Introduction
The number of older adults (aged 65 years or over) is growing, and in the near future it is expected that there will be a rapid increase in the number of people aged 85 years and over.1 For some older adults, aging can lead to increased disability and/or difficulties with completing activities of daily living (ADLs), which are essential to living independently and maintaining quality of life. This may lead to an increase in the need for healthcare services in the years to come. The World Health Organization (WHO) has emphasized a need for innovative and sustainable initiatives to meet these challenges, with a specific focus on healthy and active aging in order to develop and maintain functional ability and wellbeing in older age.2
Reablement is a multidisciplinary practice introduced during the previous two decades aiming to provide home care services that can help people regain function and independence, rather than continuing to increase services to compensate for ongoing functional losses.3-6 Different terms have been used for reablement such as "everyday rehabilitation" and "restorative care". For the purpose of this study, the term "reablement" will be used and is defined as rehabilitative initiatives that aim to maximize functional ability and independence among home care service users, by offering intensive, time-limited, multidisciplinary, person-centered and goal-directed home care services.6 Although the duration of reablement interventions typically have been six to 12 weeks, reablement interventions lasting up to six months will also be considered in this review, since the beneficial duration of these services previously has been questioned.6 A common feature of reablement is that the services are person-centered, with an emphasis on identifying and working towards the participants' own prioritized activity goals.6 Reablement is reported to consist of various components, such as, but not limited to, training in daily activities,7,8 adaptations of the environment,7 medication and nutrition management,8 and physical activity/exercise programs.7,8 Reablement may involve different combinations of disciplinary groups such as nurses, occupational therapists and physiotherapists, as well as healthcare assistants or support staff.9
Several recent systematic reviews have investigated different perspectives on the effectiveness of reablement.3-6,9,10 Although some promising implications have been reported,4,10 there is limited evidence on the effect of reablement for improving function and independence compared to standard home care.3,5,6,9 The specific characteristics of reablement provided in the included intervention studies are reported to be poorly described, and little is known about the effect of individual components included in reablement practice.5,6,10 Hence, there is a need to fill this gap and investigate how components that are assumed to be essential for improving older adults' function and independence are performed within reablement practice. The focus of this review will therefore be on how physical activity is integrated in reablement, as physical activity is considered an important factor for improving and maintaining older adults' function.11
For the purpose of this study, "physical activity" will be defined in accordance with the definition used by the WHO as "any bodily movement produced by skeletal muscles that requires energy expenditure".12(para.1) This includes different activities, such as leisure time physical activity, transportation, occupational activity, household activity, games, sports, everyday activities and exercise. Within this broad definition of physical activity, the focus of this study will be on general physical activity facilitation and also exercise strategies and prevention of sedentary behavior. "Exercise" will be defined as "physical activity that is planned, structured, repetitive, and purposive in the sense that improvement or maintenance of one or more components of physical fitness is an objective".13(p.128) "Sedentary behavior" will be defined as "any waking behavior characterized by low energy expenditure [horizontal ellipsis] while in a sitting, reclining or lying posture".14(p.9)
Research demonstrates the positive effects of regular physical activity and exercise for older adults such as reduced risk of falling,15 reduced level of frailty16 and improved performance in ADLs.17 The WHO recommends that older adults be physically active for at least 150 minutes a week, including activities that are adapted to the individuals' functional level.11 They also recommend including activities that enhance muscle strength and balance at least twice a week and reducing sedentary behavior. However, physical activity levels decrease substantially in older populations, and only 12-18% of people aged 75 years and over are reported to meet these physical activity guidelines18,19 Furthermore, it has been reported that older adults spend an average of 9.4 hours a day being sedentary.20
Inactivity among older adults affects their physical fitness (e.g. cardiorespiratory and muscular endurance, muscular strength, flexibility, balance, mobility or speed of movement) and is correlated to frailty, risk of falling and functional limitations.21 Improvement of physical fitness in itself is unlikely to be a goal prioritized by older adults receiving reablement, but may be essential for achieving goals related to functional mobility and also to maintain functional capacity and independence over time. Functional mobility (e.g. inside and outside walking, transferring or climbing stairs) was the main prioritized goal among older adults receiving reablement in a Norwegian study.22
There are many factors, however, that are perceived by older adults as barriers to being physically active, such as health status, lack of knowledge about physical activity, low energy/fatigue, low self-esteem, fear of falling and local environment.23,24 It has been recommended that health professionals pay special attention to inform older adults about the health benefits of physical activity and that they consider the person's personal, social and environmental constrains for being physical active.23 Furthermore, it has been suggested that more attention be directed to real-life contexts of physical activity interventions among community-dwelling older adults.25
Rationale for this review
As outlined above, there is a need to investigate how physical activity strategies (including general physical activity facilitation, exercise and prevention of sedentary behavior) are integrated into reablement services for older adults. Physical activity or exercise strategies have been reported as part of the reablement intervention in some systematic reviews published over the previous few years,4,6,9,10 but no further characteristics of these strategies are provided. No identified systematic review has mentioned strategies aimed at reducing sedentary behavior among participants.3-6,9,10
Due to their effectiveness-related inquiries, most of the identified reviews only include randomized controlled trials (RCTs) and other forms of clinical trials (e.g. non-RCTs, controlled before and after studies or interrupted time series studies).3,5,6,10 It is anticipated that experimental, quantitative and qualitative study designs may provide evidence relevant to the objective of this scoping review, and the aim is therefore to include a broader range of study designs than what has been previously included. Although two of the identified systematic reviews intended to also include qualitative studies (both searching for studies published in 2014 or earlier),4,9 only one qualitative study was included. It is anticipated that several qualitative studies published more recently may add further evidence for the objective of this review.
A search of the Cochrane Library, PubMed, PROSPERO, DARE and JBI Database of Systematic Reviews and Implementation Reports indicated that there are no existing scoping reviews or systematic reviews specifically related to physical activity strategies within reablement. Therefore, a scoping review is necessary to identify and map available evidence on how physical activity strategies are integrated into reablement for community-dwelling older adults. The mapping of this evidence is expected to provide greater understanding of the use of physical activity strategies within reablement and/or identify gaps that are important for further research in order to continually improve reablement services for older adults.
Review questions
i. To what extent are physical activity strategies used in reablement for older adults, and what are the reported characteristics of these strategies?
ii. What evidence regarding experiences (of older adults, carers or professionals) and barriers related to physical activity facilitation in a reablement setting can be identified?
iii. What is the scope of assessment methods used in relation to reablement that can inform about older adults' changes in physical activity behavior and physical fitness?
Inclusion criteria
Participants
This review will include studies that focus on older adults, aged 65 years and over, who are receiving reablement services. Studies focusing on professionals working with reablement and carers of reablement participants will also be included. Studies focusing on people with a need for end-of life care will be excluded.
Concept
This review will include studies that investigated or explored the concept of reablement. Studies investigating reablement with a duration of more than six months will be excluded. Within these studies, information about intervention characteristics, experiences, barriers and outcome measures related to physical activity, exercise, sedentary behavior and physical fitness will be included.
Context
This review will include studies that have investigated or explored reablement provided by multidisciplinary home care services (managed by local government or not-for-profit agencies) in the participant's home (including a variety of housing arrangements) or local environment. There will be no restriction regarding country of origin of the study. Studies focusing on reablement interventions provided in long-term care facilities/nursing homes or housing arrangements with 24-hour care will be excluded. Studies investigating reablement in relation to transition from a hospital setting will be included if they meet all other eligibility criteria.
Types of studies
This review will include research with different study designs, including (but not limited to) clinical trials (e.g. RCTs, controlled trials, case-control studies), qualitative studies, quantitative research and mixed method research. Text (e.g. political documents or government recommendations) and opinion papers will be excluded. Studies published in English, Norwegian, Danish, Swedish and German will be considered for inclusion in this review.
Reablement is a relatively new intervention with the majority of studies being published in the 2000s.3,4,6,9,26 Given that the 2015 search by Cochrane et al.6 had no date restrictions yet found few studies (i.e. only those in the 2000s), we have decided, like Ryburn,26 to contain the search between 1996 and the present.
Methods
We will use a scoping review method following recommendations from the JBI methodology.27,28
Search strategy
In this review, the following three-step search strategy aims to trace published and unpublished studies. Firstly, an initial limited search in PubMed and CINAHL will be undertaken to identify relevant keywords and search terms used in titles and abstracts in studies published within the topic. Secondly, based on search terms identified in this initial search, specific search strategies will be developed with assistance from a librarian to fit with the following databases: PubMed, Cochrane Central Register of Controlled Trials, Embase, PsycINFO, AMED, PEDro and CINAHL, from 1996 to the present.
In addition to this, ProQuest Dissertations and Theses and Google Scholar will be searched to identify gray literature that potentially meets the eligibility criteria. The reference lists of all included studies will be searched, and a citation search of included studies will be performed through Google Scholar to identify eligible studies that may not have been found through the previous search strategy. Authors of included studies will be contacted if further information about the study is required.
Study selection
The preliminary search strategy for PubMed is presented in Appendix I and includes search terms related to participants (aged/older adults), concept (reablement) and context (home care services). Relevant MESH terms and headings will be identified and used where required. We will only use English search terms in the search strategy. The specific terms may change slightly depending on the database; however, the main keywords will be used throughout.
After removing duplicates, one reviewer (HLM) will perform an initial screening of titles and exclude studies that clearly do not meet the inclusion criteria. Two reviewers (HLM, CFM) will then independently perform screening of titles/abstracts and again exclude studies not meeting the inclusion criteria. The full text of eligible studies will be retrieved and further evaluated for eligibility independently by two reviewers (HLM, CFM). Disagreements will be solved by discussion or by involving a third reviewer for consensus (LU or EB). Microsoft Excel (Redmond, Washington, USA) and EndNote X8 (Clarivate Analytics, PA, USA) will be used to manage records and data throughout the review.
Data extraction
Two reviewers (HLM, CFM) will independently extract and chart data using predefined data charting forms. The preliminary data extraction forms are presented in Appendix II and III. Consensus will be reached through discussion or by involving another researcher (LU or EB).
For clinical trials, observational and descriptive studies, key information about author, year, country of origin, study design, study purpose, multidisciplinary team, reablement characteristics, population and main outcome(s) or findings will be extracted. Furthermore, information about physical activity strategies will be extracted, including type of physical activity strategy, characteristics of physical activity strategies, social support, follow-up initiatives regarding physical activity, methods for targeting physical activity strategies, assessment methods for (changes of) physical activity levels and physical fitness, and an open field for other findings of relevance to this scoping review objective.
For qualitative studies, key information about author, year, country of origin, study design, study purpose, method, reablement characteristics, population, main findings, context and theoretical perspectives will be collected. Furthermore, information about reported experiences and barriers related to physical activity in these studies will be extracted.
If other study designs with relevance are identified, extraction form(s) based on the current forms will be developed to fit these designs. All data charting forms will be piloted in advance, using two or three studies on a related topic. The data charting forms may be refined during the review process to leave openness for inclusion of additional unforeseen data that can be relevant for our inquiry. A qualitative content analytical technique will be used to facilitate the mapping of the results. This process will be conducted by one reviewer (HLM) in cooperation with the rest of the review team.
Data presentation
Results will be presented in a narrative, descriptive section including a summary of extracted data, key findings, identified knowledge gaps and recommendations. Additionally, we will present findings in diagrammatic or tabular form as we deem appropriate considering the nature of the findings. The data charting forms presented in Appendix II and III will be used as the basis for developing and refining tables for data presentation. A PRISMA flow diagram will be presented to visualize the process of identifying and selecting studies and also reasons for exclusion of full-text studies.29
Funding
The study is part of a PhD project undertaken by the first author, HLM, and funded by Nord University, Norway.
Appendix I: Search strategy for PubMed
Appendix II: Data extraction form for clinical trials and observational/descriptive studies
Appendix III: Data extraction form for qualitative studies
References