Effects of multicomponent exercises on muscle strength and balance in frail older: a systematic review and meta-analysis of randomized controlled trials
Abstract
Objective. To analyze the effects of multicomponent exercises on muscle strength and balance in frail older individuals.
Methods. This systematic review and meta-analysis followed the PRISMA criteria. The databases used were MEDLINE (via PubMed), SPORTDiscus, Web of Science, Science Direct, Scopus, and SciELO. Eligible RCTs in this study were evaluated using Rob 2, and TESTEX was used to assess the methodological quality of the studies and reports. RevMan was used to analyze the meta-analysis and the GRADE tool to assess the level of evidence.
Results. A total of 1538 publications were found and after using the selection criteria, 13 RCTs were included in this systematic review and meta-analysis. The assessment instruments used to assess balance were the Time Up Go, Dynamic Sitting Balance and Berg Balance Scale, and for muscle strength the handgrip test and knee flexion and extension strength. In the analysis of the balance variable, the estimated mean SMD was 0.43, [-0.18 to 1.03], p = 0.17, I² = 92%. In the variable muscular strength, the estimated mean SMD was 0.27 [0.12 to 0.42], p = 0.0003, I² = 41%.
Conclusions. This meta-analysis found that multicomponent exercises improve muscular strength but do not improve balance in frail older individuals.
INTRODUCTION
Frailty is described as a biological syndrome related to aging, characterized by a reduction in the body’s functional reserve and its ability to adapt to stressors. In older adults, frailty compromises the performance of activities of daily living (ADL), resulting in reduced muscle strength and balance. In addition, it is associated with a high risk of negative health outcomes, such as increased mortality, institutionalization, falls, and prolonged hospitalizations 1,2.
There is great concern among global health organizations regarding physical inactivity, and the rapid increase in the global older population is notable. The decline in functional capacity with aging and the overall health of older adults have been frequent targets of scientific research. It is worth noting that as people age, they tend to adopt a more sedentary lifestyle, which leads particularly to musculoskeletal and cardiovascular impairments 3-5.
Multicomponent exercise appears to be a strategy used by health professionals among the various types of physical exercise modalities aimed at improving the physical capacities of older adults. This type of exercise combines two or more components such as resistance, strength, balance, and flexibility training, and has been the most recommended form of exercise for this population, demonstrating significant improvements in physical fitness 6.
Multicomponent exercise programs that primarily include muscle-strengthening, walking, and balance exercises are more effective in improving physical fitness and muscle strength in frail older adults compared to isolated exercise interventions 7-12.
This study is justified as an update on the effects of multicomponent exercise on the physical variables of balance and muscle strength in frail older individuals. Three previous meta-analyses 5,13,14 examined similar outcomes in the same population as the present study; however, they included a smaller number of articles and/or reported different results. Another important aspect is that studies by Li et al. (2023) and Yang et al. (2024) did not include a publication bias analysis. In the case of study by Li et al. (2023), this was likely due to the number of included studies being below the threshold recommended by Cochrane (fewer than 10 studies), which may have generated uncertainty and reduced reliability in decision-making. It is also worth noting that studies Li et al. (2023) and Yang et al. (2024) included works 15,16 in their meta-analyses in which the control groups received physical exercise interventions, thereby introducing potential confounding bias. Therefore, the aim of this study was to analyze the effects of multicomponent exercise on muscle strength and balance in frail older individuals.
METHODS
This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria 17, and was approved by the international prospective registry of systematic reviews (PROSPERO) under number CRD420250654547.
INCLUSION CRITERIA
The PICOS strategy was used 18, considering a population of older adults (aged ≥ 60 years) of both sexes; the intervention consisted of multicomponent exercise programs (combining two or more components such as resistance, strength, balance, and flexibility training); the comparison was made with a control group; and the outcomes were muscle strength and balance, even when assessed using different instruments. The study design included randomized controlled trials (RCTs). There were no restrictions on the duration of the intervention. Systematic reviews and meta-analyses, studies involving animals, participants under 60 years of age, and studies that did not use multicomponent exercise as the main intervention were excluded.
SEARCH STRATEGY
The databases used were MEDLINE (via PubMed), SPORTDiscus, Web of Science, ScienceDirect, Scopus, and SciELO, from February 8 to 15, 2025. The electronic search was conducted by two independent and experienced evaluators, without language or time filters, and any conflicts were resolved by a third reviewer. The search terms were combined using the Boolean operators (AND, OR) in a single search phrase. The descriptors used were older adults and multicomponent exercise (Appendix 1). Keywords related to the topic were selected based on a literature review and verified using the Medical Subject Headings (MeSH) metadata system. The studies were selected by identifying and removing duplicates with Zotero 6.0.30, followed by title and abstract screening, and full-text reading according to the established inclusion criteria.
RISK OF BIAS ASSESSMENT
Eligible RCTs in this study were assessed using the Cochrane Collaboration risk of bias tool (Rob 2), available at . Two experienced authors independently assessed them, and any discrepancies were resolved by a third author. Version 2 of the Cochrane Risk of Bias Tool for Randomized Trials (RoB 2) is ideal for assessing the risk of bias in randomized trials. RoB 2 uses domains of bias, according to different aspects of the design, conduct and reporting of the studies. Each domain represents a series of questions that seek information about trial characteristics that are relevant to the risk of bias. The judgement may be of ‘Low’ or ‘High’ risk of bias, or may express ‘Some concerns’ 19.
ASSESSMENT OF METHODOLOGICAL QUALITY
The Tool for the assessment of Study qualiTy and reporting in EXercise (TESTEX) was used to assess the methodological quality of studies and reports, specifically designed for use in experimental studies of physical exercise training. It is a 15-point scale (5 points for study quality and 10 points for reporting) 20.
DATA EXTRACTION
The extracted data was divided by authors, year of publication, country of origin, characteristics of the study population, intervention data including details of general and specific exercises, outcomes and results.
META-ANALYSIS AND EVIDENCE-LEVEL ASSESSMENT
The Review Manager (RevMan) software, version 5.4 (Cochrane Collaboration, 2020), was used to analyze the effects of multicomponent exercise on muscle strength and balance in frail older adults. Random- or fixed-effects models were applied for each outcome analyzed. The fixed-effects model assumes a single true effect common to all studies, whereas the random-effects model assumes that true effects vary across studies and that observed differences result from both between-study variability and sampling error. This means that the random-effects model accounts for an additional source of variability. Each standardized mean difference (SMD) was weighted using the inverse variance method. The SMD values from each study were pooled using a random-effects model, as heterogeneity was found to be significant. Heterogeneity between studies was analyzed using I2 statistics. I2 values are interpreted as low heterogeneity (0-50%), moderate heterogeneity (50-74%), and high heterogeneity (≥ 75%) 21,22. SMD values were interpreted as: 0.2 ≤ TE < 0.5 (weak); 0.5 ≤ TE ≤ 0.8 (moderate); TE ≥ 0.8 (strong) 23. A statistically significant effect was indicated by p < 0.05. The funnel plot was used to check for possible publication bias.
The certainty of the evidence was assessed by two independent authors, and a third author was consulted in cases of disagreement. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was applied using the GRADEpro software, available at . GRADE classifies the certainty of evidence into four levels: high, moderate, low, and very low, which are applied to a body of evidence. Randomized controlled trials (RCTs) start as high-quality evidence. Five factors can decrease the quality of evidence: methodological limitations, inconsistency, indirectness, imprecision, and publication bias 24.
RESULTS
The databases searched were MEDLINE (via PubMed, n = 265), Scopus (n = 322), Web of Science (n = 388), ScienceDirect (n = 488), SciELO (n = 11), and SPORTDiscus (n = 64), totaling 1,538 publications. After applying the selection criteria, 13 randomized controlled trials (RCTs) were included in this systematic review (Figure 1). However, only 10 studies were included in the forest plot analysis. This is because six studies reported outcomes for either balance or muscle strength, but not both.
Table I presents population characteristics and data on the type of intervention, the training volume and the results presented in the studies included in this systematic review. The basic characteristics of the studied population, the origin of the studies were: Spain 25,26, Germany 27, Thailand 2,28, Mexico 29, Japan 30,31, China 32,33, Italy 34, Denmark 35 and Iran 36. The total number of participants was 773, being 387 in the CG and 386 in the EG. The average age was 76.5 years and 85% of the studies used both sexes in the experiment, while 15% 30,35 used only women. BMI assessment was performed by 10 of the 13 studies included in this review, only 3 studies 30,33,35 did not provide information on this variable. The studies of 30,36 used strength and balance training, studies of 32,33 strength and aerobic training, studies of 34 aerobic training and flexibility, and studies of 2,25-29,31,35 used strength, balance and aerobic training. Different tests were used in this systematic review to evaluate muscle strength and body composition. The studies of 2,26,29-32,34,36 used the TUG to assess balance, however, there is a wide variation in tests to assess this variable, so the study of 25 used the BBS and the study of 27 used DSB. The variable muscular strength was evaluated by studies of 2,25,27,30-35 with the handgrip test, while the 28,32 used the knee extension/flexion test.
In Figure 2 a total of n = 10 studies were included in the analysis. The observed standardized mean differences ranged from -0.71 to 3.26, with the majority of estimates being positive (70%). The estimated average standardized mean difference based on the random-effects model was 0.43 (95% CI: -0.18 to 1.03). Therefore, the average outcome did not differ significantly from zero (z = 1.39, p = 0.17). According to the Q-test, the true outcomes appear to be heterogeneous I2 = 92%.
In Figure 3 a total of n = 10 studies were included in the analysis. The observed standardized mean differences ranged from -0.24 to 0.99, with the majority of estimates being positive (80%). The estimated average standardized mean difference based on the random-effects model was 0.27 (95% CI: 0.12 to 0.42). Therefore, the average outcome differed significantly from zero (z = 3.58, p = 0.0003). The Q-test for heterogeneity was not significant, but some heterogeneity may still be present in the true outcomes (I2 = 41%).
Figure 4 presents the results of the risk of bias analysis using the Cochrane risk of bias tool for randomized trials. Of the studies included in this meta-analysis, 3 studies 31,33,35 presented some concerns in the domain “deviations from intended interventions”.
Table II shows the results of the methodological quality assessment using the TESTEX tool. Although all studies were blinded, only the studies of 2,26,30,32,34 blinded the evaluators and scored item 5.
In Figure 5A (Balance), neither the rank correlation nor the regression test indicated any funnel plot asymmetry (p = 0.73 and p = 0.78, respectively). In Figure 5B (Strenght), neither the rank correlation nor the regression test indicated any funnel plot asymmetry (p = 0.38 and p = 0.42, respectively).
In Table III, the level of evidence of the RCTs was assessed using the Cochrane Collaboration’s GRADE tool. In the strength variable, all domains were classified as “not serious”, while in the balance variable, only the Inconsistency domain was classified as “serious”. However, high heterogeneity was explained in the meta-analysis result with the random-effects model.
DISCUSSION
The results of this meta-analysis corroborate the scientific literature. A cross-sectional study conducted by Pizzaro-Mena et al. (2022) analyzed a group of 45 frail older adults who performed multicomponent exercises (strength, aerobic, and balance) for 12 weeks, 3 times a week and 60 minutes per session, showing improvements (p < 0.05) in balance and cardiorespiratory fitness. However, 32 frail older adults were investigated and divided into two groups (multicomponent exercise vs. concurrent training) for 20 weeks, with three sessions per week. No significant differences were found in balance or muscle strength in the intragroup evaluation 37. Another randomized controlled pilot study 38, involving 96 frail older adults who trained twice weekly for 60 minutes per session over 12 weeks, reported significant improvements (p < 0.05) in muscle strength and balance among participants who performed multicomponent exercises (aerobic, qigong, and strength training). Another randomized controlled pilot study conducted by involving 96 frail older adults who trained twice a week for 60 minutes per session over 12 weeks reported significant improvements (p < 0.05) in muscle strength and balance among those who performed multicomponent exercises (aerobic, qigong, and strength training).
It is worth noting that, although muscle strength showed improvements while balance did not in this meta-analysis, this may be attributed to differences in training emphasis and exercise prescription, as most studies prioritized strength training over balance training. It is possible that equating the volume or frequency of strength and balance training, or scheduling balance training on separate days rather than concomitantly with strength training, could yield better outcomes for balance. A study protocol for a randomized clinical trial 39 proposes this approach, emphasizing balance training for a longer duration compared with the studies included in this meta-analysis.
Another important point to be discussed is clinical diversity (different assessment instruments, populations) and methodological diversity (outcomes), which may have contributed to the heterogeneity observed in this study. The outcome related to balance showed high heterogeneity, whereas muscle strength exhibited low heterogeneity. It is clear that caution is required when evaluating the results. Objective methods to quantify the levels of clinical and methodological heterogeneity are urgently needed to enable a reliable determination of the precision of meta-analyses 21.
The aim of this protocol is to improve muscle strength and balance and, consequently, reduce falls in older adults. Supporting this, a randomized clinical trial 40 involving 149 frail older adults implemented a 12-week training program combining strength and balance exercises (twice a week for 60 minutes per session) and found significant improvements (p < 0.05) in both muscle strength and balance.
This study included 13 randomized controlled trials (RCTs) in which the experimental groups performed multicomponent exercise programs (aerobic, strength, balance, and flexibility training) averaging 53 minutes per session, three times per week, over a period of 16 weeks. The pooled results demonstrated significant improvements (p < 0.05) in muscle strength among frail older adults.
One of the limitations of this study was the predominance of RCTs involving older men, considering that gender differences may influence the effects of physical exercise due to biological individuality. A major strength of this meta-analysis is the substantial number and high quality of the studies included.
CONCLUSIONS
This meta-analysis found that multicomponent exercise improves muscle strength but not balance in frail older adults. Randomized clinical trials reported in the literature corroborate the findings of this study. Future research employing multicomponent exercise interventions in frail older adults should also examine additional physiological parameters such as heart rate, oxygen uptake, and ventilatory thresholds to further enhance quality of life in this population and provide guidance for health professionals in prescribing safe and effective exercise programs.
The results of this meta-analysis demonstrate the clinical implications of evidence-based interventions using multicomponent exercises on outcomes related to key physical qualities important for older adults’ health, particularly muscle strength and balance. However, the heterogeneity observed, sample size, intervention duration, and outcome measures should be taken into account when interpreting the results. Randomized clinical trials with high methodological rigor are needed to support evidence-based practice.
Conflict of interest statement
The authors declare no conflict of interest.
Funding
This research did not receive any funding from agencies in the public, commercial, or not-for-profit sectors.
Author contributions
DGL, RGSV, GCPSMS: conceptualization; DGL, CJBP, JFSS: methodology; DGL, CJBP, JFSS, ABMCM: formal analysis and investigation; DGL, BGL: writing – preparation of the original draft; DGL, LLS, LSC: writing - review and editing; DGL, RGSV, GCPSMS: resources; RGSV, CJB: supervision.
Ethical consideration
Not applicable.
History
Received: April 28, 2025
Accepted: November 3, 2025
Published online: Dec 18, 2025
Figures and tables
Figure 1.Prisma flowdiagram.
Figure 2.Forest plot (balance).
Figure 3.Forest plot (strength).
Figure 4.Risk of bias (Rob 2).
Figure 5.Funnel plot (Balance and strength).
| Author-year/country | Age mean (sd) | BMI mean (sd) | Sex | Groups (n) | Intervention | VT | Results |
|---|---|---|---|---|---|---|---|
| Arrieta et al. 25/ Spain | CG: 84.7 (6.1)EG: 85.1 (7.6) | CG: 28.2 (5.3)EG: 28.2 (5.1) | ♂♀ | CG= 47 EG= 45 | EG: Aerobic exercises: 5-15 min (walking); Muscle strength: 45 min; Balance: 10 min CG: No exercise | 45 min x session/ 2 x week/ 36 weeks | Strenght: CG: ↔ handgrip EG: ↔ handgrip Balance: CG: ↓ BBS EG: ↑ BBS |
| Cordes et al. 27/ Germany | CG: 80.12 (11.37)EG: 82.69 (10.26) | EG: 24.93 (6.22)CG: 27.46 (5.88) | ♂♀ | CG= 26 EG= 26 | EG: Warm-up: 5-10 min; Coordination and motor-cognitive exercises: 5–10 min; task-specific exercises for ADL: 10 min; strength and aerobic exercises: 15 min; Cool down: 5-10 min CG: No exercise | 50-55 min x session/ 32 sessions/ 16 weeks | Strenght: CG: ↔ handgrip EG: ↔ handgrip Balance: CG: ↔ DSB EG: ↔ DSB |
| Chittrakul et al. 28/ Thailand | CG: 68.89 (3.86)EG: 69.14 (3.55) | CG: 24.32 (4.36)EG: 24.46 (4.06) | ♂♀ | CG= 36 EG= 36 | EG: Warm-up; Strenght; balance; Reaction time; cooldown. CG: Flexibility exercises | 60 min x session, 3 x week, 12 weeks | Strenght: CG: ↓ Knee extension EG: ↑ Knee extension |
| Edna Mayela et al. 29/ México | CG: 68.90 (5.14)EG: 68.17 (6.25) | CG: 28.07 (4.40)EG: 28.26 (4.11) | ♂♀ | CG= 42 EG= 46 | EG: Warm-up and aerobic: 10 min; Strength, aerobic and balance: 35-45 min; Cooldown: 15 min CG: no exercise | 60-70 min x session, 3 x week, 12 weeks | Balance: CG: ↓ TUG EG: ↑ TUG |
| Kim et al. 30/ Japan | CG: 80.3 (3.3)EG: 81.1 (2.8) | NI | ♀ | CG= 33 EG= 33 | EG: Warm-up: 5 min; Balance and gait training: 20 min; strength: 30 min; Cooldown: 5 min CG: No exercise | 60 min x session, 3 x week, 12 weeks | Strenght: CG: ↔ handgrip EG: ↔ handgrip Balance: CG: ↔ TUG EG: ↑ TUG |
| Liu et al. 32/ China | CG: 75.6 (6.35)EG: 74.2 (4.67) | EG: 24.93 (6.22)CG: 27.46 (5.88) | ♂♀ | CG= 45 EG= 41 | EG: Walking: 10 min; Strenght exercise: 7 exercises, total session time not reported CG: No exercise | 12 weeks | Strenght: CG: ↔ handgrip; ↔ Knee flexion; ↔ Knee extension EG: ↑ handgrip; ↑ Knee flexion; ↑ Knee extension Balance: CG: ↔ TUG EG: ↑ TUG |
| Makizako et al. 31/ Japan | CG: 75.8 (7.3)EG: 74.1 (6.6) | CG: 20.6 (2.1)EG: 20.9 (2.7) | ♂♀ | CG= 36 EG= 36 | EG: Brief warm-up involving stretchin; resistance training: 25-30min; Balance and aerobic exercises: 20-25 min; cool-down: 5 min CG: No exercise | 60 min x session/ 12 weeks | Strenght: CG: ↓ handgrip EG: ↔ handgrip Balance: CG: ↔ TUG EG: ↑ TUG |
| Poli et al. 34/ Italy | CG: 70.77 (6.24)EG: 69.33 (4.59) | CG: 27.88 (6.01)EG: 25.71 (5.53) | ♂♀ | CG= 9 EG= 12 | EG: Aerobic exercises: 15 min; Flexibility: 1-3 sets of 30-60 seconds with 60 seconds rest between sets; 1-3 sets of 10-15 reps with 60-120 seconds rest interval; The Cool down period consisted of breathing and stretching exercises CG: No exercise | 2 x week/ 60 min x session/ 10 weeks | Strenght: CG: ↔ handgrip EG: ↑ handgrip Balance: CG: ↔ TUG EG: ↑ TUG |
| Sadjapong et al. 2/ Thailand | CG: 78.87 (1.32)EG: 76.68 (1.14) | CG: 21.28 (0.69)EG: 21.37 (0.68) | ♂♀ | CG= 32 EG= 32 | EG: Aerobic Training: 10-20 min; Resistance Training with Theraband: 25-30 min; Balance training: 10 min CG: no exercise | 3 x week/ 60 min x session/ 24 weeks | Strenght: CG: ↔ handgrip EG: ↑ handgrip Balance: CG: ↓ TUG EG: ↑ TUG |
| Sedaghati et al. 36/ Iran | CG: 71.07 (2.26)EG: 70.42 (2.70) | CG: 23.59 (1.11)EG: 23.68 (1.21) | ♂♀ | CG= 14 EG= 14 | EG: Warm-up: 5 min; Strength lower extremity: 4-5 exercises, 2 sets x 8-12 rep; Balance: 2-5 exercises; Dual-task (cognitive function): 2–5 of strength exercises; Balance: 2-4 exercises; Cooldown: 5 min CG: no exercise | 3 x week/ 60 min x session/ 8 weeks | Balance: CG: ↓ TUG EG: ↑ TUG |
| Tarazona-Santabalbina et al. 26/ Spain | CG: 80.3 (3.7)EG: 79.7 (3.6) | CG: 30.0 (4.2)EG: 29.9 (5.6) | ♂♀ | CG= 42 EG= 40 | EG: Warm-up: 5 exercises of mobility; Aerobic: 30-40 min; Strength: 9 exercises; Balance: 8 exercises; Cooldown: 5 min CG: no exercise | 65-70 min x session, 5 x week, 24 weeks | Balance: CG: ↔ TUG EG: ↔ TUG |
| Vestergaard et al. 35/ Denmark | CG: 82.7 (3.8)EG: 81.0 (3.3) | NI | ♀ | CG= 25 EG= 25 | EG: Flexibility and dynamic balance: 15 min; strength: 6 min; Aerobic: 5 min CG: No exercise | 30 min x session, 3 x week, 20 weeks | Strenght: CG: ↔ handgrip EG: ↑ handgrip |
| Yu et al. 33/ China | CG: > 50 EG: > 50 | NI | ♂♀ | CG= 61 EG= 66 | EG: Warm-up: 5 min; Aerobic: 25 min; Strenght: 25 min CG: no exercise | 60 minutes x session, 2 x week, 12 weeks | Strenght: CG: ↔ handgrip EG: ↔ handgrip |
| EG: Experimental group; CG: Control Group; NI: Not informed; sd: standard deviatio; TUG: Time Up Go; DSB: Dynamic Siting Balance; BBS: Berg Balance Scale | |||||||
| Study | Study quality | Sub-total (0 to 5) | Study reporting | Sub-total (0 to 10) | Total (0 a 15) | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | 6a | 6b | 6c | 7 | 8a | 8b | 9 | 10 | 11 | 12 | ||||
| Arrieta et al. 25 | 1 | 1 | 1 | 1 | 0 | 4 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 10 | 14 |
| Cordes et al. 27 | 1 | 1 | 1 | 1 | 0 | 4 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 10 | 14 |
| Chittrakul et al. 28 | 1 | 1 | 1 | 1 | 1 | 5 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 10 | 15 |
| Edna Mayela et al. 29 | 1 | 1 | 1 | 1 | 0 | 4 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 10 | 14 |
| Kim et al. 30 | 1 | 1 | 1 | 1 | 1 | 5 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 10 | 15 |
| Liu et al. 32 | 1 | 1 | 1 | 1 | 1 | 5 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 10 | 15 |
| Makizako et al. 31 | 1 | 1 | 1 | 1 | 0 | 4 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 10 | 14 |
| Poli et al. 34 | 1 | 1 | 1 | 1 | 1 | 5 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 10 | 15 |
| Sadjapong et al. 2 | 1 | 1 | 1 | 1 | 1 | 5 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 10 | 15 |
| Sedaghati et al. 36 | 1 | 1 | 1 | 1 | 0 | 4 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 10 | 14 |
| Tarazona-Santabalbina et al. 26 | 1 | 1 | 1 | 1 | 1 | 5 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 10 | 15 |
| Vestergaard et al. 35 | 1 | 1 | 1 | 1 | 0 | 4 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 10 | 14 |
| Yu et al. 33 | 1 | 1 | 1 | 1 | 1 | 5 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 1 | 10 | 14 |
| Study quality: 1 = specific eligibility criteria; 2 = type of randomization specified; 3 = hidden allocation; 4 = similar groups at baseline; 5 = raters were blinded (at least one main outcome); 6 = outcomes assessed in 85% of participants (6a = 1 point if more than 85% completed; 6b = 1 point if adverse events were reported; 6c = if exercise attendance was reported); 7 = intention-to-treat statistical analysis; 8 = statistical comparison between groups was reported (8a = 1 point if between-group comparisons are reported for the primary outcome variable of interest; 8b = 1 point if statistical comparisons between groups are reported for at least one secondary measure); 9 = point measures and measures of variability for all outcome measures that were reported; 10 = activity monitoring in the control group; 11 = relative exercise intensity remained constant; 12 = exercise volume and energy expenditure were reported. | ||||||||||||||||||
| Certainty assessment | № of patients | Effect | Certainty | Importance | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| № of studies | Study design | Risk of bias | Inconsistency | Indirectness | Imprecision | Other considerations | Exercise | Control | Absolute (95% CI) | ||
| Balance | |||||||||||
| 10 | Randomised trials | Not serious | Seriousa | Not serious | Not serious | None | 318 | 319 | SMD 0.43 SD higher (0.18 lower to 1.03 higher) | ⊕⊕⊕⊕ Moderatea | IMPORTANT |
| Strenght | |||||||||||
| 10 | Randomised trials | Not serious | Not serious | Not serious | Not serious | None | 352 | 350 | SMD 0.27 SD higher (0.12 higher to 0.42 higher) | ⊕⊕⊕⊕ High | IMPORTANT |
| CI: confidence interval; SMD: standardised mean difference; a. The high heterogeneity was accounted for in the meta-analysis result by using the random-effects model. | |||||||||||
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