sessions (p=0.0004). The training was coordinated with physiotherapists, who were more
skilled at improving mobility than providing health training education (p=0.04).
Conclusions: Group-based OEP is helpful for improving physical function, frailty and health status in older
nursing home residents. Specifically, 30-minute sessions and coordinating with physiotherapists may be the
most appropriate and effective options.
© 2022 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)

Introduction
As the aging trend intensifies, the demand for long-term care
services and nursing home (NH) care is also increasing. According to
statistical data, more than 1.2 million Americans over age 65 live in
NHs.1 Additionally, facing the great challenge of aging, China is rap-
idly expanding services and increasing the number of beds in NHs by
an average of 10% per year. As of July 2019, there were nearly 30,000
aged care services nationwide, with approximately 7.46 million beds
in NHs.2,3 In Europe, approximately 750,000 people over age 65 live
in NHs, and the number of older care-dependent adults is expected
*Corresponding author at: The Second Affiliated Hospital of Dalian Medical Univer-
sity, Department of Nursing, 467 Zhongshan Road, Dalian, Liaoning 116023, China.
E-mail addresses: 627717753@qq.com (Y. Zhang), slydl2007@163.com (L. Sha).
1
Yu Peng and Jing Yi contributed equally as co-first authors.
2
Liyan Sha will handle correspondence at all stages of refereeing and publication
to increase to 4.5 million in 2060.4 The rapid increase in aging is plac-
ing a growing burden on the global health service system.
Aging is generally accompanied by a deterioration in physical
function, including decreased mobility, imbalance and impaired mus-
cle function, which can directly lead to increased dependency and
decreased quality of life among older adults.5,6 Notably, older adults
in NHs have more severe physical impairments. Compared with older
adults who live in communities, older NH residents are more likely to
suffer from a loss of skeletal muscle mass, strength and function,
which is collectively known as sarcopenia and leads to adverse health
outcomes such as fractures, reduced function, hospitalization and
even mortality.7 Additionally, NH residents are more likely to have
multiple illnesses, which can result in the worsening of patients’ con-
ditions and an increased potential for falls. The annual fall rate of NH
residents is approximately 30-50%, of which 40% are recurrent falls.8

https://doi.org/10.1016/j.gerinurse.2022.10.014
0197-4572/$ see front matter © 2022 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
 Y. Peng et al. / Geriatric Nursing 49 (2023) 30 43
The disability rate among these individuals is as high as 50%, and they
are greatly dependent on others for care (30%).9,10
Frailty, another common phenomenon among older NH residents,
is characterized by decreased physiological function reserve,
increased susceptibility to external stressors and signs of progression
from mild cognitive impairment to full dementia.11 Frail older adults
often suffer from physical and cognitive impairments, leading to
increased health risks.12 Statistics show that 30-85% of NH residents
experience physical frailty,13 and 65% have moderate to severe cogni-
tive impairment,2 which is much higher than the percentage among
older adult residents living in the community. Frailty is related to a
reduced quality of life of NH residents, as well as increased risks of
dementia, disability, falls and death due to a multidimensional
decline in physiological function, which is closely related to adverse
outcomes.14,15
Exercise is considered to be the main method of improving older
adults’ physical conditions. Specifically, a multimodal exercise pro-
gram that combines strength training, balance training and aerobic
exercise is considered to be the optimal strategy.16 A recent study
published in The Lancet17 pointed out that mobility and balance train-
ing, coupled with progressive resistance training, can improve physi-
cal reserves and cognitive function, which can benefit frail NH
residents. The Otago Exercise Program (OEP) is a multimodal training
method that integrates warm-up exercises (5 movements), progres-
sive muscle strength training (5 movements), balance training (12
movements), walking sessions and aerobic exercise. Strength training
and balance training have four levels of difficulty.18 Studies have
shown19,20 that the OEP can help improve physical function in older
community groups through balance and strength training and reduce
the incidence of falls and fall injuries by 35%. Further, it can delay or
reverse frailty status, improve cognitive function, and enhance the
overall health status of residents.21,22 Currently, the OEP adapts the
difficulty level to participants’ physical conditions and abilities to
make it more suitable for frail NH residents.
The latest research has revealed that the effect of the group-based
OEP is better than that of individual interventions.16,23 However, the
available evidence is insufficient to support the effect of the group-
based OEP on older NH residents. No meta-analysis has been con-
ducted to specifically determine the effects of the group-based OEP
on NH residents’ physical function. It is also necessary to investigate
whether the group-based OEP improves NH residents’ frailty status.
Additionally, the optimal choices considering the participants’ char-
acteristics (age) and interventions (duration of each exercise, training
frequency, total intervention period and training format) are not
clear. Therefore, the purpose of this systematic review and meta-
analysis was to explore the group-based OEP effects on NH residents’
physical function, frailty, and health status and provide the optimal
possible OEP strategy for reference.
Material and methods
This study was registered with the International Prospective Reg-
ister of Systematic Reviews (PROSPERO), under registration number
CRD42022346957. We reported this review by following the Pre-
ferred Reporting Items for Systematic Reviews and Meta-Analysis
(PRISMA) Statement (Supplementary file 1).
Search strategy
We searched for relevant studies in the PubMed, Embase, Web of
Science, CINAHL, Cochrane Library and Ovid (MEDLINE) databases
from inception until 4 July 2022 with the help of a health science
librarian. The search methods used were Medical Subject Headings
(MeSH) and free text words, and language restrictions were not
applied. Further, we evaluated the gray literature, references of
31
screened literature, and articles of forward citations and actively con-
tacted authors for additional information. Our search strategies are
presented in Supplementary file 2.
Eligibility criteria
The following study selection criteria were formulated according
to the Population, Intervention, Comparison, Outcome, Study design
(PICOS) framework: (1) The study population must include individu-
als aged >65 years residing in any type of institutional facility for
older adults, including NHs or long-term care or residential care facil-
ities (residence duration
3 months). (2) The intervention must com-
prise the original OEP with a group format. (3) The comparison group
must receive an alternative treatment method that is not any form of
the OEP or no treatment. (4) The primary outcomes must include
physical function-, frailty-, and health status-related targets. The sec-
ondary outcomes must include aerobic endurance, fear of falling and
the number of fall-related targets. (5) The study design is a random-
ized controlled trial (RCT) or quasi-experimental study. Studies with
the following characteristics were excluded: 1) study design with
noncontemporaneous controls; 2) inaccessible full text; 3) secondary
analysis; 4) inadequately described intervention measures and insuf-
ficient statistical data for analysis; 5) conference abstracts, study pro-
tocols, and literature reviews; and 6) non-English literature.
Study selection and data extraction
Two researchers independently screened the literature and
extracted and cross-checked the data. The first literature screening
was conducted by reading and evaluating the titles and abstracts
according to the predesigned criteria. After the exclusion of irrelevant
literature, the full texts were read to identify eligible literature. If
there was any difference in opinion between the two researchers, a
third researcher was consulted to resolve the dispute. The extracted
data included the following: (1) basic information (author names,
publication year, location and study methods); (2) participant details
(characteristics, sample size, mean age, and sex); and (3) intervention
characteristics (format, frequency, and total intervention period).
Outcome measures
Several of the studies evaluated in our research reported their final
results in different ways, which made them difficult to synthesize.
Thus, we extricated the information according to similar structures
and methods to create an outcome indicator that could be assessed.
The main outcome measures were evaluated for physical function,
frailty, and health status. Farinatti pointed out that there are three
main aspects of the age-related decline in physical function: impaired
mobility, balance and muscle strength.24 Mobility is the ability to
quickly change the position and orientation of certain parts of the
body or limbs. The Timed Up and Go test (TUG) measures gait speed,
stride size and motor ability and is the preferred test for assessing
mobility.25 According to the Shumway-Cook model, balance can be
separated into different categories, including static balance, dynamic
balance, active balance and reactive balance.26 However, as there
were multiple variables in the single outcome category included in
the studies, only one representative outcome variable was selected
for analysis. We used the Berg Balance Scale (BBS), which measures
participants’ static balance, dynamic balance and active shifting abil-
ity (active balance) simultaneously, to evaluate the participants’ bal-
ance.27 Lower limb muscle strength is the ability of muscle
contractions to produce a certain level of tension. In this study, we
combined three tools, the Chair Stand Test (STS-5), Five Times Sit to
Stand Test (FTSST) and Chair Rising Test (CRT), which have similar
evaluation methods and indicators.28,29 Lower limb muscle strength
32 Y. Peng et al. / Geriatric Nursing 49 (2023) 30 43
was assessed by measuring the participants’ sitting speed and ampli-
tude. Frailty is a complex health condition associated with aging and
is accompanied by a multidimensional decline in physiological func-
tion. Therefore, we chose to use the Edmonton Frail Scale (EFS),
which assesses nine domains (i.e., independence of physical function,
cognitive function, health, self-control, etc.), to evaluate the partici-
pants’ frailty status.30 Finally, we selected the Short Form-12 health
survey (SF-12) scale for the evaluation of health status, including
physical health status (physical component summary, PCS) and men-
tal health status (mental component summary, MCS).31
For the assessment of secondary outcome measures, we selected
the 6MWT to examine the participants’ aerobic tolerance, i.e., the
maximum walking distance within 6 minutes.32 Furthermore, we
adopted the Modified Survey of Activities and Fear of Falling in the
Elderly (mSAFFE)33 and the short version of the Falls Efficacy Scale-
International (Short FES-I)34 to evaluate the participants’ fear of fall-
ing. The number of falls was used to assess the participants’ fre-
quency of falling.
Risk of bias assessment
The quality of the literature was evaluated according to the
assessment criteria suggested by the Cochrane Handbook (5.1.0).17
Two researchers independently completed the evaluation, and dis-
agreements were resolved through discussion or by a third party. The
evaluation index includes the following seven items: randomization
sequence generation, allocation concealment, a blinding method for
study subjects and interveners, a blinding method for results mea-
surement, incomplete result data, selective reporting bias and other
bias. Each item was rated as having "high bias", "unclear" or "low
bias". We considered studies that met all of the above criteria as
high-quality studies, and to prevent biased results, low-quality stud-
ies that did not meet any criteria were excluded from our analysis.
Statistical analysis
RevMan 5.3 (Cochrane Collaboration, Oxford, UK) statistical soft-
ware was employed for meta-analysis. The X2 test was used to deter-
mine whether there was clinical heterogeneity among the studies.
The fixed effect model was applied for P
0.1 and I2 values of 25%-
49%, which were considered to indicate low heterogeneity. The ran-
dom effect model was selected for P<0.1 and I2 values of 50%-74%,
which were considered to indicate moderate heterogeneity, and for
I2 values of >75%, which were considered to indicate high heteroge-
neity. Statistical variables for continuous data measurements are
reported as the standard mean difference (SMD) or mean difference
(MD). Statistical variables for counting data are reported as relative
risks (RRs), and the effect size was assessed using 95% confidence
intervals (CIs). If interstudy heterogeneity was considered to be high,
then subgroup analysis, sensitivity analysis or descriptive analysis
was performed (a=0.05). Additionally, Begg’s and Egger’s tests were
used to generate funnel and bias plots with Stata 14.0 statistical soft-
ware (StataCorp, LLC, College Station, TX, USA) to analyze potential
publication bias. The trim and fill methods were also carried out for
verification, and p<0.05 was considered statistically significant. Fur-
thermore, subgroup analysis was conducted to explore whether the
participant characteristics or intervention characteristics influenced
the interstudy effect size.
Results
Study selection
A total of 2,054 studies were preliminarily identified by the prede-
signed retrieval strategy. Then, EndNote software was used to screen
and exclude 331 duplicate studies. The remaining 1,723 studies were
screened by title and abstract, and 1,640 were excluded because they
did not conform to the PICOS criteria. The full texts of 83 studies were
screened, and 71 were subsequently excluded for the following rea-
sons: uncorrelated outcomes (n=22); not RCTs or quasi-experimental
studies (n=18); use of a mixed intervention of multiple patterns (n=3);
inaccessibility of the full text (n=4); non-English studies (Chinese=3,
Korean=5, Iranian=1); secondary analysis of initial data (n=5); and
insufficient data for our analysis (n=10). Ultimately, 12 studies35-46
were included in our final analysis. We used a PRISMA flow diagram to
show the detailed study selection process, as depicted in Fig. 1.
Study characteristics
The 12 included studies were published from 2008 to 2022 and
were conducted in Turkey (n=1), China (n=3), Spain (n=1), the United
States (n=1), Indonesia (n=1), the United Kingdom (n=1), Iran (n=1),
Korea (n=1), Serbia (n=1) and Canada (n=1). All the studies were con-
ducted with a concurrent, controlled study design. There were 696
eligible participants in the included studies, the majority of whom
were women (74.86%). The average participant age ranged from
71.55 to 87.30 years (one study lacked baseline age data).39 One
study was conducted in long-term care facilities,38 one was per-
formed in assisted living facilities (ALFs),39 three were carried out in
social older adult institutions,41,44,46 and the remainder were con-
ducted in NHs or care homes.35-37,40,42,43,45 The intervention groups
included in all studies used a group-based OEP. The control groups
were given other active interventions, such as traditional physical
therapy,39 inspiratory muscle training,42 and received routine care
and activities. The duration of each exercise ranged from 30 to 60
minutes, the training frequency was 2 or 3 times per week, and the
total intervention period was 8-48 weeks. Seven studies reported
physiotherapist coordination with training, in which physiothera-
pists directed and supervised the OEP implementation throughout
the course, helping the participants understand the course and pro-
gram structure (e.g., by demonstrating motor and breathing techni-
ques and providing safety information, verbal instructions, and visual
instructions), allowing the participants to achieve personalized load-
ing and progression.37-40,44-46 Other studies used health training edu-
cation, which included providing knowledge, explaining the benefits
of exercise and giving recommendations on physical activity, and the
participants were provided with an OEP instruction manual (text and
pictures) or visual tools (projectors, etc.) to help them learn and
improve their awareness of the training, after which they performed
scientific exercises.35,36,41-43 Four studies conducted data surveys at
four, six, and twelve weeks of follow-up.37,40,43,45 The effective com-
pliance rates ranged from 71-93%, and the reasons for loss to follow-
up mainly included surgery (two participants),35,43 hospitalization
(two participants),37,40 unwillingness to participate or the cause of ill-
ness was discontinued (13 participants),37,40,42,45,46 relocation (four
participants),45 and death (three participants),45,46 and one study did
not report the causes of loss to follow-up.41 The additional details
and characteristics of the included studies are presented in Table 1.
Quality assessment
According to the Cochrane Handbook assessment criteria, the
overall quality of the 12 included studies was high. The included
studies demonstrated reasonable control for randomization, baseline
comparability, intergroup comparison, outcome measurement, and
study report design. Four studies did not use random assignment,
resulting in a high risk of bias.36,39,41,42 The other 8 studies reported
that their random sequence-generating method mainly included a
simple randomization method (coin flipping) and computer-gener-
ated random numbers. Four studies mentioned allocation
 Y. Peng et al. / Geriatric Nursing 49 (2023) 30 43
Fig. 1. PRISMA flow diagram of the study selection process.
concealment,37,38,45,46 and five used single-blind methods (assessor-
blind methods).37,38,40,45,46 All of the studies reported complete
results, indicating that there was minimal possibility of selective
reporting. However, the included studies did not blind participants
or therapists because this process was difficult to achieve. Figs. 2 and
3 present the risk of bias summary.
Effects on the main outcome
Physical function
Mobility. Nine studies were compared in terms of mobility,36,38-42,44-
46
and the heterogeneity test results showed no significant between-
study heterogeneity (I2=0%, P=0.70), so the fixed effect model was
used to combine the effect values. The results showed that the
group-based OEP had a significant effect on improving the mobility
of older NH residents [SMD=-0.64, 95% CI (-0.83,-0.45), Z=6.55,
p<0.001] (Fig. 4). Egger’s test revealed that there was no significant
publication bias (p=0.734), as presented in Table 2.
Balance. Five studies were compared in terms of balance,36,38,40,43,45
and one study was excluded from the meta-analysis because it
reported different statistical units for the outcome indicators.36 The
33
heterogeneity test results showed a high level of heterogeneity
(I2=86%, P=0.0001), so the random effect model was used to combine
the effect values. The results revealed that the group-based OEP had
a significant effect on improving the balance of older NH residents
[MD=4.72, 95% CI (3.54, 5.90), Z=7.84, p<0.001] (Fig. 4). Due to the
high between-study heterogeneity, sensitivity analysis was per-
formed, which showed that the study of Kocic45 was the main source
of heterogeneity. Egger’s test revealed that there was no potential
publication bias (p=0.705), as shown in Table 2.
Lower limb strength
Three studies were compared in terms of lower limb
strength,38,40,45 and the heterogeneity test results showed no signifi-
cant heterogeneity (I2=0%, P=0.69), so the fixed effect model was used
to combine the effect values. The results showed that the group-
based OEP significantly improved the lower limb strength of older
NH residents [SMD=-1.09, 95% CI (-1.40, -0.79), Z=7.01, p<0.001]
(Fig. 4). Egger’s test revealed that there was no obvious publication
bias (p=0.345), as presented in Table 2.
Frailty
Four studies assessed frailty among the participants,35,37,40,42 and
the heterogeneity test results showed no significant between-study
34
Table 1
Characteristics of the included studies.
Author/year (location)
Sahin 202235 (Turkey)
Zou 202236 (China)
Chen 202237 (China)
García-Gollarte 202138 (Spain)
Knott 202139 (US)
Chen 202140 (China)
Kiik 202041 (Indonesia)
Y. Peng et al. / Geriatric Nursing 49 (2023) 30 43
Methods Participants
RCT Characteristics: Older nursing
home residents
Total N: EG/CG: 36/36
Complete N: EG/CG: 35/36
Age (yrs): EG/CG: 74.60 § 5.94/
75.8 § 4.54
Sex (female): EG/CG: 26/27
Sex (male): EG/CG: 9/9
Quasi-experimental Characteristics: Older adults liv-
ing in nursing homes
Total N: EG/CG: 29/28
Complete N: EG/CG: 29/28
Age (yrs): EG/CG: 85.17 § 3.10/
85.79 § 5.06
Sex (female): EG/CG: 27/22
Sex (male): EG/CG: 2/6
Double-blinded RCT Characteristics: Older adults liv-
ing in nursing homes
Total N: EG/CG: 31/31
Complete N: EG/CG: 29/30
Age (yrs): EG/CG:
75
Sex (female): EG/CG: 24/18
Sex (male): EG/CG: 5/12
Double-blinded RCT Characteristics: Older adults liv-
ing in long-term care facilities
Total N: EG1/EG2/CG: 39/38/34
Complete N: EG1/EG2/CG: 39/
38/34
Age (yrs): EG1/EG2/CG: 86.0 §
5.9/84.9 § 6.0/87.3 § 5.3
Sex (female%): EG1/EG2/CG:
76.9/68.4/61.8
Sex (male%): EG1/EG2/CG: 23.1/
31.6/38.2
Quasi-experimental Characteristics: Older adults
residing in assisted living facil-
ities (ALFs)
Total N: EG/CG: 30/29
Complete N: EG/CG: 30/29
Sex (female): EG/CG: 24/19
Sex (male): EG/CG: 6/10
Double-blinded RCT Characteristics: Older adults liv-
ing in nursing homes
Total N: EG/CG: 31/31
Complete N: EG/CG: 29/30
Age (yrs): EG/CG:84.59 § 4.21/
84.75 § 5.41
Sex (female): EG/CG: 24/18
Sex (male): EG/CG: 5/12
Quasi-experimental Characteristics: Older adults liv-
ing in social institutions for
older adults
Total N: EG/CG: 22/22
Complete N: EG/CG: 21/21
Age (yrs): EG/CG: 76.41 § 9.26/
71.55 § 7.79
Interventions Outcomes/results
EG: Otago Exercise Program 1 Frailty EFS (score)
CG: Routine health care
Format: Group (9 participants)
Health training education (provided an
Otago exercise booklet and training
sessions)
Frequency: Minutes per session: 45
Times per week: 3
Total: 12 weeks
EG: Otago exercise session 1 Physical function
CG: Routine care (1) Mobility
Format: Group (4-7 participants) TUG (s)
Health training education (taught and
(2) BalanceFSBT (%)
instructed by OEP-trained assistants
2 Fear of Falling mSAFFE (score)
and provided an exercise guidance
manual)
Frequency: Minutes per session: 40-
60
Times per week: 2
First phase: 4 weeks
Second phase: 8 weeks
Total: 12 weeks
EG: Otago Exercise Program 1 Frailty
CG: Health education Fried phenotype (score)
Format: Group
2 Health statusADL: Barthel Index
Physiotherapist coordination with
(score)
training (guiding participants to the
appropriate exercise frequency
according to the exercise level table)
Frequency: Minutes per session: 30
Times per week: 3
Total: 12 weeks
EG1: Otago Exercise Program 1 Physical function
EG2: Otago Exercise Program + nutri-
tional supplementation (2) Mobility
CG: Daily living activities TUG (s)
Format: Group
Physiotherapist coordination with
(3) Balance
training (conducted and supervised
the implementation of the Otago BBS (score)
Exercise Program)
Frequency: Minutes per session: 45- (4) Lower limb strength
60 STS-5 (s)
Times per week: 3 5 Aerobic endurance6MWT (m)
Total: 6 months (24 weeks)
EG: Otago-Based Exercise Program 1 Physical function
CG: Traditional Physical Therapy (1) MobilityPOMA (score)
Format: Group 2 Number of falls (n)
Physiotherapist coordination with
training (provided Otago-based
Exercise Program)
Frequency: Minutes per session: 30
Times per week: 2
Total: 12 months (48 weeks)
EG: Otago Exercise Program 1 Physical function
CG: Health education (1) Mobility
Format: Group TUG (s)
Physiotherapist coordination with
(2) Balance
training (guided the implementation
of the Otago Exercise Program) BBS (score)
Frequency: Minutes per session: 30 (3) Lower limb strengthFTSST (s)
Times per week: 3 2 Frailty
Total: 12 weeks EFS (score)
3 Health statusSF-12 (score)
EG: Otago training 1 Physical function
CG: Routine health care (1) MobilityTUG (s)
Format: Group 2 Health statusSF-12 (score)
Health training education
Frequency: Minutes per session: 40
Times per week: 2
Total: 12 weeks
(continued)
 Y. Peng et al. / Geriatric Nursing 49 (2023) 30 43
Table 1 (Continued)
Author/year (location) Methods Participants
Sex (female): EG/CG: 13/11
Sex (male): EG/CG: 9/11
Ferraro 202042 (UK) Controlled trial Characteristics: Care home for
older residents
Total N: EG/CG: 18/19
Complete N: EG/CG: 14/11
Age (yrs): EG/CG: 82.0 § 7.0/
74.0 § 4.0
Sex (female): EG/CG: 10/7
Sex (male): EG/CG: 4/4
Jahanpeyma 202043 RCT Characteristics: Older nursing
(Iran) home residents
Total N: EG/CG: 36/36
Complete N: EG/CG: 35/36
Age (yrs): EG/CG: 74.6 § 5.9/
75.8 § 4.5
Sex (female): EG/CG: 26/27
Sex (male): EG/CG: 9/9
Leem 201944 (Korea) Controlled trial Characteristics: Older adults liv-
ing in social institutions for
older adults
Total N: EG1/EG2/CG: 10/10/10
Complete N: EG1/EG2/CG: 10/
10/10
Age (yrs): EG1/EG2/CG:79.50 §
4.55/76.30 § 5.16/81.10 §
3.07
Sex (female): EG1/EG2/CG: 10/
10/10
Kocic 201845 (Serbia) Double-blinded RCT Characteristics: Older nursing
home residents
Total N: EG/CG: 38/39
Complete N: EG/CG: 27/33
Age (yrs): EG/CG: 78.3 § 8.1/
78.5 § 7.2
Sex (Female): EG/CG: 28/23
Sex (male): EG/CG: 10/16
Liu-Ambrose 200846 (Canada) Double-blinded RCT Characteristics: Older adults liv-
ing in social institutions for
older adults
Total N: EG/CG: 31/28
Complete N: EG/CG: 28/24
Age (yrs): EG/CG: 81.4 § 6.2/
83.1 § 6.3
Sex (Female): EG/CG: 22/19
Sex (male): EG/CG: 9/9
Note: BBS, Berg Balance Scale; CG, control group; CRT, Chair Rising Test; EG, experimental group; EFS, Edmonton Frail Scale; FTSST, Five Times Sit to Stand Test; FSBT, Four-Stage Bal-
ance Test; mSAFFE, Modified Survey of Activities and Fear of Falling in the Elderly; mFIM, motor Functional Independence Measure; RCT, randomized controlled trial; STS-5, Sit to
Stand Test-5; SF-12, 12-Item Short Form Health Survey; TUG, Timed Up and Go Test; POMA, Performance-Oriented Mobility Assessment; yrs, years; 6MWT, 6-Minute Walk Test.
heterogeneity (I2=0%, P=0.75), so the fixed effect model was used to
combine the effect values. The results showed that the group-based
OEP significantly improved the frailty status of older NH residents
[SMD=-0.73, 95% CI (-1.01, -0.45), Z=5.13, p<0.001] (Fig. 4). Egger’s
test revealed that there was no significant publication bias (p=0.130),
as shown in Table 2.
Health status
Four studies assessed health status among the
participants,37,40,41,45 and the heterogeneity test results revealed a
low level of significant heterogeneity (I2=36%, P=0.19), so the fixed
effect model was used to combine the effect values. The results
showed that the group-based OEP significantly improved the health
status of older NH residents [SMD=0.47, 95% CI (0.20, 0.74), Z=3.44,
35
Interventions Outcomes/results
EG: Otago exercise program 1 Physical function
CG: Inspiratory muscle training (1) Mobility
Format: Group (7 participants) TUG (s)
Health training education (Otago exer- 2 Frailty
cise program training guide) EFS (score)
Frequency: Minutes per session: 30
Times per week: 2
Total: 8 weeks
EG: Otago exercise 1 Physical function
CG: walking
Format: Group (4-7 participants) (2) Balance
Health training education (with a pam- BBS (score)
phlet illustrating Otago exercises)
3 Aerobic endurance
Frequency: Minutes per session: 45
Times per week: 3 6MWT (m)
Total: 12 weeks 4 Number of falls (n)
EG1: Otago exercise + action observa- 1 Physical function
tion (1) MobilityTUG (s)
EG2: Otago exercise 2 Fear of falling
CG: Regular care Short FES-I (score)
Format: Group
Physiotherapist coordination with
training (guided physical training
based on the video content)
Frequency: Minutes per session: 50
Times per week: 3
Total: 12 weeks
EG: Otago exercise
CG: Standard care and activities (1) Physical function
Format: Group Mobility
Physiotherapist coordination with
training (demonstrated and cor- TUG (s)
rected exercises, ensured safety)
Frequency: Minutes per session: 40 (2) Balance
Times per week: 3 BBS (score)
Total: 24 weeks
(3) Lower limb strength
CRT (s)
(4) Health status mFIM (score)
EG: Otago exercise
CG: Regular care (1) Physical function
Format: Group Mobility
Physiotherapist coordination with TUG (s)
training (prescribed a selection of Number of falls (n)
exercises and made progressive
adjustments based on Otago exer-
cises)
Frequency: Minutes per session: 30
Times per week: 3
Total: 24 weeks
p=0.0006] (Fig. 4). Egger’s test revealed that there was no publication
bias (p=0.147), as shown in Table 2. The trim-and-fill method was
used to impute one study, and the results were subjected to trim-
and-fill adjustment [SMD=0.324, 95% CI (0.154, 0.684)] (Table 2).
Effects on the secondary outcome
Aerobic tolerance
Two studies assessed the participants’ aerobic tolerance,38,43 and
the heterogeneity test results showed moderate heterogeneity
(I2=65%, P=0.09), so the random effect model was used to combine
the effect values. The results showed that the group-based OEP had
no significant effect on improving the aerobic tolerance of older adult
residents in NHs [MD=17.05, 95% CI (-18.42, 52.52), Z=0.94, p=0.35].
36 Y. Peng et al. / Geriatric Nursing 49 (2023) 30 43
Fig. 2. Risk of bias in the included studies.
Additionally, the trim-and-fill method was used to impute one study
of aerobic tolerance, and the results were subjected to trim-and-fill
adjustment [MD=12.80, 95% CI (-9.458, 35.058)], as shown in Table 2.
Fear of falling
Two studies assessed the participants’ fear of falling.36,44 Due to
large differences in the research tools used in the two studies, the
results were not combined, and only descriptive analysis was con-
ducted. One study showed that the group-based OEP reduced activity
avoidance due to fear of falling among the participants (p<0.05).36
Another study revealed that the group-based OEP improved self-effi-
cacy of falling among the participants and decreased the fear of fall-
ing score by 5.0 points (18.1 to 13.1 points, p<0.05).44
Fig. 3. Risk of bias summary in the included studies.
Number of falls
We assessed the number of falls as 0-1 falls, 2-3 falls and
4 falls.
Due to the low heterogeneity between the two studies (I2=42%,
P=0.13), the fixed effect model was used to combine the effect
values.39,46 The results showed that the group-based OEP had a sig-
nificant but small effect on participants with more than 4 falls
[RR=0.24, 95% CI (0.06, 0.92), Z=2.08, p=0.04]. However, it is impor-
tant to note that we measured secondary outcomes in only two sepa-
rate studies, so the results should be carefully interpreted. The effects
on the secondary outcomes are shown in Fig. 5.
Subgroup analysis
Our results showed that the group-based OEP had significant
effects on the physical function, frailty, and health status of older NH
residents. Therefore, subgroup analyses were conducted to deter-
mine whether the participant or intervention characteristics influ-
enced the effect size. The subgroup analysis revealed that 30-minute
sessions were significantly superior to >30-minute sessions for
improving balance (p=0.0004). Moreover, 30-minute sessions also
showed higher effect values indicating improvements in mobility
and frailty, although there was no significant difference compared
with >30-minute sessions [SMD=-0.73, 95% CI (-0.98, -0.47); SMD=-
0.82, 95% CI (-1.16, -0.47)]. The OEP training, conducted in coordina-
tion with physiotherapists, was more effective than health training
education for improving mobility (p=0.04). Similarly, the effect value
of the therapist-coordinated training format on improvement in bal-
ance and frailty status was higher than that of health training educa-
tion, but this difference was not significant [SMD=4.96, 95% CI (3.61,
6.31); SMD=-0.77, 95% CI (-1.14, -0.39)]. However, the effects of the
group-based OEP on physical function, frailty and health status did
not differ by age, training frequency, or total intervention period. The
subgroup analysis results, including the effects of the study partici-
pant characteristics and intervention characteristics on physical func-
tion, frailty and health status, are shown in Table 3.
Discussion
Intensification of the aging process is expected to increase the
number of institutionalized older adults, and strategies for improving
the physical condition of older adults based on the principles of com-
prehensive, coordinated, continuous and patient-centered care are
urgently needed.47 Physical exercise could decrease the incidence of
chronic diseases, reduce the risk of hospitalization and delay func-
tional decline and is thought to be beneficial for improving frailty sta-
tus in older adults.48 The OEP is a multicomponent exercise model
that emphasizes the combination of balance training and muscle
strengthening exercises with walking. It has been shown to be effec-
tive for seniors living in the community, but there is still a lack of
 Y. Peng et al. / Geriatric Nursing 49 (2023) 30 43 37

Fig. 4. Forest plots of main outcomes. A: mobility; B: balance; C: lower limb strength; D: frailty status; E: health status (OEP, Otago Exercise Program). Horizontal lines, 95% CIs of
each study; green squares, MDs or SMDs of each study (size represents the weight given to the study in the meta-analysis): diamond, summary estimate; solid vertical line, null
value.

evidence for its role in the well-being of older NH residents.18 There-
fore, we conducted this systematic review and meta-analysis mainly
to explore the impacts of the OEP on physical function, frailty and
health status in older adults living in NHs, to provide a reference for
its effects on aerobic tolerance, fear of falling and the number of falls
and to study which OEP program best enhances the physical
conditions of older adults. Twelve studies reported that the group-
based OEP had significant effects on physical function, frailty, health
status, fear of falling and the frequency of falls (
4 times). Addition-
ally, subgroup analysis showed that 30-minute sessions and physio-
therapist-coordinated sessions resulted in more significant
improvements in balance and mobility. However, the effects on
38 Y. Peng et al. / Geriatric Nursing 49 (2023) 30 43

Table 2
Meta-analysis of outcome indicators included in the study.

Outcome indicator Study detail Effect measure Heterogeneity Publication bias

Studies (n) SMD/MD/RR (95% CI) P value I2(%) Egger P value Trim-and-fill Trim-and-fill adjusted
imputed studies SMD/MD/RR (95% CI)

Physical function
Mobility 9 -0.64 (-0.83, -0.45) <0.001 0 0.734 0 -
Balance 4 4.72 (3.54, 5.90) <0.001 86 0.705 0 -
Lower limb strength 3 -1.09 (-1.40, -0.79) <0.001 0 0.345 0 -
Frailty 4 -0.73 (-1.01, -0.45) <0.001 0 0.130 0 -
Health status 4 0.47 (0.20, 0.74) 0.0006 36 0.147 1 0.324 (0.154, 0.684)
Activity endurance 2 17.05 (-18.42, 52.52) 0.35 65 - 1 12.80 (-9.458, 35.058)
Number of falls 2 1.00 (0.79, 1.27) 1.00 42 - - -
0-1 2 1.22 (0.98, 1.52) 0.07 0 - 1 1.151 (0.956, 1.385)
2-3 2 0.91 (0.37, 2.25) 0.84 29 - 1 0.514 (0.238, 1.110)

4 2 0.24 (0.06, 0.92) 0.04 0 - 0 -

physical function, frailty and health status did not differ by age, train-
ing frequency or total intervention period.
Effects of the group-based OEP on physical function
Age-related declines in physical function appear to be more pro-
nounced among older NH residents than among those living in the
community. The aging process results in a significant loss of muscle
mass and strength and impaired balance. This leads to reduced walk-
ing speed and physical function, followed by a loss of mobility and
walking independence.24 Our results showed that the group-based
OEP significantly improved the physical function of older NH resi-
dents, especially in terms of mobility, balance and lower limb
strength. Our conclusions were also supported by several studies.

Fig. 5. Forest plots of secondary outcomes. A: aerobic tolerance; B: number of falls (OEP, Otago Exercise Program). Horizontal lines, 95% CIs of each study; green or blue squares,
MDs or RRs of each study (size represents the weight given to the study in the meta-analysis): diamond, summary estimate; solid vertical line, null value.
 Y. Peng et al. / Geriatric Nursing 49 (2023) 30 43 39

Zou et al.36 reported that after 12 weeks of group-based OEP training

0.68

0.68

0.09

0.32

0.09
pb
in a NH, the mobility of the OEP training group was superior to that

0.56 (0.24, 0.88) 0.0006

of the control group who received routine care, as measured by the

0.009

0.009

0.003

0.003
0.02

0.02

0.02

0.26 (-0.25, 0.77) 0.33

0.02
TUG. Shubert et al.49 revealed that an 8-week institutionalized OEP
pa
Health status

0.54 (0.14, 0.94) intervention significantly improved functional balance, as assessed

0.42 (0.06, 0.79)

0.42 (0.06, 0.79)

0.54 (0.14, 0.94)

0.98 (0.34, 1.62)

0.37 (0.07, 0.66)

0.37 (0.07, 0.66)

0.98 (0.34, 1.62)

with the BBS. Similar to our results, García-Gollarte et al.38 found that
N SMD (95% CI)

lower limb strength (STS-5) was significantly improved after 24

weeks of group resistance exercise in older adults receiving institu-
tional interventions.
This study demonstrates that the positive changes in physical
2
2

2
2

1
3

3
1

1
function may be attributed to the effects of the OEP strength training
0.69

0.40

0.43

0.76
on increasing the body’s demand for protein and enhancing muscle
NA
b
p

protein synthesis and muscle oxygen consumption, thereby increas-

-0.82 (-1.16, -0.47) < 0.001

-0.69 (-0.98, -0.40) < 0.001

-0.73 (-1.01, -0.45) < 0.001

-0.77 (-1.14, -0.39) < 0.001

-0.68 (-1.04, -0.33) 0.0002
-0.80 (-1.25, -0.35) 0.0005

ing muscle content and improving lower limb muscle strength.50

-0.68 (-1.09, -0.26) 0.001

-0.56 (-1.04, -0.09) 0.02

-1.06 (-1.91, -0.20) 0.02

NA

From the perspective of biomechanics, improving lower limb muscle

a
p

strength could help to enhance physical mobility. Additionally, the

Frailty

OEP is a multicomponent exercise program in which active and

N SMD (95% CI)

dynamic training components help to improve executive function,

walking speed and independence and enhance physical mobility.21
Resistance training included in the OEP may also enhance cognition
NA

by increasing insulin-like growth factor-1 (IGF-1) 51 levels, lowering

serum homocysteine, and further improving physical balance. This
2
2

2
2

1
3

4
0

2
0.50

0.86

0.86

connection results from shared common neural pathways between

NA

NA
b
p

cognitive and balance networks.51 Further, the program includes 12

-1.17 (-1.54, -0.79) < 0.001

-1.11 (-1.48, -0.74) < 0.001

-1.09 (-1.40, -0.79) < 0.001

-1.11 (-1.48, -0.74) < 0.001

-1.09 (-1.40, -0.79) < 0.001

balance movements, which help train the coordination of the brain,

-0.94 (-1.48, -0.40) 0.0006

-1.05 (-1.60, -0.51) 0.0002

-1.05 (-1.60, -0.51) 0.0002

Lower limb strength

muscles and nerves, improve the proprioception ability of the body,

NA

NA
a
p

train visual vestibular function, and restore balance in unconscious

movement. Other research has shown that regular exercise mini-
mizes the impact of a sedentary lifestyle and may further promote
N SMD (95% CI)

positive changes in physical function.40

NA

NA

Effects of the group-based OEP on frailty

1
2

1
2

0
3

1
2

Frailty is a type of biological syndrome that is commonly seen in

0.0004
0.09

0.53

0.29

older adults and is considered to reflect deficiencies in physical func-

NA
b
p

tion, cognition, movement, and nutrition.52 Epidemiological surveys

6.03 (5.47, 6.59) < 0.001
< 0.001
< 0.001

4.38 (3.65, 5.10) < 0.001

< 0.001

< 0.001
< 0.001

< 0.001

< 0.001

have shown that approximately half of the older adults in NHs are at
risk of frailty, and 38.5% are experiencing frailty.53 Multicomponent
NA
a
p
Balance

exercise helps to improve skeletal muscle mass and strength, reduce

3.49 (1.96, 5.02)
5.30 (3.90, 6.70)

4.72 (3.54, 5.90)

5.05 (2.86, 7.25)

4.17 (2.45, 5.88)

4.96 (3.61, 6.31)

3.77 (2.06, 5.48)

inflammation and enhance blood circulation, thereby reversing

N MD (95% CI)

frailty status.54 Our results showed that the group-based OEP was
effective for improving frailty among older NH residents, which is
consistent with the findings of a recent study.55 The OEP involves a
NA

regular and systematic multicomponent exercise pattern. With this

2
2

1
3

0
4

2
2

program, the levels of inflammatory cytokines, such as interleukin 6,

0.04
0.15

0.31

0.72

0.53

tumor necrosis factor a and C-reactive protein, can be reduced

Subgroup analysis of study participant and intervention characteristics.

b
p

Differences between subgroups; 95% CI, 95% confidence interval.

through regular training. These cytokines are thought to contribute

-0.99 (-1.24, -0.74) < 0.001
< 0.001

< 0.001

< 0.001
< 0.001

< 0.001
< 0.001
0.0003

to declines in muscle density and skeletal muscle mass, leading to

0.010

0.004

cognitive frailty.56 Each movement of the OEP is easy to learn, with

a
p
Mobility

moderate intensity and high safety, which is suitable for older adults
-0.43 (-0.76, -0.10)
-0.74 (-1.01, -0.48)

-0.73 (-0.98, -0.47)

-0.53 (-0.82, -0.24)

-0.60 (-0.89, -0.30)

-0.67 (-0.92, -0.42)

-0.71 (-0.99, -0.42)

-0.58 (-0.84, -0.33)

-0.53 (-0.89, -0.17)

in NHs. Adhering to OEP training is helpful for improving the coordi-

N SMD (95% CI)

nation between the brain and muscle nerves, proprioception ability

and visual vestibular function, and overall frailty.40 Moreover, group-
based exercise is more likely to create a relaxed and comfortable
atmosphere, reduce the fear of falling, enhance confidence in train-
ing, and relieve frailty caused by excessive tension in the cerebral
4
4

5
4

4
5

5
4

3
Physiotherapist coordination

cortex.
Health training education

Effects of the group-based OEP on health status

Subgroup studies.
Minutes per session

Times per week

Training format

with training

Physical exercise, including exercise training, balance training,

Total weeks

strength training, play sessions and deep breathing, can be beneficial

Mean age
Variables

for improving the health status of older adults.57 To prove this point,
Table 3

> 80

> 30

> 12
 80

 12

we conducted a meta-analysis to evaluate the relationship between

>2
30

b
a

the group-based OEP and health status among older adults in

40 Y. Peng et al. / Geriatric Nursing 49 (2023) 30 43
institutions. We found that application of the group-based OEP
resulted in improved health status, such as motor functional inde-
pendence and mental health. Our findings revealed that application
of the OEP effectively and significantly improved the health status
score by 0.47 points (P=0.0006). In line with our results, Bjerk et al.58
reported that Otago-based training programs significantly improved
physical health status. However, Mat et al.59 showed that six months
of Otago training did not improve chronic disease symptoms such as
osteoarthritis in older adults. Therefore, follow-up studies should be
performed, such as RCTs with more samples and more scientific indi-
cators, to further verify the effects of the OEP on improving physical
health status. According to Albornos-Mun ~ oz et al.60 Otago training
improves independence and social activities and promotes mental
health. These improvements are due to the frequent meetings and
interactions of older adults who follow the group-based OEP and
achieve improved mental health through socialization.
Effects of the group-based OEP on activity endurance
In terms of activity endurance, our results showed that among
older adults in NHs, application of the group-based OEP did not effec-
tively improve aerobic endurance. A recent study has suggested that
older adults may not be able to improve their aerobic endurance
through short-term functional exercise due to the coexistence of
multiple underlying diseases.59 We found that the participants
included in one study were affected by the use of crutches, and the
results of the 6-minute walking test did not significantly change after
application of the OEP, which may account for the moderate hetero-
geneity among studies. After applying the trimming method and add-
ing one study, the corrected effect value was 0.260 (P<0.05),
confirming the effectiveness of the previous conjecture. However, we
still suggest that scholars incorporate more basic studies in the future
to observe the effect of the OEP on activity tolerance among older
adults in NHs.
Effects of the group-based OEP on fear of falling
Fear of falling, defined as a “persistent feeling related to the risk of
falling during one or more activities of daily living”,61 has been
reported to be closely related to health issues among older adults in

NHs. Angeles et al.62 conducted a 12-month OEP for community-
dwelling older adults and found that the participants’ fear of falling
decreased; additionally, the findings verified the correlation between
the fear of falling and female sex, psychotropic drug use and a history
of falling. Our analysis revealed that the group-based OEP reduced
the fear of falling among older adults in NHs. This may be because of
the moderate intensity and high safety of the OEP. Further, the format
of the group OEP can improve the level of social support among older
adults and help to create a harmonious exercise atmosphere through
mutual encouragement,63 enhancing self-efficacy of falling and self-
confidence in activities, improving the enthusiasm for activities, and
reducing the fear of falling.
Effects of the group-based OEP on the number of falls
The literature review revealed that researchers have assessed his-
tory of falls when evaluating falls in older adults and have expressed
fall history as both numbers and frequency. Our results showed that
the group-based OEP had a small effect on reducing falls among NH
residents with more than four falls. Research has shown that
response inhibition is a significant determinant of successful obstacle
avoidance.46 The OEP is helpful for improving physical function,
thereby enhancing executive function and strengthening response
inhibition, which may reduce the frequency of falls to a certain
extent. However, the reasons and mechanism behind the effect on
the specific fall frequency need to be further discussed in the future.
Characteristics of participants and interventions
Our subgroup analysis showed that the 30-minute group-based
OEP session resulted in more significant improvement in balance
among older NH residents. Moreover, it showed higher effect values
for improving mobility and frailty. However, the effects of the group-
based OEP on physical function, frailty, and health status did not dif-
fer by participant characteristics (age) or training frequency, and the
total intervention period also had no significant effect on our results.
At the beginning of the OEP training design, it was pointed out that
exercise intensity should be based on individual tolerance.18 Com-
pared with older community-dwelling adults, NH residents are more
likely to be frail with chronic diseases and comorbidities, resulting in
a generally poor physical condition.64 This may lead to a lack of activ-
ity tolerance for high-intensity training. In our analysis of secondary
outcome measures, we found that the group-based OEP did not sig-
nificantly improve participants’ aerobic tolerance, which supported
our view to some extent. Recommended in the Guidelines of the
International Association of Gerontology and Geriatrics Global Aging
Research Network (IAGG-GARN), group multicomponent exercise
training for 35 to 45 minutes, twice per week, can improve physical
function and reduce the risks of various chronic diseases among older
adults requiring long-term care. However, the guidelines specifically
emphasize the need to constantly adjust the training intensity
according to participants’ abilities. For frail older adults, the exercise
duration should be appropriately reduced, and moderate-intensity
training is considered feasible, effective and safe.65 In fact, the origi-
nal OEP manual recommended 30-minute sessions, three times per
week, for six months, as the most effective exercise regimen.16,23
Therefore, we recommend a group-based OEP with a duration of 30
minutes and an appropriately adjusted exercise intensity as a more
effective strategy for older adult residents in NHs.
To promote the implementation of an exercise plan, the selected
training format must consider participants’ goal expectations, per-
sonal preferences, beliefs and attitudes, personalized guidance and
supervision, and social support.66 Our subgroup analysis showed that
the physiotherapist-coordinated group-based OEP had a more signifi-
cant effect on participants’ mobility and showed greater effect values
for improving balance and frailty than health training education. Pre-
vious studies have confirmed the effectiveness of OEP online educa-
tion and guidance by professional trainers.16,36 However, this cannot
replace the professional guidance and supervision of physiothera-
pists, who teach training movements and requirements, provide
safety information and verbal and visual instructions, and adjust
exercise levels and protocols based on individual abilities. These
measures could help participants to understand the training struc-
ture and process, ensure for the accurate and safe completion of
training tasks, and effectively overcome the problem of group train-
ing related to meeting the needs of personalized exercise intensity in
a timely manner.67 At the same time, the support and encouragement
of physiotherapists could help improve participants’ confidence in
self-management, training motivation and compliance and enhance
their sense of self-efficacy. Therefore, we recommend that NHs
implement the group-based OEP with physiotherapist training to
improve residents’ physical conditions. However, the implementa-
tion of this plan requires comprehensive consideration of social sup-
port for NHs and improvement of their service quality.
Strengths and limitations
In terms of strengths, this systematic review and meta-analysis
included older NH residents as research subjects for the first time to
 Y. Peng et al. / Geriatric Nursing 49 (2023) 30 43
verify the application effects of the group-based OEP. It is helpful for
enhancing the representativeness of multimodal exercise program
research applied to NH residents and can serve as a reference for
improving older adult residents’ physical conditions. Moreover, the
outcomes of the review also focused on frailty, which is known to
have a higher incidence among NH residents. Furthermore, we con-
ducted an in-depth analysis of the characteristics of the participants
and interventions to determine which form of the OEP was the opti-
mal strategy.
Nevertheless, there are some limitations to this study. First, most
of the participants were older adult women, accounting for up to
74.86% of the sample, and the results may be affected by this imbal-
ance in the male‒female ratio. Second, although the overall quality of
the included studies was high, the participants and interveners were
not blinded because they both needed to know the entire exercise
process and precautions; thus, the lack of blinding may have limited
the credibility of our results. Third, according to the Shumway-Cook
model, balance should be divided into four types: static, dynamic,
active and reactive balance.26 However, there is no consensus on vali-
dated and preferred objective outcome indicators for assessing differ-
ent types of balance, especially in the evaluation of reactive balance
indicators.68 Therefore, to ensure the rigor of our study, we did not
combine types of balance indicators and instead used the representa-
tive outcome variable of BBS scores to analyze the participants’ bal-
ance. This may have led to a gap in our assessment of balance,
limiting the breadth of the research results. Future studies should
aim to develop standardized and objective outcome measures that
integrate the four types of balance and increase the comparability of
studies. Additionally, studies based on laboratory assessments could
provide an objective assessment of various conditions and also detect
subtle changes that cannot be measured by clinical tests to verify the
reliability of the results. Fourth, in the statistical analysis of the bal-
ance index, we found high heterogeneity among the studies. Sensitiv-
ity analysis revealed that the Kocic et al.45 study was the main source
of heterogeneity. Based on the subgroup analysis, we considered that
the intervention characteristics (duration of exercise) might be a rea-
son for the high heterogeneity. Further, after reading the full texts
closely, we found that there were differences in the mFIM between
the baseline data of the two groups in the Kocic study, which may be
another cause of heterogeneity. Therefore, the results of the balance
index analysis must be interpreted with caution. Finally, the compari-
sons of some outcome indicators in this meta-analysis included only
a few studies. Therefore, future studies should adopt a multicenter
study design, identify recruitment methods and systematically
recruit participants to conduct more high-quality, large-sample RCTs
to expand the research scope and further confirm the reliability of
such results.
Conclusions
This systematic review and meta-analysis demonstrates that the
group-based OEP improves physical function, frailty, and health sta-
tus in older NH residents and provides some reference value for
reducing the fear of falling and preventing the frequency of falls (
4
times). However, the effect of aerobic tolerance needs further explo-
ration. Notably, our study found that administering the group-based
OEP in 30-minute sessions and coordinating with physiotherapists
may be the most appropriate and effective strategy. Future studies
need to use a high-quality multicenter study design and blinding pro-
cedures, unify outcome indicators and accurately measure outcomes
to further test the effectiveness of the group-based OEP in older NH
residents. Additionally, considering the availability of resources and
cost-effectiveness, we sincerely hope that financial support is
increased so that NHs can improve their institutional systems.
41
Ethical approval
Not applicable.
Informed consent
Not applicable.
Data availability
All data utilized in this review are included in this published arti-
cle.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influ-
ence the work reported in this paper.
Supplementary materials
Supplementary material associated with this article can be found
in the online version at doi:10.1016/j.gerinurse.2022.10.014.
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