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Center based versus home based geriatric rehabilitation on sarcopenia components: a systematic review and meta-analysis

  • Author Footnotes
    a Qiaowei Li, Fang Wang and Xiaoqun Liu contributed equally to the study,
    Qiaowei Li
    Footnotes
    a Qiaowei Li, Fang Wang and Xiaoqun Liu contributed equally to the study,
    Affiliations
    Shengli Clinical Medical College of Fujian Medical University

    Department of Geriatric Medicine, Fujian Provincial Hospital

    Fujian Key Laboratory of Geriatrics

    Fujian Provincial Center for Geriatrics
    Search for articles by this author
  • Author Footnotes
    a Qiaowei Li, Fang Wang and Xiaoqun Liu contributed equally to the study,
    Fang Wang
    Footnotes
    a Qiaowei Li, Fang Wang and Xiaoqun Liu contributed equally to the study,
    Affiliations
    Department of Nursing, Fujian Provincial Hospital
    Search for articles by this author
  • Author Footnotes
    a Qiaowei Li, Fang Wang and Xiaoqun Liu contributed equally to the study,
    Xiaoqun Liu
    Footnotes
    a Qiaowei Li, Fang Wang and Xiaoqun Liu contributed equally to the study,
    Affiliations
    Shengli Clinical Medical College of Fujian Medical University
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  • Huijuan Zhong
    Affiliations
    Shengli Clinical Medical College of Fujian Medical University
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  • Feng Huang
    Correspondence
    Address for correspondence: Feng Huang, MD, Shengli Clinical Medical College of Fujian Medical University, Department of Geriatric Medicine, Fujian Provincial Hospital, Fujian Key Laboratory of Geriatrics, Fujian Provincial Center for Geriatrics. 134 East Street, Fuzhou, 350001, China. Tel: +86-13850170520.
    Affiliations
    Shengli Clinical Medical College of Fujian Medical University

    Department of Geriatric Medicine, Fujian Provincial Hospital

    Fujian Key Laboratory of Geriatrics

    Fujian Provincial Center for Geriatrics
    Search for articles by this author
  • Pengli Zhu
    Correspondence
    Address for correspondence: Pengli Zhu, MD, Shengli Clinical Medical College of Fujian Medical University, Department of Geriatric Medicine, Fujian Provincial Hospital, Fujian Key Laboratory of Geriatrics, Fujian Provincial Center for Geriatrics. 134 East Street, Fuzhou, 350001, China, Tel: +86-13799957755, Fax: +86-591-87532356.
    Affiliations
    Shengli Clinical Medical College of Fujian Medical University

    Department of Geriatric Medicine, Fujian Provincial Hospital

    Fujian Key Laboratory of Geriatrics

    Fujian Provincial Center for Geriatrics
    Search for articles by this author
  • Author Footnotes
    a Qiaowei Li, Fang Wang and Xiaoqun Liu contributed equally to the study,
Open AccessPublished:January 10, 2022DOI:https://doi.org/10.1016/j.apmr.2021.12.016

      Abstract

      Objective

      To investigate the available evidence on the components of sarcopenia in geriatric rehabilitation, and to examine whether changes in different settings are associated with sarcopenia.

      Data sources

      PubMed, the Cochrane Central Register of Controlled Trials in the Cochrane Library, and EMBASE were searched from initiation to August 30th, 2021.

      Study selection

      We included randomized controlled trials (RCTs) of older adults receiving geriatric rehabilitation that included strength exercise training.

      Data extraction

      The following study contents were extracted: study design, patient characteristics, sample size, description of the rehabilitation setting, follow-up timepoint and outcomes. The main outcomes were muscle mass, muscle strength and physical performance.

      Data synthesis

      Weighted mean difference for ‘Timed up-and-go’ score and standardized mean difference for other parameters were calculated.

      Conclusions

      Center-based geriatric rehabilitation improved lower limb strength and Timed up-and-go test score to a greater extent than home-based geriatric rehabilitation in elderly people. Center-based training seems to show a minor superior effect on gait speed in prolonged follow-up rather than at the endpoint of intervention. To draw a stronger conclusion, further high-quality trials with standard protocols and longer follow-up are needed.

      Key words

      List of abbreviations:

      RCTs (randomized control trials), GR (geriatric rehabilitation), TUG (Timed up-and-go test), LDWT (long distance walking test), 6MWT (6 minute walking test)

      Introduction

      Sarcopenia has been defined as a progressive and generalized skeletal muscle disorder that involves accelerated loss of muscle mass and function1. In terms of human health, sarcopenia is associated with increased adverse outcomes, including falls2, functional decline3, frailty and mortality4. From a financial perspective, sarcopenia directly increases healthcare costs in society5, 6. The prevalence of sarcopenia worldwide is up to 15% in healthy older adults7, approximately 76% of acutely hospitalized older patients8-10 and up to 69% of patients admitted to post-acute geriatric rehabilitation11. Thus, preventing or reversing sarcopenia is an important approach in healthy aging, from both an individual and societal perspective.
      The widely accepted diagnostic criteria for sarcopenia require measurements of three components: muscle mass, muscle strength and physical performance12, 13. Although the algorithm and test tools have undergone some changes in last decade, the main components remain the same. The components are not only applied for diagnosis and severity determination, but also for monitoring the development of sarcopenia.
      To date, physical activity, with a focus on resistance (strength) training, is endorsed as a first-line therapy to manage sarcopenia, evidenced by two meta-analyses9, 14. Relevant randomized control trials (RCTs) showed positive effects of resistance training on muscle mass, muscle strength and physical performance15, 16.
      As an integration of multidimensional approaches to promote activity and preserve functional reserve, geriatric rehabilitation (GR) is therefore recommended for patients with geriatric syndrome17. As sarcopenia is one of the manifestations of geriatric syndrome, GR with resistance training can play a role in preventing and treating functional decline related to sarcopenia. So far, GR has been offered in a diverse range of modes, such as hospital-based, home-based or community-based. Although the beneficial effects of resistance training have been shown14, the implementation of care and effective therapeutic interventions of sarcopenia remain far from sufficient. Most studies on sarcopenia intervention are regarding home-based exercise training15, 18, which emphasizes the active role of patients, convenience of transportation and cost-effectiveness. As an alternative approach, center-based rehabilitation has shown a superior effect in some studies on body composition, muscle strength and reducing all-cause mortality19-21. There is uncertainty as to whether there are differential effects of GR on sarcopenia between center-based and home-based settings. The current review aimed to investigate available evidence on the components of sarcopenia in GR including resistance exercise training, and to examine whether differences in settings are associated with sarcopenia.

      Methods

       Search strategy and selection criteria

      The following electronic databases were searched from inception to August 30th, 2021: PubMed, the Cochrane Central Register of Controlled Trials in the Cochrane Library, and EMBASE. The language was restricted to English, and the reference list of a previous relevant review was scrutinized22. After removing duplicates, two researchers performed title/abstract screening independently. The eligible groups were compared, and inconsistencies were discussed and resolved. Then, the full texts of potentially eligible records were accessed by two authors for final determination of eligibility and data extraction. The search strategy and full search terms are shown in Supplementary Table 1.
      To be included in this review, studies had to meet the following criteria: (1) RCT or quasi-RCT design comparing center-based (defined as fixed public area such as a clinic, rehabilitation service or community gym) geriatric rehabilitation with home-based geriatric rehabilitation; (2) the rehabilitation included strength or resistance exercise training; (3) the exercise intensity was comparable or approximately comparable between the two groups; and (4) participants were mainly older adults with an average age over 60 years. The geriatric rehabilitation was performed in patients with a wide range of medical conditions, including fracture, joint replacement, cardiac, pulmonary, and stroke rehabilitation.

       Data extraction

      Data extraction was performed by three researchers. The following study contents were extracted: study design, patient characteristics, sample size, description of the rehabilitation setting, follow-up timepoint and outcomes. The methodological quality of the individual studies was assessed in accordance with the Cochrane guidelines, focusing on the following criteria: sequence generation, allocation concealment, blinding of analysts (it was impossible to blind the participants in an exercise-based intervention), incomplete data, selective reporting and other sources of bias23. Thus, we used the tool recommended by the Cochrane guidelines to assess the risk of bias in order to enhance the comparability of the risk of bias assessments between the different types of studies. The risk of bias was rated as high, low or unclear. The extracted data were entered into Review Manager version 5.3 and checked for accuracy by two researchers.

       Data synthesis

      The meta-analysis was performed on the parameters of sarcopenia, including muscle mass, muscle strength and physical performance. As the above parameters were reported using different methods with a variety of units, we calculated weighted mean difference (WMD) for the Timed up-and-go test (TUG) score and standardized mean difference (SMD) for other continuous outcomes. When a study applied more than one instrument to assess the same parameter, the most appropriate and widely-used measurement instrument was selected. In addition, for parts of the studies assessing the outcome at multiple points in time, we used the outcome at the endpoint of intervention and a further prolonged timepoint after completion of the intervention. If the number of available studies for a specific parameter was more than 10, we used subgroup analysis to show the immediate and long-term effects of the intervention. Heterogeneity between studies was first assessed by visual inspection of the forest plot. Next, we computed the Q-statistic and I2. Substantial statistical heterogeneity was assumed if the Q-statistic was significant (p < 0.05) and the I2 value was more than 50%. A fixed-effects meta-analysis was used, except when statistical heterogeneity was identified. In that case, the more conservative random-effects model was used and sensitivity analysis was performed by exclusion of each study one by one to evaluate the stability of results without estimation of bias from the individual study. This process allowed for identification of any single study that may have a great influence on the overall results. Funnel plots were used to explore the possibility of publication bias24. All analyses were performed using R, version 4.0.4 (Vienna University of Economics and Business, Vienna, Austria) (https://www.R-project.org/).

      Results

       Study selection

      The PRISMA flowchart of the entire research and selection procedure in shown in Figure 1. In summary, 25 of the 8896 articles met the inclusion criteria and were included in the systematic review25-49. Since two articles reported data from the same study27, 28, we included 24 studies in the qualitative synthesis. Twenty-one of the these were finally included in the meta-analysis of the outcome26-31, 33-47, 49. Reasons for exclusion in the full-text assessment phase were incomparable exercise intensity or contents, no exercise or strength exercise intervention, or lack of a center-based exercise group. We also excluded one conference abstract without full text published50. Several trials25, 42 contained three parallel groups: individual supervised exercise, group exercise and home-based exercise. As we aimed to compare the effects of different places on rehabilitation training, the results of individual supervised and group exercises were combined and further compared with those of home training.

       Study characteristics

      The summary of the study characteristics can be found in Tables 1 and 2. The mean age of the participants of the 24 studies ranged from 60.4 to 81.0 years and the patients were admitted for a variety of reasons. The study designs were primarily randomized controlled trials (RCTs), with one quasi-RCT35. The included subjects varied from healthy elderly adults to men with prostate cancer, due to a broad definition of geriatric rehabilitation. Tsekoura et al.49 conducted the only study which compared the effect of center- and home-based rehabilitation specifically on patients with sarcopenia. Six studies investigated elderly people who were frail or who had experienced a fall, populations that are relevant to sarcopenia26, 30, 33, 34, 40, 47. The follow-up ranged from 2 weeks to 14 months. More than half of the total studies adopted interventions consisting of mixed exercise, incorporating aerobic (endurance), resistance, and flexibility training25, 29, 38-48. Five studies involved a combination of resistance and balance training26, 33, 34, 36, 49. Among a variety of resistance training types, the majority of studies used the application of self-weight, elastic bands or free weight training (dumbbells or ankle weights)26, 29, 30, 36, 40, 41, 43, 47, 49, but seldom adopted weight equipment27, 28, 47. In 14 of the studies, center-based exercise training was supervised, monitored, reviewed or documented by physical therapists25-30, 34, 36-38, 40, 41, 43, 44, 47. Ten of the studies involved regular phone calls or messages to supervise the home-based training25, 26, 29, 32, 34, 35, 37, 43, 45, 49.
      Table 1Characteristics of included studies
      First author, year of publicationDesignNo. of participants for intention-to-treat analysis (CB: HB)No. of participants for pre-protocol analysis (CB: HB)RegionsAverage age (years)InclusionFollow-up
      Alibhai,2019RCT with three parallel groups (individual, group-based, HB)59(39:20)42(28:14)Canada69.9men with prostate cancer on androgen deprivation therapy3, 6, 9 and 12 months
      Almeida,2013RCT with three parallel groups (CB, HB, control)89(45:44)76(28:22)Brazil79.1older adults with previous falls4 months
      Bieler,2017,2018RCT with three parallel groups (CB, HB, control)152(50:52)74(40:34)Denmark69.8patients with clinical hip osteoarthritis2, 4 and 12 months
      Bittar,2016RCT60(30:30)34(16:18)Brazil67.3sedentary postmenopausal women12 months
      Boshuizen,2005RCT with three parallel groups (CB, HB, control)73(24:26)32(16:16)Netherlands78.8frail elderly10 weeks and 6 months
      Bourne,2017RCT90(26:64)67(21:46)UK70.3patients with COPD7 weeks
      Carmeli,2006RCT63(34:29)55(29:26)Israel70.8elderly patients after hip surgery7 and 14 weeks
      Comans,2010RCT107 (52:55)79(35:41)Australia79older fallers2 and 6 months
      Costa2020RCT25(14:11)25(14:11)Brazil69prefrail older women12 weeks
      Cyarto,2008quasi-experimental trial with three parallel groups (CB, HB, control)119(81:38)119(81:38)Australia78.8older adults20 weeks
      Donat,2007RCT42(21:21)32(17:15)Turkey80older adults8 weeks
      Dunstan,2006RCT consisted of two phases57(28:29)53(27:26)Australia61.5overweight and sedentary adults with type 2 diabetes2 and 14 months
      Galea,2008RCT23(11:12)23(11:12)Australia67.6people after hip replacement8 weeks
      Hansen,2020RCT134(67:67)87(49:42)Denmark68.3patients with severe COPD22 weeks
      Helbostad,2004RCT77(39:38)53/77(26/38:27/39)
      , number of subjects included into analysis was variant in different parameters.
      Norway81older adults with mobility and balance problems3 and 9 months
      Hwang,2017RCT53(29:24)50/49(26/26:24/23)
      , number of subjects included into analysis was variant in different parameters.
      Australia67patients with chronic heart failure12 and 24 weeks
      King,2015RCT with three parallel groups (individual, group-based, HB)59(42:17)58(41:17)Portland63.9patients with Parkinson disease4 weeks
      Lacroix,2016RCT with three parallel groups (supervised, unsupervised, control)44(22:22)40/39(21:19/18)
      , number of subjects included into analysis was variant in different parameters.
      Germany73healthy older adults12 weeks
      Madsen,2013RCT80(40:40)70/68(36:34/32)
      , number of subjects included into analysis was variant in different parameters.
      Denmark66.6patients after total knee arthroplasty3 and 6 months
      Martel,2018RCT with three parallel groups (CB, HB, control)34(16:18)32(16:16)Canada73.5older adults after a minor injury2 and 12 weeks
      McCarthy,2004RCT214(111:103)151(80:71)UK64.7people with knee osteoarthritis.6 and 12 months
      Meng,2020RCT146(74:72)106(57:49)China (Taiwan)76.6frail or prefrail older adults3 months
      Reeder,2008RCT172(84:88)152(73:79)Canada60.4older adults with chronic health conditions3 months
      Tsekoura,2018RCT with three parallel groups (CB, HB, control)36(18:18)36(18:18)Greece72.9elderly with sarcopenia12 and 24 weeks
      No., number; RCT, randomized control trial; CB, center-based group; HB, home-base group; COPD, chronic obstructive pulmonary disease.
      # , number of subjects included into analysis was variant in different parameters.
      Table 2Interventions of included studies
      First author, year of publicationCB interventionCB supervisionCB otherHB interventionHB supervisionHB other
      Alibhai,2019mixed modality exercise incorporating aerobic, resistance, and flexibility training, 4–5 days per weekmonitored by a certified exercise physiologist or health coacheducationprotocol of CB interventionweekly health coach (by smartphone) communicationseducation component during weekly phone calls
      Almeida,2013exercises included stretching, dynamic and static balancing, and resistance and dual-task exercises, 3 times per weeksupervised at centerN/Aprotocol of CB intervention (attended the center every other week)monthly phone callsN/A
      Bieler,2017,2018strength training, 3 times per weeksupervised by experienced physical therapistsindividual counseling interviewhip range of motion, stretching and strengthening exercises progressed with elastic bandsparticipants kept a training diaryN/A
      Bittar,2016free weight and elastic bands protocol: stretch, impact, strengthen exercise, twice per weekcontrolled by an attendance card on which the physiotherapist registered attendanceN/Aprotocol of CB intervention using an illustrated handbooktelephone by interviewer every 2 months for 1 yearN/A
      Boshuizen,2005exercises included a variation of concentric, isometric, and eccentric knee-extensor activity, 3 times per weeksupervised by a physical therapistN/Aprotocol of CB intervention (1 supervised class and 2 home sessions per week)N/AN/A
      Bourne,2017strength training of upper and lower limbs without instruments, 2 supervised sessions and 3 times home exercise per weekN/Aeducational sessions presented and discussed orallyonline exercise 2-5 times per weekthe physiotherapist leading the online programme also delivered the face-to-face programmeseducational sessions
      Carmeli,2006exercise included active movement patterns with 8 up to 12 repetitions for leg-lifts, and pelvic elevation and curls, nearly 3 sessions per weekN/AN/Aprotocol of CB interventionmonitored via a phone call every other week and a once-a-month visit by therapistsN/A
      Comans,2010exercise programs consisted of balance and strength exercises and functional tasks, once per weekN/Arecommendations for home modifications and educationprotocol of CB intervention (with identical apart from substituting outdoors walking for the indoor walking circuit and activities of daily living for the upper limb circuit)N/Asame to CB
      Costa2020progressive training programs proposed to improve lower-limb strength and balance, 3 times per weekguided by physical educators or physiotherapistsN/Aprotocol of CB intervention (1 supervised session per week and 2 individual sessions per week at home)electronic messages on the days of the exerciseN/A
      Cyarto,2008resistance training program, 2 sessions per weekN/AN/Aprotocol of CB intervention (one-on-one instruction during the first month)telephone support at the first month, recorded in a log bookN/A
      Donat,2007exercise programme based on balance training, strengthening and stretching of the lower limbs, 3 times per weektracked by the physiotherapist using a common chartN/Aprotocol of CB interventionmeet the physiotherapist at the end of the second and fourth weeksN/A
      Dunstan,2006resistance exercise training for 2 months at the Institute's exercise laboratory, followed by a 12-month maintenance program, 2-3 times per weektelephoned monthlyhealthy lifestyle information sessionprotocol of CB interventiontelephoned monthlysame to CB
      Galea,2008exercises focused on functional tasks, daily living tasks, balance, strength, and endurance, twice per weekmodified and recorded by a physiotherapistN/Aprotocol of CB intervention guided by illustrationsinstructed to keep a daily record of the exercisesN/A
      Hansen,2020exercise incorporated endurance and resistance training, twice per weekN/Apatient education sessionsexercise sessions incorporated muscle endurance training via a videoconference software system, 3 times per weekN/Apatient education sessions
      Helbostad,2004progressive strength and balance training, twice per weekphysical therapists were responsible for planning and running the programsN/Anon-progressive exercises, aimed at improving functional aspects of balance and strengthlocal physical therapists responsible for planning and running the programsgroup meetings
      Hwang,2017aerobic and strength training exercise, 2 sessions per weekcontinuously reviewed by the treating physiotherapisteducation sessionsprotocol of CB intervention guided by physiotherapist through two-way audiovisual communicationN/Aeducational topics delivered as electronic slide presentations with embedded audio files
      King,2015exercise with sports skill activities focused on improving basic postural system, 3 times per weekN/AN/Aindividualized home exercise program by physical therapistN/AN/A
      Lacroix,2016training session comprised either static balance exercises, dynamic balance exercises or strength/power exercises for leg and trunk muscles, twice per week at a local gym and once per week at home.each session documentedN/Aprotocol of CB interventioncontrolled by phone calls every fortnightN/A
      Madsen,2013session consisted of strength and endurance training in machines, twice per weeksupervised by physiotherapistseducation sessionsprotocol of CB intervention1-2 planned visited with a local physiotherapistN/A
      Martel,2018exercise programs included cardiovascular/aerobic exercises, strengthening and balance exercises, twice per week"N/Alifestyle education classestherapist designed individual program identical in frequency, intensity and durationmonitored by telephone

      the exercise therapist
      lifestyle education
      McCarthy,2004balance exercises, twice per week"N/AN/Aprotocol of CB intervention using the Jintronix rehabilitation softwareN/AN/A
      Meng,2020exercise programme aimed at increasing lower limb strength and endurance and improving balance, twice per weeksupervised by senior physiotherapistN/Aexercise intervention (addressed muscle weakness, muscle fatigue, reduced locomotor function and reduced balance)N/AN/A
      Reeder,2008exercise training included stretching, aerobic and resistance training, 3 sessions per weekN/AN/Aillustrated handouts describing calisthenics including stretching and resistance, 3 times per weekN/AN/A
      Tsekoura,2018exercise sessions consisted of stretching, vigorous endurance and light resistance training, 3 times per weekN/Alifestyle education classestherapist designed individual program identical in frequency, intensity and durationmonitored by telephoneN/A
      CB, center-based group; HB, home-base group; N/A, not available.
      Five of the included studies reported data on muscle mass,29, 37, 43, 47, 49 using various means, including appendicular lean mass index, lean body mass, fat free percent and skeletal muscle mass. Six of the studies measured upper limb strength, mostly by handgrip strength35, 37, 41, 45, 47, 49. Among them, Cyarto et al.35 reported arm curl repetition, and Meng et al.47 reported both strength of grip and elbow flexors. The approaches for evaluating lower body strength or power were inconsistent across the studies. Two of the studies adapted the gold standard of isokinetic dynamometry to assess knee muscle strength34, 49. Bieler et al.27, 28 conducted measurement of maximal isometric thigh muscle strength, the 30-s chair stand test, the timed stair-climbing test, and leg extensor power measurement, which demonstrated muscle strength of the lower limbs from both static and dynamic aspects. The 30s-chair stand was the most widely used bare-handed method for evaluating lower limb strength. In terms of physical performance, gait speed, 400m (or a longer distance) walking, and the timed up-and-go test were mostly used. Although these tests are all recommended by the Sarcopenia Consensus from European and Asian Working Group for Sarcopenia12, 13, we treated them separately in the meta-analysis in consideration of the different focuses of these measurements.

       Critical appraisal

      A summary of the risk of bias assessment of the included studies is presented in Supplemental Figures 1.1 and 1.2. The most frequent source of methodological bias was lack of complete blinding. However, it was impossible to blind the participants during an exercise training-based intervention. Hence, we classified the risk as low. In addition, nearly half of the studies did not describe “blinding of outcome assessment”, thus they were classified as unclear risk. The risk of bias was judged to be low in most domains in all included studies.

       Outcome

      All of the included studies (total 2008 participants) compared center-based exercise with home-based exercise for at least one of the sarcopenia components. In general, fourteen studies drew conclusions that center-based exercise showed superior improvement at least in one of the sarcopenia components, compared to home-based exercise25, 29, 30, 32-34, 36, 37, 42, 43, 46-49. However, ten studies reported that center- and home-based exercise had comparable effects on muscle and physical function26-28, 31, 35, 38-41, 44, 45 (Table 3).
      Table 3Relevant outcomes, conclusion and considerations of included studies
      First author, year of publicationRelevant outcomeConclusionConsiderations
      Alibhai,2019peak oxygen consumption, upper body strength, lower body functional capacityBenefits may be attenuated with HB programs compared to CB programs.without raw data, not included into meta-analysis
      Almeida,2013the 400-m walk, TUG, STSSimilar results were achieved by both trained groups.included into meta-analysis
      Bieler,2017,2018maximal isometric hip and thigh muscle strength, muscle power, 30-second chair stand test, timed stair climbing test, 6MWTCB exercise is not superior to HB exercise for improving muscle function.included into meta-analysis
      Bittar,2016body compositionExercises under direct supervision can increase lean body mass more than exercises without direct supervision.included into meta-analysis
      Boshuizen,2005maximal knee-extensor torque, 20-m timed walking test, TUG, box-stepping testHigh-guidance group increased more in strength than the medium-guidance group.included into meta-analysis
      Bourne,20176MWTNon-inferiority of the role of online pulmonary rehabilitation to improve clinical outcomes compared with the CB exercise.included into meta-analysis
      Carmeli,200625-m walk test, climbing 12 stairsCB exercise showed superior improvement in the quality of life (physical performance) compared to the HB exercise.without SD or 95%CI of relevant outcomes, not included into meta-analysis
      Comans,2010muscle strength, TUGCB exercise performed better on the primary outcome measures (falls and quality of life). The study was not powered to detect differences in these secondary measures (TUG, reaction time, and step test).included into meta-analysis
      Costa2020lower-limb strength, the 4-m walking test speed, STSThe effects of HB exercise were similar to those found for a CB exercise program. However, time to complete walking and sit-to-stand tests and dual-task gait parameters improved more in the CB exercise group.included into meta-analysis
      Cyarto,200830s-STS, 30-second arm-curl test (upper-body strength), 2minute step test (instead of 6MWT)The only significant difference observed among CB exercise and HB exercise was for flexibility.included into meta-analysis
      Donat,2007muscle strength, TUGCB exercise is effective at improving balance, functional mobility, flexibility, strength and proprioception, whereas HB only improve balance.included into meta-analysis
      Dunstan,2006lean body mass, muscle strengthWith the exception of the change in lower body muscle strength, no between-group differences were observed during the maintenance period.included into meta-analysis
      Galea,2008TUG, stair climbing, 6MWT, walking speedBoth groups had similar improvements in physical function, pain, QOL, and gait.included into meta-analysis
      Hansen,20206MWD, 30s-STSsupervised HB pulmonary rehabilitation was not superior to conventional CB pulmonary rehabilitation regarding walking capacity (6MWD).included into meta-analysis
      Helbostad,2004walking speed of 3m, STS, TUG, muscle strengthHB exercise was effective in improving functional abilities, and that supplementary individualized CB exercises did not have an additional effect.included into meta-analysis
      Hwang,20176MWD, 10-m walk test, grip strength, quadriceps strengthTelerehabilitation was not inferior to centre-based rehabilitation program in patients with chronic heart failure on the primary measure of 6MWD change. The between-group differences for the other outcomes suggest that telerehabilitation is at least similarly effective to traditional rehabilitation.included into meta-analysis
      King,2015TUG test, stride velocityThe individual exercise and group class showed the most improvements in functional, balance measures and gait. The home exercise program improved the least across all outcomes.included into meta-analysis
      Lacroix,2016body composition(baseline), lower extremity muscle powerthe supervised (CB) group showed larger effects in most investigated variables compared to HB group.included into meta-analysis
      Madsen,2013peak leg extensor power, 10-m walking test, 30s-STS, 5 times STSPatients receiving group based (CB) rehabilitation do not recover faster than patients receiving supervised HB exercises in total knee arthroplasty patients.included into meta-analysis
      Martel,2018handgrip strength, SPPB, TUG, unipodal balance testsHB exercise using a gerontechnology (Jintronix©) had comparable effects on functional capacities such as walking speed and one leg balance, than a community-based (CB) exercise group program.included into meta-analysis
      McCarthy,2004eight-meter walk time, stair ascent and descent time, muscle strengthThis finding suggests that supplementation of CB led to a short-term differential improvement in lower limb strength.included into meta-analysis
      Meng,2020body fat and lean mass percentages, strength of hand grip, elbow flexors, knee extensors and flexors, submaximal leg press strengthHB exercise program improved walking speed and strength of the limb muscles as did a supervised (CB) program, though CB group showed more improvements in the physical performance tests compared with HB group.included into meta-analysis
      Reeder,20086MWT, upper- and lower-body muscular enduranceExamination of the between-group comparisons revealed that with the exception of the functional fitness test, the degree of change from baseline to 3 months was not significantly different between the 2 programs.without SD or 95%CI of relevant outcomes, not included into meta-analysis
      Tsekoura,2018body composition, muscle strength(handgrip strength, knee muscle strength), physical function tests(walking speed, TUG, STS)Supervised group-based (CB) exercise seems to be superior to home-based (HB) exercise therapy in almost all variables.included into meta-analysis
      CB, center-based group; HB, home-base group; TUG, timed up and go test; STS, sit- to- stand test; 6MWT, 6 minute walking test.

       Muscle mass

      Five of the included studies reported data on muscle mass29, 37, 43, 47, 49, with one of them assessing the muscle mass at two timepoints49, while Lacroix et al.43 reported only skeletal muscle mass at baseline. Thus, we used four studies for data pooling. One of the studies reported unsupervised home-based exercise47. Participants in the other three studies were asked to keep an exercise diary and received telephone calls from a physiotherapist to monitor adherence29, 37, 49. Furthermore, the physiotherapist took four visits to each participant's home in the study of Tsekourac et al49. Although studies showed that mean improvement of muscle mass was slightly, but non-significantly, higher in center-based groups, there was no significant difference in pooled muscle mass between center- and home-based geriatric rehabilitation [fixed effects weighted standard mean difference 0.15 (-0.07, 0.38), heterogeneity χ2 = 0.33, df = 4, p = 0.99, I2 = 0%], at follow-up points of 3–14 months (Figure 2).
      Figure 2
      Figure 2Pooled muscle mass changes in center-based (CB) and home-based (HB) geriatric rehabilitation

       Muscle strength

      Twenty-one studies reported on muscle strength at 2–14 months of follow-up25-28, 30, 32-41, 43-49. Among them, three studies25, 32, 48 could not be included in the meta-analysis due to lack of comprehensive descriptive data. The three remaining studies tended to find center-based exercise more effective in building muscle strength than home-based programs. Due to the wide variation in methods of muscle strength measurement, we pooled across studies separately for the upper and lower limbs.
      Figure 3 showed no evidence of differences in upper limb strength change between center- and home-based groups [fixed effects weighted standard mean difference 0.05 (-0.14, 0.24), heterogeneity χ2 = 7.70, df = 5, p = 0.17, I2 = 35%]. A funnel plot was visually symmetric (Egger test, p = 0.79). Sensitivity analysis was consistent with the primary result. Among the studies used for upper limb strength analysis, three reported mixed exercise incorporating aerobic (endurance), resistance, and flexibility training41, 45, 47. Two of the studies applied a software or internet-based platform to guide and monitor the exercise program41, 45.
      Figure 3
      Figure 3Pooled upper limb strength changes in center-based (CB) and home-based (HB) geriatric rehabilitation
      In terms of the lower limbs, especially the quadriceps strength, center-based exercise resulted in a stronger positive effect than seen in the home-based group, despite the application of different strength-testing technologies [fixed effects weighted standard mean difference 0.11 (0.01, 0.20), heterogeneity χ2 = 25.95, df = 27, p = 0.52, I2 = 0%; Figure 4]. Subgroup analysis showed that the difference was prominent at the endpoint of intervention. After a longer follow-up period (up to 10 months after the intervention46), this difference weakened. Of all of these studies included in the lower limb strength analysis, two37, 46 reported that center-based exercise had a superior effect on lower limb strength compared to home-based exercise. McCarthy et al.46 demonstrated a smaller difference over a longer follow-up period. In both of the studies, the participants conducted mixed exercise at least twice weekly, consisting of warm-up, weight-bearing exercise, stretching and cool-down period in different settings. Participants in center-based group were required to attend designated place, where supervision, advice or assistance were provided face to face. Dunstan et al.37 employed similar telephone monitoring for both home- and center-based training.
      Figure 4
      Figure 4Pooled lower limb strength changes in center-based (CB) and home-based (HB) geriatric rehabilitation stratified by intervention endpoint or a longer follow-up

       Physical performance

      Twenty-one trials reported parameters related to physical performance25, 26, 28, 30-36, 38-45, 47-49. Eighteen trials were entered into the quantitative analysis (288 people in the center-based group and 257 people in the home-based group)26, 28, 30, 31, 33-36, 38-45, 47, 49. In consideration of variation in the methods, we summarized the indicators into three categories: gait speed, long distance walking test (LDWT) and TUG.
      Ten studies30, 34, 38, 40-42, 44, 45, 47, 49 provided information on gait speed, with four presenting longer-term data40, 41, 44, 49. As displayed in Figure 5, there is no evidence of a significant difference in gait speed change between center-based and home-based groups [fixed effects weighted standard mean difference -0.12 (-0.03, 0.26), heterogeneity χ2 = 22.83, df = 13, p = 0.04, I2 = 43%]. The symmetric funnel plot (Figure 6) and Egger test (p = 0.50) indicate that the heterogeneity is substantial. Subgroup analysis showed that, with a longer follow-up, center-based exercise played a bigger role in the improvement of gait speed. However, when we removed the data from the study by Tsekoura et al.49 from the analysis, the difference in gait speed between the groups was not significant. Considering the type of participants, Tsekoura et al.49 was the only study targeting elderly people with sarcopenia. Two of the studies showing a trend favoring home-based exercise38, 44 were focused on patients after total hip replacement, in which low intensity training of the hip and knee was delivered in both groups.
      Figure 5
      Figure 5Pooled gait speed changes in center-based (CB) and home-based (HB) geriatric rehabilitation
      Figure 6
      Figure 6Funnel plot for meta-analysis of gait speed change
      Eight studies reported LDWT26, 28, 31, 38, 39, 41, 47, 48, but we excluded the study by Reeder et al.48 from the quantitative synthesis due to lack of information regarding the standard deviation. No difference in pooled LDWT was found between the groups at follow-up points between 1.5 and 12 months [fixed effects weighted standard mean difference -0.04 (-0.18, 0.10), heterogeneity χ2 = 4.21, df = 9, p = 0.90, I2 = 0%, Figure 7]. Subgroup and sensitivity analyses were consistent with the primary analysis.
      Figure 7
      Figure 7Pooled LDWT change in center-based (CB) and home-based (HB) geriatric rehabilitation
      Fourteen studies26, 28, 30, 33, 35, 36, 38, 40-43, 45, 47, 49 reported TUG score, and the outcomes from all of these studies were entered into the meta-analysis. TUG score at follow-up was 0.31 s (95% CI 0.05, 0.50) shorter for center-based compared to home-based geriatric rehabilitation (heterogeneity χ2 = 15.88, df = 19, p = 0.67, I2 = 0%, Figure 8). However, when we removed the data from the study by Lacroix et al.43 or Meng et al.47 from the analyses, the differences were not significant. These two studies involved same exercise routine incorporating stretching and resistance training between home- and center- groups, except that the home-training was unsupervised. The linear regression test of funnel plot asymmetry was not significant (Egger test, p = 0.79, Figure 9).
      Figure 8
      Figure 8Pooled TUG change in center-based (CB) and home-based (HB) geriatric rehabilitation
      Figure 9
      Figure 9Funnel plot for meta-analysis of TUG change

      Discussion

      In this systematic review, we assessed the evidence from RCTs and quasi-RCTs that compared sarcopenia-related parameters between center-based and home-based geriatric rehabilitation. We found that center-based exercise improved lower limb strength and TUG score to a greater extent than home-based exercise in elderly people, but not other components of the sarcopenia diagnostic criteria, including muscle mass, upper limb strength, gait speed and the 6-minute walking test (6MWT).
      This is the first meta-analysis focusing on whether center-based exercise is superior compared to home-based exercise in comprehensive sarcopenia rehabilitation. Although the measurement methods varied, our results from 18 small-sample studies indicate a significantly larger improvement in lower limb strength in center-based than home-based training, at least at the endpoint of intervention. Our findings corroborate the results of a meta-analysis focusing on improvement in muscle strength/power in healthy older adults between supervised and unsupervised training22. Furthermore, we calculated the precise improvement of TUG (0.31 s mean difference) seen when comparing center-based training to home-based training, which may be added to future cost-effectiveness calculations, based on the prognosis predictive effect of TUG.
      This review identified four studies showing a slight trend of greater improvement in muscle mass in center-based exercise. However, the meta-analysis of the pooled data did not find a statistical difference in favor of center-based exercise. This may be explained by high diversity in effect values due to minor original changes in muscle mass from each study. As a former review51 regarding the influence of exercise on muscle quality showed an inconsistent effect on muscle mass, there is a need for a trial with a larger sample size in order to draw a stronger conclusion.
      In terms of upper limb strength, only one of the studies was in favor of center-based training49, with the others finding no difference. Unsurprisingly, the meta-analysis showed a nearly equal effect of the center- and home-based exercise. Unlike the differences found in lower limb strength between the two intervention settings, we did not observe a positive association between setting and upper limb strength. There were several factors to consider when exploring the inconsistent results. First of all, as balance training alone can help to improve lower limb muscle strength52, resistance combined with balance training may have a larger impact on lower-limb strength compared to upper body strength34, 36, 43, 46. Second, as upper limb strength was normally assessed by isometric grip test41, 45, 49, improvement due to isotonic motion could have been missed by this mode of testing. Third, effective training for the lower limbs may require intensive resistance load, while home-based exercise with limited instruments mostly encourages low-load exercise47, 49. This would reduce the stimulation of the muscles of the lower limbs, leading to a difference between center-based and home-based settings. For example, Dunstan et al.37 reported a significant difference in lower limb strength, but not in upper limb strength. The underlying reason may be that the home-based group were provided only with dumbbells so they could replicate the center-based upper body exercises, but not facilities necessary to replicate the center-based lower body exercises. In comparison, Tsekoura et al.49 instructed a consistent workload for home-based limb training using free weights and ankle cuffs, and demonstrated no difference in lower limb strength after intervention. Finally, as preventing falls26 and encouraging walking46 are important rehabilitation goals for older adults, the implementation of strength training usually focused on the lower limbs.
      A recent systematic review including four RCTs and three non-randomized interventional studies reported a profound effect of exercise on physical performance51. In further exploration, we observed a slightly greater improvement in physical performance measured by TUG and gait speed during prolonged follow-up in center-based training when compared to home-based training. Nevertheless, the difference in long-distance walking test represented by 6MWT was absent. This may be explained by the fact that TUG evaluates both mobility and balance ability53, while the 6MWT is more sensitive to cardiopulmonary function54. Thus, TUG seems to be a more appropriate method to detect physical performance than 6MWT in resistance exercise assessment. It is unsurprising that resistance training would have a greater effect on TUG compared to the 6MWT, especially with the addition of balance training26, 33, 34, 36, 38, 40, 43, 45, 46, 49. Moreover, provisions for effective resistance and balance training tend to be more easily provided in supervised center-based exercise.

       Study limitations

      Although we believe this to be the first comprehensive systematic review of RCT-based evidence for improvements in sarcopenia components during center- and home-based geriatric rehabilitation in adults aged over 60, we acknowledge a number of limitations. It should be noted that there were few specific studies investigating the difference between the effects of home- and center-based training on sarcopenia. Thus, eligible studies included subjects with a wide range of medical conditions, such as prostate cancer, previous falls, hip osteoarthritis, frailty, COPD and type 2 diabetes. Since geriatric rehabilitation does not, in principle, differ from rehabilitation for specific diseases with regard to its approach and its aims, the mix of patients may be a good real-world reflection of the current practice of geriatric rehabilitation55. Second, the resistance exercises used a variety of approaches and combinations. Third, several detection methods were applied for the same parameter both between and within groups, which makes it impossible to calculate results from pooled data with clinical significance.
      Based on our results, we cannot recommend a single optimal protocol to all older adults for sarcopenia intervention, whether at home or in a central setting. Regarding the diversity of patients and sarcopenia intervention, geriatricians should consider patient referral to a tailored center-based program over a home-based physical activity prescription in certain conditions, such as for overweight older adults with type 2 diabetes37, knee osteoarthritis46 or previous falls26. Cited barriers to participation in center-based rehabilitation were cost, transportation and lack of support17. For that reason, the decision to carry out traditional home- or center-based rehabilitation needs to be combined with the wishes and conditions of the older adults, the opinions of their doctors, and the support of caregivers. To improve feasibility, future intervention trials should pay attention to conducting a similar program with a longer follow-up, both in a center and at home. Standard assessments of muscle mass, strength and physical function in line with sarcopenia consensus requirements12, 13 would reduce barriers to comparison across similar research. There is also a need to examine the cost-effectiveness of the two models of service delivery.

      Conclusion

      Center-based geriatric rehabilitation improved lower limb strength and TUG score to a greater extent than home-based geriatric rehabilitation in people aged over 60. Center-based training seems to show a minor superior effect on gait speed in prolonged follow-up rather than at the endpoint of intervention. To draw a stronger conclusion, more high-quality trials with standard protocols and longer follow-up are needed.

      Author contribution

      Source of funding

      Scientific research project of youth, Fujian Health Committee (Grant number: 2020QNA001). Innovation and entrepreneurship training program for College Students, Fujian Medical University (Grant number: L20011). Startup Fund for Scientific Research, Fujian Medical University (grant number 2020QH1143).

      Acknowledgements

      N/A.

      Conflict of interest

      All authors declare no conflicts of interest.

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      Appendix. Supplementary materials