Effects of walking exercise on cognitive and physical functions: ­meta-analysis of older adults

Figures & data

Figure 1. PRISMA flow chart

Table 1. Characteristics of selected articles

No	Authors (year)	Study country	Sample size(n)		Study design	M:W	Participants	Intervention					Outcome variable
			EG	CG				Type	Duration (weeks)	Frequency	Time (min)	Intensity	Cognitive function	Physical function
1	Song and Kim (2018)	South Korea	10	10	RCT	All women	Age > 70years women	Complex	12	3	60	THR 50 ∼ 70%	MMSE-K	–
2	Hong (2012)	South Korea	16	10	NRCT	EG 11:5 CG 5:5	Age > 60years	Complex	8	2-3	60	–	MMSE-K	Agility, upper body strength, lower body strength
3	Jeong and Oh (2013)	South Korea	16	19	NRCT	All women	Age > 65years with dementia(mmse11-23) or moderate dementia(10m walk)	Complex	12	3	60	RPE 9-11	MMSE-K	Agility, cardiorespiratory endurance, upper body strength, lower body strength
4	Huh et al. (2014)	South Korea	14	14	RCT	All women	Age > 65years women	Walking	13	3	60	HRR 70%	–	Agility, upper body strength, lower body strength
5	Chu and Shon (2012)	South Korea	14	11	NRCT	All women	Age > 65years women	Complex	16	3	60	–	–	cardiorespiratory endurance, upper body strength, lower body strength
6	Kim et al. (2014)	South Korea	10	10	NRCT	All women	Age > 65years women	Walking	12	5	60	HRR 50-80%	MMSE-K	–
7	Zhang (2021)	South Korea	14	12	NRCT	All women	Age > 70years women	Complex	12	3	60	HRR 40-60%	MMSE-K	Agility, cardiorespiratory endurance, upper body strength, lower body strength
8	An et al. (2019)	South Korea	21	17	NRCT	All women	Age > 70years women	Complex	16	3	60	HRR 60-70%	MMSE-DS	Agility, upper body strength(2), lower body strength
9	An and Choi (2019)	South Korea	10	10	NRCT	–	Age > 70years	Complex	8	3	60	RPE≦13	–	Agility, cardiorespiratory endurance, upper body strength, lower body strength
10	Kim (2017)	South Korea	15	15	NRCT	All women	Age > 65years women	Walking	12	3	50	RPE 10-12	MMSE-K	–
11	Lee and Joo (2021)	South Korea	20	23	NRCT	–	Age > 65years	Walking	12	2	20	HRR 60-70%	MMSE-DS	–
12	Park et al. (2014)	South Korea	20	20	NRCT	All women	Age > 65years women	Complex	12	3	80	HRR 60-70%	–	cardiorespiratory endurance, upper body strength(2)
13	Kim (2008)	South Korea	10	10	NRCT	All women	Age > 60-65years women	Walking	12	3	60	HRR 50-60%	–	Agility, lower body strength
14	Cho and Baek (2017a)	South Korea	9	9	RCT	All women	Age > 65 years women	Walking	12	4	60	RPE 9-11	–	Agility, cardiorespiratory endurance, upper body strength, lower body strength
15	Cho and Baek (2017b)	South Korea	9	9	RCT	All women	Age > 65 years women	Complex	12	4	60	RPE 9-11	–	Agility, cardiorespiratory endurance, upper body strength, lower body strength
16	Lee and Lee (2012)	South Korea	14	13	RCT	All women	Age > 65 years women	Complex	12	3	60	HRR 40-70%	MMSE-K	–
17	Hong (2013)	South Korea	15	7	NRCT	–	Dementia	Complex	24	2	60	–	MMSE-K	Agility, cardiorespiratory endurance, upper body strength, lower body strength
18	Yang and Park (2018)	South Korea	9	10	NRCT	All women	Age > 60 years women	Complex	12	3	70	RPE 6-17	–	Agility, cardiorespiratory endurance, lower body strength
19	Park et al. (2019)	South Korea	25	24	RCT	–	Age > 60 years	Complex	24	–	110	HRR 55-80%	MMSE-K	Agility, lower body strength
20	Fonte et al. (2019)	United States	27	30	RCT	–	Age > 60 years	Complex	24	3	90	HRR 70%	IADL	Cardiorespiratory endurance
21	Sanders et al. (2020)	United States	39	30	RCT	–	Mild and moderate dementia	Complex	24	3	90	RPE 9-11	MMSE	Agility(2), cardiorespiratory endurance, lower body strength
22	Holthoff et al. (2014)	Germany	15	15	RCT	–	Mild and moderate dementia	Complex	12	3	30	–	MMSE, ADCS-ADL	Agility
23	Barreto et al. (2017)	France	44	47	RCT	–	Alzheimer or dementia	Complex	24	2	60	–	MMSE, IADL	Cardiorespiratory endurance
24	Pitkänen et al. (2019)	Finland	86	89	RCT	–	Dementia	Complex	92	6	45	–	ADCS-ADL	BMI
25	Jeoug et al. (2021)	South Korea	13	13	RCT	–	Mild dementia	Complex	12	2	90	–	MMSE-K, ADCS-ADL	–
26	Aguiar et al. (2014)	Brazil	17	17	RCT	–	Alzheimer	Complex	24	2	60	–	MMSE, ADCS-ADL	Agility
27	Lee (2016)	South Korea	15	17	RCT	–	Age > 65years	Walking	5	3	50	–	–	Agility, cardiorespiratory endurance, upper body strength(2), lower body strength

EG: Experimental group; CG: Control group; RCT: Randomized Controlled Trial; NRCT: Non-randomized Controlled Trial; Complex: Interventions that combine walking with other exercise or activities; THR: Target Heart Rate; RPE: Rating of Perceived Exertion; HRR: Heart Rate Reserve; MMSE: Mini Mental State Examination; ADL: Activities of Daily Living; IADL: Instrumenta-ADL; ADCS: Alzheimer’s Disease Cooperative Study; BMI: Body Mass Index; Complex: walking and strength

Table 2. Characteristics of selected articles

Domain	Risk of bias
	Unclear	Low	High
Random sequence generation (selection bias)	–	13	1
Allocation concealment (selection bias)	3	11	–
Blinding of participants and personnel (performance bias)	–	14	–
Blinding of outcome assessment (detection bias)	–	14	–
Incomplete outcome data (attrition bias)	–	14	–
Selective reporting (reporting bias)	–	14	–
Other bias	–	14	–

Table 3. Risk of bias for non-randomized controlled trial studies (RoBANS)

Domain	Risk of bias
	Unclear	Low	High
Participants selection	–	13	–
Confounding variables	4	9	–
Measurement of exposure	–	13	–
Blinding of the outcome assessments	–	13	–
Incomplete outcome data	–	11	2
Selective outcome reporting (reporting bias)	–	13	–

Figure 2. Effect size with MMSE scores

Figure 3. Effect size scores on activities of daily living

Figure 4. Effect size on agility

Figure 5. Effect size on cardiorespiratory endurance

Figure 6. Effect size on upper body strength

Figure 7. Effect size on lower body strength

Table 4. Moderation effects on MMSE scores

Variables	Categories	k	Hedges's g	95% CI	I^2 (%)	Qb (p)
Size of experimental group	10-19	11	0.83	0.5240 ∼ 1.2262	50.1	20.28 (.0001)
	20-29	3	0.93	0.0915 ∼ 2.0873	86.4
	30-39	1	−0.06	0.5240 ∼ 1.2262	–
	40<	1	−0.19	−0.6062 ∼ 0.2181	–
Exercise type	Complex	13	0.56	0.2308 ∼ 0.8891	67.3	13.50 (.0002)
	Walking	3	1.68	1.1817 ∼ 2.1795	11.8
Exercise duration (weeks)	<10	1	0.92	0.0854 ∼ 1.7555	–	25.56 (.0001)
	10-19	10	1.14	0.7658 ∼ 1.5219	54.0
	20-29	5	0.00	−0.2420 ∼ 0.2450	0
Exercise frequency (weekly)	2	5	0.41	−0.1961 ∼ 1.0183	77.9	8.39 (.0387)
	3	9	1.01	0.5501 ∼ 1.4707	73.4
	5	1	1.38	0.3831 ∼ 2.3762	–
	<5	1	0.12	−0.4368 ∼ 0.6846	–
Exercise time (minute)	20	1	1.49	0.8100 ∼ 2.1787	–	32.61 (.0001)
	30	1	1.10	0.3241 ∼ 1.8740	–
	50	1	2.3	1.3507 ∼ 3.2467	–
	60	10	0.76	0.3575 ∼ 1.1588	70.4
	90	2	−0.01	−0.4169 ∼ 0.3929	0
	110	1	0.12	−0.4368 ∼ 0.6846	–

Note. k = number of studies; CI = Confidence Interval; Q_b = Q-value between subgroups.

Table 5. Moderation effect on agility

Variables	Categories	k	Hedges's g	95% CI	I^2 (%)	Qb (p)
Sample size (Experimental group)	10<	3	0.23	−0.7771 ∼ 1.2450	69.9	3.54(.3514)
	10-19	9	−1.20	−2.3355 ∼ −0.0698	88.3
	20-29	3	−0.45	−1.0256 ∼ 0.1344	52.0
	30-39	2	−0.34	−0.6791 ∼ −0.0001	0.0
Exercise type	Complex	13	−0.88	−1.6839 ∼ −0.0736	84.8	2.91(.0879)
	Walking	4	−0.88	−0.5220 ∼ 0.3657	25.2
Exercise duration (weeks)	<10	2	−1.90	−1.2916 ∼ −0.0425	96.2	1.46(.4811)
	10 ∼ 19	10	−0.69	−0.8169 ∼ −0.2836	82.9
	20 ∼ 29	5	−0.26	−0.5189 ∼ −0.0055	13.4
Exercise frequency (weekly)	2	2	−0.17	−1.1930 ∼ 0.8623	69.0	9.50(.0234)
	3	12	−1.03	−1.8308 ∼ −0.2264	83.7
	4	2	0.69	−0.0650 ∼ 1.4466	17.8
	–	1	−0.27	−0.8329 ∼ 0.2928	0
Exercise time (minutes)	30	1	−4.87	−6.3624 ∼ −3.3669	–	37.18(.0001)
	50	1	0.14	−0.5597 ∼ 0.8307	–
	60	11	−0.53	−1.2028 ∼ 0.1432	79.7
	70	1	−0.69	−1.6230 ∼ 0.2434	–
	90	2	−0.34	−0.6791 ∼ −0.0001	0.0
	110	1	−0.27	−0.8329 ∼ 0.2928	–

Note. k = number of studies; CI = Confidence Interval; Q_b = Q-value between subgroups

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