This review evaluated rehabilitation of older adults with musculoskeletal disorders in home and hospital settings. The authors concluded that home-based rehabilitation was as effective as in-patient rehabilitation. Limitations in the primary studies, use of self-report outcome measures and limitations in the review synthesis mean that the authors’ conclusions may be too strong for the evidence presented.

To evaluate the effect on patient outcomes of in-patient rehabilitation of older adults with musculoskeletal disorders compared to rehabilitation at home.

MEDLINE, CINAHL and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for studies in English published up to August 2011. Search terms were provided. References of full-text articles were handsearched for additional relevant studies.

Studies that compared home-based and in-patient rehabilitation for older adults with musculoskeletal disorders were included. Studies of patients with respiratory disorders, stroke, cardiovascular diagnoses or intermittent claudication were excluded. Older populations were defined as those with a mean age of over 55. In-patient rehabilitation was considered to be occupational therapy or physiotherapy provided while residing in an acute care hospital or other rehabilitation facility. Home-based rehabilitation had to be provided by an occupational therapist or physiotherapist in the patient’s home while the patient was living at home; outpatient care was not considered to be home-based. Only patient outcomes such as functional ability and mortality were considered; studies that focused on cost-effectiveness were excluded.

Study populations included patients with hip fracture, hip or knee replacements or miscellaneous orthopaedic conditions. Sample sizes ranged from 50 to 268. Mean age in all studies was 63 or over. Some studies required patients to be living at home or in the community prior to hospitalisation and some excluded patients without an adequate home environment for home rehabilitation. Home-based rehabilitation programmes could include early discharge, speech therapy, podiatry and social work visits alongside physiotherapy or occupational therapy. Where reported, the number of visits ranged from four to 20 (mean 9.7). In-patient settings included acute care hospitals and rehabilitation centres. Follow-up generally ranged from three to 12 months but could be as little as 48 hours following discharge. Various tools to assess functional outcomes were used. Quality of life was most commonly assessed with the Short Form-36 (SF-36).

One author selected studies for inclusion from a review of titles and abstracts. Where there was uncertainty two second authors examined the full text article and inclusion was resolved by discussion.

Methodological quality of included studies was evaluated using the PEDro scale for internal validity of RCTs. Non-RCTs were also evaluated using PEDro. Items covered included randomisation, allocation concealment, blinding, attrition, reporting of eligibility criteria and outcome measures and similarity of groups at baseline. Studies that scored above 5 were considered moderate to high quality (maximum score 11).

Validity assessment was performed independently by two reviewers followed by a consensus meeting with a third reviewer.

It appeared that the authors extracted mean scores and standard deviations at baseline and follow-up and the statistical significance of between-group differences.

The authors stated neither how the data were extracted for the review nor how many reviewers performed the data extraction.

A narrative synthesis was performed due to variation in study design, study populations, interventions and outcome measures. RCTs were not considered separately from non-RCTs.

Eight RCTs (1,146 participants) and four cohort studies (597 participants) were included. The authors reported a total of 1,596 rather than 1,743; the source of the difference between these figures was unclear. Study quality was generally moderate: all four cohort studies scored 5 points and RCTs scored from 7 to 9. Allocation concealment was not reported in only one RCT and blinded outcome assessment was reported in only two RCTs.

Rehabilitation provided in the home led to equal or higher gains in function and quality of life compared to in-patient rehabilitation. The two studies that assessed effects on cognition used three different scales and this made it difficult to make any conclusions on this outcome. Statistically significant gains in functional outcomes were observed in four studies (three RCTs) and in quality of life in four RCTs. Length of stay in hospital was reduced in home-based patients in four studies (three RCTs) and rehabilitation periods were found to be longer in two studies (one RCT). Four studies (three RCTs) found no difference in mortality.

Home-based rehabilitation may be an effective alternative for treating older patients with musculoskeletal conditions

The aim of the review was clearly set out and was reflected in the inclusion criteria which were also clearly specified. The electronic search covered several databases. Only studies in English were included and no attempt was made to identify unpublished literature, which risked language and publication biases. A recognised scale for assessment of RCTs was used but the appropriateness of using the same scale to assess non-RCTs could be questioned. Some study details were presented. Further details of patient characteristics would have been useful to enable generalisability to be assessed. Some study results were not reported fully so that the statistical significance of some results could not be confirmed. The authors acknowledged that many of the studies recruited a selective group of patients and that this limited generalisability.

There were some discrepancies between the text and tables in terms of number of patients included. It appeared that the review methods were generally good but the authors could have been clearer regarding data extraction. The narrative approach to synthesis appeared appropriate given the different study populations and interventions. The limitations of self-reported outcome measures could have been acknowledged.

The small number of studies and other limitations in the review mean that the authors' conclusions are likely to be too strong for the evidence presented.

Practice: The authors stated that home-based rehabilitation was no less effective than in-patient rehabilitation for older adults with musculoskeletal disorders. Health professionals should consider rehabilitation at home as an alternative to hospital rehabilitation.

Research: The authors stated that future research should aim to standardise home interventions and assessment methods, should recruit larger samples to examine outcomes such as morbidity and hospital readmissions and should compare the cost of home-based and in-patient rehabilitation.

Canadian Institutes of Health Research.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.