To our knowledge this is the first systematic review of chair-based exercise programmes specifically in a frail elderly population identifying the need for this work. Although the body of literature surrounding CBE is broad and diverse (e.g., wheelchair athletics and spinal injuries), literature specifically for frail older people appears sparse. This systematic review only found six studies examining the effects of chair-based exercises provided specifically for frail older people. All studies were small (range of participants 20–82) and performed in single sites. The duration of the interventions varied (range 6 weeks–6 months) as did the age (range 70 years–99 years). Meta-analysis was not feasible due to the diversity of the outcome measures used. In addition, the disparity in interventions and settings made comparison between studies challenging. Conflicting poor quality evidence regarding the effectiveness of CBE programmes provides little guidance for clinicians, care providers, and commissioners.
Conducting research and particularly randomised controlled trials in frail elderly populations is often more challenging and complex in comparison to younger healthy adults [16
]. The diversity of the older person in terms of culture, health beliefs, age, and functional abilities makes it more difficult to recruit truly representative study populations which in turn can impact on the study findings. This is apparent where Hruda et al. [11
] make note of a trend for subjects in the control group to be younger than those in the intervention group potentially confounding comparisons. The effect of the intervention may also be influenced by the heterogeneity of older people as participants of studies identified by Nicholson et al. [14
] who suggest that “the effect of the exercise intervention may have been obscured by the large differences between individuals.”
Based on this review defining chair-based exercise as an intervention for frail older people would appear challenging. All studies in this review described different interventions delivered in different setting and with a very different focus. These disparities identify the flexibility of CBE to adapt to specific needs and contexts. However, the lack of standardisation limits the ability of this review to clearly define CBE programmes for frail older people and determine their effectiveness. The diversity of programmes in terms of duration, frequency, exercise type and intensity, and followup clearly identifies a lack of consensus on the fundamental principles of chair-based exercise programmes for frail elderly populations.
This review has identified variations in interventions in key areas such as target population, length, and frequency and setting which need to be carefully considered and related to programme aims. For example the length of an intervention needs to be carefully considered to ensure that it maximises change; both Nicholson and Thomas report that their intervention was too short and at suboptimal frequencies to demonstrate changes.
All studies noted high adherence rates. Motivational reasons may have contributed to this in some studies; for example, participants in the post-hip-fracture study may have had a strong desire to return home [14
A total of 26 diverse outcome measures were found within the included studies (range 3–9) acknowledging the wide-ranging perceived effects of CBE programmes. Benefits in the domains of mobility and postural stability, cardiorespiratory fitness, and mental health were identified. However findings and the strength of findings were contradictory between studies. The included studies in this review provide encouragement for the use of CBE for frail older people with significant improvements in function, mobility, and mental health reported. It is important to take note of these encouraging findings in a vulnerable frail elderly population where guidance over appropriate physical activity is lacking. This review has identified that chair-based exercise programmes have the potential to provide a safe and accessible form of exercise for a vulnerable population who cannot participate safely in other forms of exercise.
The purpose and role of CBE programmes however need to be established to ensure appropriate evaluation. Careful selection of outcome measures underpinned by the focus and rationale for the intervention is imperative for accurate evaluation and to ensure that treatment effects are not missed.
This review has some limitations. The findings are limited due to the relatively small number and poor quality of the studies identified making it difficult to form clear conclusions regarding the effects of CBE programmes. The challenge of defining chair-based exercise programmes has been highlighted within the review and as such it is possible that relevant literature was not included in the review due to the methodology of the search strategy. Searching for literature of this kind is challenging with few studies explicitly stating chair-based or -seated exercise programmes within key terms and titles. A further limitation of this review is that the studies were selected using a broad description of frailty. There are frailty definitions in the literature [17
], but they have narrow criteria and very few studies have used such specific definitions. We deliberately used wider inclusion criteria for frailty so that we captured all available literature.