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No evidence that it causes harm- (Hospital Associated Deconditioning Evidence)

Evidence Summary

Adverse events / complications

In a meta-analysis from 2020 of exercise interventions alone (including walking and strength and balance activities) in older adults acutely admitted to hospital with a medical problem, 9 of the 12 included RCTs monitored the incidence of adverse events related to the exercise intervention (e.g. asthma exacerbation, dizziness, falls, musculoskeletal) and none reported any adverse event [1].  Six RCTs in this review assessed the incidence of falls during hospitalisation but the effect of exercise interventions was uncertain (OR 1.14; 95% CI 0.36 to 3.57; p=0.82; 1148 participants). 

Another recent meta-analysis, looking at exercise interventions alone or as part of multidisciplinary interventions (which include geriatric wards, occupational therapy and discharge planning) has also demonstrated uncertainty with regards to the effect of exercise interventions on falls (OR 0.63; 95%CI 0.13 to 3.03; p=0.56, 855 participants, low certainty evidence) [2].  This review also included two RCTs in patients with pulmonary embolism (PE) and exercise interventions were shown to decrease the recurrence of PE (pooled OR 0.33; 95% CI 0.14 to 0.78; p<0.01; I2=0%; 321 participants; moderate certainty evidence)

In a Cochrane review by de Morton from 2007, the effect of exercise interventions, alone or as part of multidisciplinary interventions, in acutely admitted medical patients was assessed.  In multidisciplinary interventions, there was little or no difference patient complications during admission (pneumonia, skin breakdown, confusion, falls, infection or other) (RR 0.94; 95% CI 0.68 to 1.29; 2 studies; 550 participants) [3]. Meta-analyses of two studies (of exercise interventions alone 396 participants) showed an uncertain effect on the incidence of falls (RR 1.12, 95% CI 0.40 to 3.15) and admission to ICU (RR 1.06; 95% CI 0.04 to 30.44).

Two systematic reviews of physical activity in acutely hospitalised older medical patients reported adverse events narratively, one found 9 out of the 12 included studies registered adverse events and no adverse events were reported [4]. The other review found only one adverse event (conscious collapse) reported (in a control group) out of five studies that registered adverse events. [5]. 

Re-hospitalisation

The meta-analysis by Valenzuela et al.  assessed the effect of exercise interventions on rehospitalisation 3-6 months post discharge and found this was uncertain (OR 1.29; 95% CI 0.86 to 1.93; p=0.23; I2=0%; 4 studies; 863 participants) [1].

Mortality

The meta-analysis by Valenzuela et al. also assessed the effect of exercise interventions on mortality at 1-3 months post-discharge and found this was uncertain (OR 0.74; 95% CI 0.40 to 1.35; p=0.32; I2= 0%; 4 studies; 1127 participants) [1].

The effect of exercise interventions on mortality as part of a multidisciplinary interventions (mortality at discharge RR 0.99; 95% CI 0.59 to 1.64; 6 studies, 3552 participants; mortality 3 months after discharge RR 0.99; 95% CI 0.83 to 1.17; 3 studies; 2595 participants) and in exercise intervention alone (mortality at discharge RR 1.98; 95% CI 0.64 to 6.18; 3 studies; 696 participants)  was also found to be uncertain in the Cochrane review by de Morton [3].

One RCT from the UK investigating the effects of six weeks of progressive rehabilitation (walking and strength training) in patients acutely admitted with an exacerbation of a chronic respiratory disorder found increased mortality at 12 months in the intervention group (OR 1.74, 95% CI 1.05 to 2.88; p=0.03; 389 participants) [6]. However, this difference in mortality only started to occur after 5 months and there was no difference in mortality when per protocol analysis was performed [7]. A subsequent narrative review identified 7  trials of rehabilitation interventions performed during an acute COPD exacerbation and found no other trials reported increased mortality [8].

Most RCTs were performed in medically stable patients who were able to mobilise without help at either admission or before admission. Some studies excluded patients who were medically unstable or near the end of life. It is therefore difficult to extrapolate this evidence to all medical inpatient populations.

Quality of Evidence

B – Three systematic reviews found no adverse events reported relating to the intervention groups in the RCTs contained within. There is an uncertainty in the evidence regarding effect on falls, re-hospitalisation and mortality

Strength of recommendation

1 – clear benefits to physical activity and no adverse events related directly to interventions reported. No evidence of a difference in mortality or falls.

Conclusion

No adverse events directly related to exercise interventions have been identified.  There is no evidence of a difference between exercise interventions and controls on falls, re-hospitalisation and mortality. Overall physical activity appears to be safe and not associated with increased mortality.

References

  1. Valenzuela PL, Morales JS, Castillo-García A, et al. Effects of exercise interventions on the functional status of acutely hospitalised older adults: A systematic review and meta-analysis. Ageing Res Rev 2020;61:101076. doi:10.1016/j.arr.2020.101076
  • Cortes OL, Delgado S, Esparza M. Systematic review and meta-analysis of experimental studies: In-hospital mobilization for patients admitted for medical treatment. J Adv Nurs 2019;75:1823–37. doi:10.1111/jan.13958
  • De Morton NA, Keating JL, Jeffs K. Exercise for acutely hospitalised older medical patients. Cochrane Database Syst Rev Published Online First: 2007. doi:10.1002/14651858.CD005955.pub
  • Martínez-Velilla N, Cadore EL, Casas-Herrero, et al. Physical activity and early rehabilitation in hospitalized elderly medical patients: Systematic review of randomized clinical trials. J Nutr Heal Aging 2016;20:738–51. doi:10.1007/s12603-016-0683-4
  • Kosse NM, Dutmer AL, Dasenbrock L, et al. Effectiveness and feasibility of early physical rehabilitation programs for geriatric hospitalized patients: A systematic review. BMC Geriatr 2013;13. doi:10.1186/1471-2318-13-107
  • Greening NJ, Williams JEA, Hussain SF, et al. An early rehabilitation intervention to enhance recovery during hospital admission for an exacerbation of chronic respiratory disease: Randomised controlled trial. BMJ 2014;349:1–12. doi:10.1136/bmj.g4315
  • Spruit MA, Singh SJ, Rochester CL, et al. Pulmonary rehabilitation for patients with COPD during and after an exacerbation-related hospitalisation: back to the future? Eur Respir J 2018;51:1701312. doi:10.1183/13993003.01312-2017
  • Crisafulli E, Barbeta E, Ielpo A, et al. Management of severe acute exacerbations of COPD: an updated narrative review. Multidiscip Respir Med 2018;13:36. doi:10.1186/s40248-018-0149-0

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