Keywords

1 Introduction

Aging is characterized as a continuous, dynamic and progressive process of biopsychosocial changes that affect the health status, the level of dependence and autonomy of human beings [1]. The World Health Organization (WHO) defines elderly as any individual aged 60 years or more, however, in more developed countries, an individual aged 65 years or more is considered elderly [2,3,4], including the situation of the population in Portugal [5].

Data from the 2021 Census of the National Institute of Statistics in Portugal reveal that the age group of people aged 65 or older registered a population increase [6], representing 22.1% of the Portuguese population in 2020 [7]. In the 2019–2021 triennium life expectancy at age 65 was estimated for the total Portuguese population to be 19.35 years [8].

However, as people get older, there is an increase in morbidity and disability caused by diseases and injuries, most of which are chronic, with impact on self-care and, consequently, on quality of life [9,10,11].

Data from 2019 reveal that 52.5% of the Portuguese population has difficulties satisfying the Activities of Daily Living (ADLs) and Instrumental Life Activities, compared to 49.7% in the European Union [12].

According to the Regulation of the Specific Competences of the Specialist Nurse in Rehabilitation Nursing [13] in force in Portugal, the Rehabilitation Nurse (RN) develops a functional re-education plan aimed at improving residual functions, maintaining or regaining independence in ADLs, and minimizing the impact of installed disabilities, with a focus on empowering the person and maximizing their functionality.

Given the characteristics of the Portuguese population and the RN’s skills, there was a need to identify RN interventions for empowering the elderly with mobility impairment and a self-care deficit via this systematic literature review (SLR) of randomized controlled trials (RCT).

2 Methodology

This SLR followed the Joanna Briggs Institute (JBI) guidelines [14] and employed the PICO[D] method in formulating the research question, as follows: P - Persons aged 65 or older with mobility impairment; I - Empowerment; C - Self-care deficit; O - RN interventions; D - Randomized controlled trials. The research question “What are the RN interventions for the empowerment of older people with mobility impairment and self-care deficit?” emerged.

During the period of July 2022 a search was conducted on the EBSCO Host - Research Databases platform, selecting the following databases: Academic Search CompIete; Business Source CompIete; CINAHL Plus with Full Text; Cochrane Central Register of Controlled Trials; Cochrane Clinical Answers; Cochrane Database of Systematic Reviews; Cochrane Methodology Register; eBook Collection (EBSCOhost); eBook University Press Collection (EBSCOhost); ERIC; Library, Information Science & Technology Abstracts; MedicLatina; MEDLINE with Full Text; Nursing & Allied Health Collection: Comprehensive; PsychoIogy and Behavioral Sciences CoIIection; RegionaI Business News; SPORTDiscus with Full Text; Teacher Reference Center.

We used the MeSH (Medical Subject Heading) and CINAHL validated descriptors “elderly”, “empowerment”, “mobility”, “randomized control trial”, “rehabilitation nurse” and “self-care deficit”, using the Boolean “AND” and “OR”, resulting in the Boolean phrase [(elderly) AND (mobility) AND (self-care deficit)] AND [(rehabilitation nurs*) OR (nurs*) AND (intervention or program) OR (rehabilitation) OR (empowerment)] AND [(randomi?ed control* trial*) OR (randomi?ed clinical trial*)].

The inclusion criteria were randomized controlled studies with full text available, in English, published between 2016 and 2022, and that answered the research question. The studies should show functional gains in the elderly person resulting from rehabilitation interventions in inpatient or outpatient settings, or from the involvement of caregivers in the rehabilitation process.

Figure 1 systematizes the methodological path of the research developed through the Prisma Flow Diagram [15].

Fig. 1.
figure 1

Prisma Flow Diagram research methodology [15].

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The search resulted in a total of 136 articles, which after the elimination of duplicate results resulted in 97 articles for title and abstract analysis. After this analysis 71 articles were eliminated whose theme or methodology did not fit the intended outcome or whose results did not show positive outcomes in this area of intervention, resulting in 26 articles for full text analysis. From this analysis we obtained a total of 12 articles to be included in this review, whose methodological quality assessment [16] and levels of evidence of JBI Critical Appraisal Tools [17] meet more than 50% of the proposed quality criteria. All articles were reviewed by two authors.

This SLR is registered in PROSPERO with ID CRD42022365894.

3 Results

After the process of search, selection and validation of the studies found, a set of 12 articles was obtained, whose data were extracted and presented in Table 1. All results correspond to RCT, level of evidence 1.c [17].

Table 1. Identification of the analyzed articles
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4 Discussion

The loss of functionality that older people may suffer during or after periods of hospitalization may not only result in loss of independence in ADLs and decreased quality of life, but may also affect the rehabilitation process itself [18,19,20,21].

The introduction of a rehabilitation program, as early as possible, through a multidisciplinary team where the RN is included, is extremely important for older people with mobility impairment and self-care deficit, and has been proven by several authors [20,21,22], namely in two SLRs [20, 21], coexisting gains for individuals, family members and the community.

4.1 Conventional Exercises and Electrical Stimulation

The study by Lee et al. [23] asserts that in people with hemiplegia due to stroke, trunk stability training with selective activation of the abdominal muscles has beneficial effects on abdominal muscles, balance, and mobility. The results of this study are corroborated by other authors [24,25,26,27].

The use of electrical stimulation has also been tested. In the rehabilitation of people with foot drop due to stroke, Sharif et al. [28] proved that gait training with functional electrical stimulation produces greater gains in mobility, balance, gait performance and reduction of spasticity, when compared to muscular electrical stimulation. There are more studies solidifying the gains from the use of electrical stimulation, such as the study by Tan et al. [29] that demonstrates the efficacy of gait training and the study by Stein et al. [30] that validates the use of neuromuscular electrical stimulation in improving specificity and range of motion in people with stroke. On the other hand, Fossat et al. [31] point out that electrical stimulation of the quadriceps muscles, associated with early exercise practice with a cycloergometer and standardized rehabilitation, does not show benefits when compared to standardized rehabilitation practice alone.

The RSL conducted by Martínez-Velilla et al. [20] advocates that people should initiate short periods of walking while still in hospital, using auxiliary devices, which is corroborated by the study of Gazineo et al. [32], concluding that, in hospitalized people, an individualized assisted walking program improves the ability to walk at discharge.

In a study by Dong et al. [33], a strategy to increase activity levels in the older population with mobility impairment, namely after stroke, leading to a promotion of their functional independence, is the use of accelerometers during gait, recording the activity performed. The feedback from this instrument can serve as a stimulus (maintain activity, promote motivation and increase self-efficacy). Peel et al. [34] validated that providing participants and professionals with daily accelerometer walking times leads to an increase in average daily walking time. In contrast, in the study by Atkins et al. [35], when testing the pedometer as a motivational tool, they concluded that it does not improve functional mobility if no goals are set, although an increase in daily time in the orthostatic position was observed.

Raymond et al. [36] state that high intensity functional exercise in conjunction with individual physiotherapy sessions produces a similar effect to individual physiotherapy alone, with the benefit that group physiotherapy sessions result in greater practitioner efficiency, as they save 31 to 205 min per week. This is consistent with research by Sunde et al. [37], who found that a group exercise program led by a rehabilitation professional significantly improves functional capacity and quality of life compared with a home exercise program in older adults with, or at risk for, mobility impairment.

4.2 Application of Neuromuscular Taping

In the field of rehabilitation of the person with musculoskeletal changes, Donec and Kubilius [38] evaluated the effectiveness of neuromuscular bands (Kinesio Taping®). The intervention did not produce better results in mobility and functional improvement, compared to nonspecific knee banding. However, it did have better results on a subjective, participant-reported assessment for symptom alleviation and increased mobility experienced. The intervention had already been tested by other authors who achieved a similar result [39,40,41].

Also, Donec and Kriščiūnas [42] stated that the use of neuromuscular bands may be beneficial in reducing postoperative pain and edema, improving knee joint extension, in the early postoperative rehabilitation period of total knee arthroplasty.

In an RSL with a meta-analysis of ERC performed by Wang et al. [43], the use of the Kinesio Taping® method demonstrated benefits in lower limb rehabilitation of people with stroke, significantly improving spasticity, motor function, balance, gait ability and quality, and ADLs. However, the authors suggest further studies to identify the benefits of neuromuscular taping, due to the limited number of articles selected and the quality of the research performed.

4.3 New Technologies

The study by van den Berg et al. [44] proved that the addition of interactive video/computer-based exercises to geriatric and neurological rehabilitation of hospitalized persons induces task-specific improvements in balance, but not in mobility in general. However, Cannell et al. [45] demonstrated no significant differences in stroke patients’ rehabilitation with the use of virtual reality with gesture controlled interactive video and Li et al. [46] corroborated these results by demonstrating that the use of an app supported exercise program (mHealth) can facilitate supplemental exercise, but does not directly affect functionality outcomes compared to traditional rehabilitation programs.

Recently, Hassett et al. [47] implemented a study and contrary to previous studies, there was an improvement in mobility in the intervention group, but the time spent in the orthostatic position did not change.

Piau et al. [48] demonstrated the feasibility and acceptability of the use of a robotic walking aid (SafeWalker®), from the perspective of participants and professionals, in the context of older people with a severe fear of falling.

Homonymous hemianopia after stroke is equally impactful for independence and insertion in the community for the elderly population, some authors [49, 50] argue that these people have reduced independence and a lower quality of life when compared to people with other visual deficits [49].

Crotty et al. [49] proved that a standardized intervention using scanning techniques, using NVT scanning equipment, which allows training a set of visual enhancement techniques and mobility training, improves quality of life, when compared to usual individualized rehabilitation care.

4.4 Caregiver Involvement

Taking into account the limitations that rehabilitation units have to meet all the needs of the population, the importance of informal caregivers in the process of rehabilitation at home of older people, reaching out similar results in terms of effectiveness, freeing the elderly and their caregivers from traveling to rehabilitation units [51, 52].

Zhou et al. [53], found no benefit in caregiver empowerment as they tested a complex intervention in the rehabilitation of people with stroke that combined caregiver empowerment through a cell phone application with teachings/training during the hospital stay focusing on mobility and self-care. In parallel, Chu et al. [54], conducted another intervention study in stroke survivors focusing on mobility, self-care, and toilet use. This study concluded that the new rehabilitation model implemented by nurses and practiced by family members improved physical recovery, as evidenced by Barthel Index values, without increasing caregiver burden, compared to usual care.

Jarbandhan and his collaborators [55] certify this statement, proving that the rehabilitation care provided at home and through tele-rehabilitation, promotes better results in functional independence, when compared to general care. They also present a better cost-benefit ratio compared to rehabilitation care in hospital rehabilitation units.

5 Conclusion

The scientific evidence on the RN intervention for the empowerment of the elderly person with mobility impairment and self-care deficit is still limited. The need to develop evidence-based practice is urgent, and the consequent publication of these studies is an added value in the promotion and visibility of RN interventions within this theme.

From the analysis performed, all studies showed gains resulting from rehabilitation interventions in older people with mobility impairments, highlighting conventional exercises and electrical stimulation, neuromuscular banding, new technologies, and caregiver involvement in rehabilitation care.

To contribute to increasing the mobility and functionality of the elderly is to contribute to their empowerment for self-care, improvement of quality of life, relationships with family members, the community, and society in general.