Objectives and hypotheses
Are the objectives of the study clearly stated?
Yes. To summarize the available evidence on methods and results of randomised controlled trials that used physical training to improve motor performance or to prevent falls and included cognitively impaired older people only.
Is the study design suitable for the objectives?
Yes. A sufficient number of RCTs has been published to warrant a systematic review and meta-analysis.
Were the search methods used to locate relevant studies comprehensive?
The Cochrane Central Register of controlled trials, Medline, CINAHL, and GEROLIT were searched using a wide variety of relevant search terms. References of relevant papers were hand searched to identify further relevant studies. Researchers were contacted for additional literature.
Was this the right sample to answer the objectives?
Yes. The included studies all address the topic in question.
Inclusion criteria were:
- RCTs on physical training
- with the aim to improve physical function or prevent falls
- and with older people experiencing cognitive impairment confirmed by an established cognitive test or standardised expert rating
- and in different study settings (home dwellings or institutional care) (? - I presume the last point means regardless of study setting)
Is the study large enough to achieve its objectives?
Yes. A sizeable number of search results was reviewed, with a final number of 11 RCTs included in the review.
Were all the studies accounted for?
No QUOROM flow chart provided. The selection process is briefly described.
Were all appropriate outcomes considered?
Yes. For the purpose of the search strategy, 'physical function' and 'prevention of falls' were chosen as two very general terms and broad outcomes. This search strategy yielded a variety of relevant studies.
Has ethical approval been obtained if appropriate?
Not applicable for systematic review.
With regards to the included RCTs: not commented on by the authors. The included RCTs were assessed for their quality using the 'Cochrane Musculoskeletal Injuries Group Evaluation Tool', which does not evaluate ethical approval.
Measurement and observation
Is it clear what was measured, how it was measured and what the outcomes were?
The following data was extracted from included RCTs: study intervention, methodology, efficacy of training, study quality.
Study quality was evaluated using the 'Cochrane Musculoskeletal Injuries Group Evaluation Tool' (reference provided). The results of this evaluation is summarized in Table 3. Other results are summarized in Tables 1 and 2.
Data was independently extracted by two authors using an electronic database. The database had been designed to support standardised documentation of predefined criteria and had been tested before use. Disagreement between the two authors was resolved by consensus or by consulting a third author.
Were explicit methods used to determine which studies to include in the review?
Yes. Clear inclusion criteria and a broad search strategy.
Was the selection of primary studies re-producible and free from bias?
Re-producible: the authors do not describe their complete search strategies for the different databases searched. From the provided information only, the complete search is probably not entirely re-producible. Ideally, the complete search histories would have been made available, e.g. in an online supplement.
Free from bias: the inclusion criteria are specific, it is unlikely that there is room for selection bias.
Was the methodologic quality of the primary studies assessed?
Yes, using the 'Cochrane Musculoskeletal Injuries Group Evaluation Tool', reference provided.
The evaluation tool was slightly altered by the authors by excluding one category they thought not appropriate. The maximum (and best) score was 16. 11 included RCTs scored a mean total of 6.1 points, ranging from 1 to 11.
Are the measurements valid?
Not commented on by authors.
Are the measurements reliable?
Not commented on by authors.
Are the measurements reproducible?
Yes, references provided.
Presentation of results
Are the basic data adequately described?
Yes. Excellent summaries of included RCTs in Tables 1-3.
Were the differences between studies adequately described?
Yes. The differing quality scores as well as the broad differences in study characteristics/subjects and settings/intervention/measurements/results. Again, excellent summaries provided in Tables 1-3.
Are the results presented clearly, objectively and in sufficient detail to enable readers to make their own judgement?
Yes. Results are well summarized in the text and in Tables 1-3. The authors do not present statistical data for the included studies, but interpret the studies' results (e.g. 'no sigificant difference' or 'insufficient or contradictory data and/or analyses'). If the reader would like to make their own judgement about the authors interpretation, they will have to appraise the individual study themselves.
NB: the authors were unable to analyse the included RCTs in meta-analyses due to the wide heterogeneity of studies. It probably would not have been feasible to present statistical data for the included studies for the same reason.
Are the results internally consistent, i.e. do the numbers add up properly?
Were the results of primary studies combined appropriately?
Due to the large heterogeneity of included RCTs the authors thought it inappropriate to combine results for meta-analysis.
Has a sensitivity analysis been performed?
Were all the important outcomes considered?
Yes. The included RCTs investigated a wide range of outcomes related to physical function and falls prevention. It was appropriate to allow this variety/heterogeneity of study outcomes, as it is representative of the research/literature/evidence available.
Are the data suitable for analysis?
No, to heterogeneous.
Are the methods appropriate to the data?
Are any statistics correctly performed and interpreted?
Are the results discussed in relation to existing knowledge on the subject and study objectives?
Yes. In their introduction and discussion the authors put their systematic review in context with the increasing numbers of older people with dementia, the known beneficial effects of physical training in older people, and the limited and conflicting evidence available on physical training in older people with cognitive impairment.
Is the discussion biased?
No. The authors' discussion and conclusion adequately represent the findings of the systematic review.
Are the author's conclusions justified by the data?
Yes. See 4.3. of this appraisal.
What level of evidence has this paper presented?
CEBM level of evidence: 1a- (minus-sign due to large heterogeneity of included studies, inappropriate to perform meta-analyses).
Does this paper help me to answer my problem?
Yes. By pooling and appraising the evidence available from RCTs, this paper informs me of the current evidence base, and guides me in my communication with other professionals and family and carers of people with dementia.
Can any necessary change be implemented in practice?
No change of practice is indicated in my current area of work (physiotherapist on acute hospital ward for acute elderly medicine). The team practices a multidisciplinary approach to falls prevention and falls rehabilitation, including multidisciplinary assessment and individualized multifactorial intervention according to current UK guidelines. This approach is adapted for the older person with dementia or cognitive impairment as appropriate.
What aids to implementation exist?
What barriers to implementation exist?