Which long-term conditions benefit from exercise-based rehabilitation, and how are comorbidities considered? An overview of systematic reviews

Problem

There is a growing prevalence of multiple long-term conditions (presence of ≥2 long-term conditions (LTCs)) which is associated with reduced health-related quality of life (HRQoL), functional decline, and increased risk of healthcare utilisation, morbidity and mortality. Previous systematic reviews have shown benefits of exercise-based rehabilitation in the management of single condition LTCs for improving functional capacity and HRQoL and reducing hospital admissions. However, little research has been performed to date assessing the effects of exercise-based rehabilitation in LTCs with consideration of multiple LTC or comorbidity issues.

Approach

An overview of systematic reviews (SRs) was conducted to identify single-condition LTCs within which there is clear evidence of benefit from participating in exercise-based rehabilitation, and to explore how comorbidity or multiple-LTC issues had been previously managed. Database searches for SRs and supplementary primary studies were undertaken up to June 2022. Eligibility criteria included peer-reviewed SRs comparing exercise-based rehabilitation to usual care, no-exercise control, or alternative non-exercise interventions, in adults (≥18 years) diagnosed with an LTC from a pre-defined list of 45 LTCs. Outcomes included mortality, hospital admissions, exercise or functional capacity, frailty, disability, HRQoL and physical activity. A single SR was selected for each LTC based on recentness, comprehensiveness, focus, methodology and outcomes, and the available evidence from selected SRs was extracted and summarised using a narrative synthesis. Methodological quality of selected SRs was assessed using the AMSTAR-2 tool.

Findings

Database searches yielded 11,074 unique records, from which 617 eligible SRs were identified. Forty-one SRs across 37 LTCs were selected with three supplementary primary studies for two LTCs, resulting in a total of 990 eligible randomised trials, and 936,825 participants. Five (12%) SRs were rated as high quality, 11 (26%) moderate quality, 12 (29%) low quality, and 14 (33%) critically low quality. Results identified 25 LTCs with strong evidence that exercise training is beneficial. Evidence was unclear or conflicting for 13 LTCs, and there was no evidence identified for six LTCs. Very few SRs described participant comorbidities, and where it was mentioned, it was most often as an exclusion criterion. None of the included SRs described exercise programme modifications for co-morbidities.

Consequences

Exercise-based rehabilitation is beneficial for many LTCs but current NHS commissioning of rehabilitation services is limited to a small number of individual LTCs (e.g., pulmonary/cardiac). There is urgent need to consider provision of such rehabilitation to people living with multiple LTCs. The individual LTCs identified by our review as benefiting exercise-based rehabilitation have informed the population inclusion criteria for our NIHR funded pilot randomised controlled trial to test the feasibility/acceptability of a rehabilitation intervention targeting people with multimorbidity.