Geriatric Nursing 54 (2023) 83 93

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Featured Article

Effectiveness of an online multicomponent physical exercise intervention

on the physical performance of community-dwelling older adults:
A randomized controlled trial
De La Vega-Cordero Edna Mayela, MSNa, Lo
pez-Teros Miriam, PhDa,*,
García-Gonza
lez Ana Isabel, MSca,b, Rosas-Carrasco Oscar, MDa,b,
Castillo-Aragon Alejandra, MSNc
a
Universidad Iberoamericana, Departamento de Salud. Ciudad de M
exico, M
exico
b
Hospital General de M
exico. “Dr. Eduardo Liceaga”, Medicina Física Rehabilitacio
n, Ciudad de M
exico, M
exico
c
n en Nutricio
Centro de Investigacio
n y Salud, Instituto Nacional de Salud Pu

blica, Ciudad de M
exico, M
exico

A R T I C L E I N F O A B S T R A C T

Article history: This study aimed to assess the effectiveness of an online multicomponent physical exercise intervention
Received 5 June 2023 (MPE) on the physical performance (PP) of older adults. A randomized controlled trial was conducted, with
Received in revised form 23 August 2023 110 participants assigned to either the MPE group or the control group. The MPE group engaged in endur-
Accepted 23 August 2023
ance, strength, balance, and flexibility exercises for at least three days per week, while the control group
Available online 14 September 2023
received educational sessions. PP was evaluated using the Short Physical Performance Battery (SPPB) at base-
line and after three months. The intervention group showed a mean increase over control group of 0.81
Keywords:
points on the SPPB scale (95% confidence interval [CI] 0.23-1.40; p=0.000) and in the tandem balance test
Older adults
Multi-component physical exercise
with 1.26 more seconds (95% CI 0.21-2.31; p=0.019). These findings suggest that the online MPE intervention
Online is effective in enhancing the PP of community-dwelling older adults, which may contribute to a reduction in
Physical performance functional dependence among this population.
COVID-19 © 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)

Introduction regularly practice physical activity of moderate to vigorous intensity

have a lower risk of showing low PP and dependency in BADL and
Every country in the world is experiencing an increase in the pro- IADL.4 Among the strategies to improve PP and avoid the develop-
portion of older persons in the population. The process of aging is the ment of functional dependency, older adults must adopt healthy life-
result of an accumulation of molecular and cellular changes over styles which include increased physical activity (PA).5 The WHO
time, which causes a gradual loss of physical and mental functions, exercise guidelines for adults aged
65 years recommend 150 to
an increase in the risk of disease, and finally functional dependence 300 min of moderate-intensity or 75 to 150 min of vigorous-intensity
and death.1 physical activity per week, combined with multicomponent physical
Functional dependence is a public health problem in Mexico, activity that emphasizes functional balance and strength training at
mainly in older adults; a prevalence of 26.9% has been reported for moderate or great intensity three or more days a week to enhance
the basic activities of daily living (BADL) and 24.6% for the instrumen- functional capacity and to prevent falls.6
tal activities of daily living (IADL) among Mexican older adults (aged However, the prevalence of a sedentary lifestyle is higher in Mexi-
60 years and over). Physical performance (PP) (gait speed, balance, can older adults compared to other countries. In 2018, only 35.2% of
and muscle strength) is an indicator with a high predictive capacity the population aged 50 and over reported to exercise at least three
for adverse outcomes in older adults such as falls, functional depen- times a week.7 We must also highlight the impact of social distancing
dency, hospitalizations, and mortality. 2,3 during the COVID-19 pandemic on physical health, especially in older
In a study in Mexico, a prevalence of low PP of 17.33% was adults. The impact of social distancing led to reductions in PA, espe-
observed in 589 community-dwelling older adults. Those who cially for vigorous activities and walking time. It also affected the
number of older adult centers attending group physical activity

n Paseo de Reforma 880, Lomas de Santa Fe,
*Correspondence author at: Prolongacio programs. After this finding, it has been recommended to increase

xico, C.P. 01219, Ciudad de Me
Me
xico. physical activity levels using apps, online videos, telehealth, or
E-mail address: miriam.lopez@ibero.mx (L.-T. Miriam).

https://doi.org/10.1016/j.gerinurse.2023.08.018
0197-4572/$ see front matter © 2023 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)
84 D.L.V.-C. Edna Mayela et al. / Geriatric Nursing 54 (2023) 83 93

telegeriatrics through a multicomponent program with exercise for to-stand, tandem stand, SPPB score, single-leg standing and timed up
this population during the confinement. It is crucial to highlight that and go test results. 22
there exists a scarcity of published studies focusing on effective phys- Despite these published studies, there are still few publications on
ical exercise interventions designed for community-dwelling older RCTs that prove the effectiveness of a multicomponent physical exer-
adults, with the objective of enhancing physical performance and cise online home-based training on PP on community-dwelling older
promoting functional independence. Moreover, the availability of adults. reduce the risk of low physical performance and functional
online resources for such interventions is even more limited. 8-10 dependence, both highly prevalent conditions in the country. For this
Research studies consistently indicate that exercise interven- reason, this study could support future recommendations for this
tions involving a combination of multiple physical-conditioning population to improve their physical performance and functionality,
components, such as strength, endurance, and balance, lead to which would translate into a better quality of life.
more favorable outcomes in terms of physical performance (PP)
and functional capacity in BADL and IADL in the older adults. This Methods
contrasts with the results derived from exercises of a single type,
highlighting the effectiveness of multi-component exercise (MPE) Study design and participants
programs. 11-13
A MPE involves structured sessions combining resistance, balance, The study was a randomized controlled trial conducted from June to
aerobic, gait, and flexibility exercises. This comprehensive approach October 2021. The study population was randomly selected from the
targets multiple dimensions of fitness in the older adults, such as FraDySMex study (Frailty, Dynapenia, and Sarcopenia in Mexican
muscular strength, endurance, balance, flexibility, and cardiovascular Adults), considering adults aged 50 years and older. The adults were res-
fitness. Additionally, the program it’s adaptable to individual needs, idents of Mexico City from three different municipalities (Cuajimalpa,
abilities, and health status of older adults, motivating better engage-

Alvaro Obrego
n, and Magdalena Contreras). 23 The protocol was
ment and long-term adherence. The goal objectives of the MPE may approved by the Research Ethics Committee of the Iberoamerican Uni-
include improving functional capacity, mobility, PP, independence in versity in Mexico City (No35/2020). Informed consent was obtained
daily activities and quality of life of older adults. It can be conducted from each participant who signed after fully understanding the proce-
in groups for social support or individually, adaptable to various set- dures. The project was registered in clinicaltrials.gov (NCT058957609).
tings like community centers, homes, gyms, and care facilities, mak- The eligibility criteria were the following: adults aged 60 years
ing it accessible to diverse older adult populations. 5,14,15 and over who had an electronic device with internet access for video
Most of the published studies on MPE interventions were on calls. The main exclusion criteria were self-reported walking disabil-
frail older adults and they were institutionalized or hospitalized. ity, the inability to complete the short physical performance battery
16-19
There are few published studies on older adults living in the (SPPB) 24, severe functional dependence (defined as a Barthel index 
community, without frailty, and based on online home training 60/100 score) 25, cognitive impairment (defined as a mini-mental
programs. However, Labata-Lezaun et al. (2023) published the state examination (MMSE) score <24/30) 26, terminal illness, partici-
first meta-analysis to collect the current evidence from random- pation in a physical activity or nutritional program, a limb loss or the
ized controlled trials (RCTs) on the effectiveness of MPE programs use of lower or upper limb prostheses, those adults with a history of
for the improvement of PP in healthy older adults.20 This work injuries (fractures/falls) of less than one year in hip, knee or ankle
collects evidence from 13 articles, with a total of 808 participants joints, adults who reported a surgery in the last 6 months or who
involved and the main results showed that MPE improves PP sig- showed contraindications to perform trial activities according to the
nificantly, compared with the no-training group (standardized- medical personnel. Also, those who presented any medical condition
mean-difference (SMD): 0.78; 95% CI: 0.55, 1.00; Z = 6.84, p < or adverse symptoms during the intervention that made it impossible
0.01; I2 = 54%). In terms of the duration of the interventions, the to carry out the physical exercise program.
training programs varied from 9 to 36 weeks, with an average of
21.30§9.60 weeks, being 12 weeks the most frequent duration. Sample Size estimate/power calculations, randomized and blinding
The frequency of the training programs varied from 2 to 5 ses-
sions per week and the intensity of the training sessions ranged The sample size calculation was based on the primary outcome
from moderate to high intensity. In this meta-analysis, the studies SPPB with a power of .80 [1-b], 2-sided a-error (95% CI), 2 groups,
with MPE online home-based training were not included. and 2 measurements. One hundred participants were required to
Chaabene et al. (2021) carried out a meta-analysis to assess the detect a clinically meaningful change of
1.0 points with an SD of
effect of home-based exercise programs on PP in healthy older adults. 0.99 points.27 Considering the potential dropouts before study com-
Seventeen RCTs (N=1,477 participants) were included, with studies pletion, we inflated the sample size by 10%, resulting in a total sample
on any of the following types of training: neuromuscular, strength, size of 110 individuals (55 participants assigned to each group). From
training, power, or balance, but not exactly as the MPE training pro- a sample of 1000 adults from the FraDySMex study, after the baseline
gram stated. The results indicated small effects of home-based train- assessment was performed, participants were randomly assigned
ing on muscle strength, muscle power, muscular endurance, and using a ratio of 1:1 (intervention group and control group) within the
balance. Also, they showed that >3 weekly sessions produced larger statistical software program STATA. It was single-blind since the par-
effects on muscle strength (SMD=0.45) and balance (SMD=0.37) com- ticipants did not know which group they were in. Fig. 1 shows the
pared with 3 weekly sessions on muscle strength (SMD=0.28) and population flow diagram.
balance (SMD=0.24). The authors concluded that home-based exer-
cise appears effective to improve the components of health and phys- Safety
ical fitness.21 A recent study by Chang et al. (2023) analyzed the
efficacy of an MPE intervention in community-dwelling older adults All study staff monitored participant safety and reported three
during the COVID-19 pandemic. They were randomly assigned to the categories of adverse events: serious adverse events, unexpected
intervention group (n = 82) or the control group (n = 85). The inter- adverse events (those potentially related to study procedures or
vention consisted of a 60 min group exercise session per week during activities and not listed in the informed consent form or study proto-
weeks 1-8 and an online home exercise program during weeks 9-16. col), and adverse events that occurred while the participant was
On week 16, the intervention group showed better grip strength, sit- under the supervision or guidance of the study staff.
 D.L.V.-C. Edna Mayela et al. / Geriatric Nursing 54 (2023) 83 93 85

Fig. 1. Selection, recruitment, allocation and study intervention flowchart.

Interventions exercises to improve neuromuscular activity, muscle mass,

strength, power and functional capacity and 3) 10 min back to
Intervention group. A multicomponent physical exercise program normal exercises consisting of neck flexion movements, shoulder
(MPE) was implemented, consisting of a combined program of endur- and arms stretches and limbs stretches exercises. These exercises
ance, strength, coordination, balance, and flexibility exercises were different for each group (level A, B and C), for example for
depending on the level of functional capacity (i.e. severe, moderate, older adults in group A the exercises were using some type of
and mild limitation). The recommendations of the ViviFrail project support or help or sitting compared to level C who performed
were followed to form the groups depending on the SPPB scores. 28 exercises with greater challenges, weight, or intensity. (Table 1).
Three types of physical exercise programs were designed accord- Videos of the exercise programs for each session and level were
ing to the physical performance level of each participant. The first created and uploaded to a YouTube channel. https://www.you
type of exercise program training was performed for frail adults with tube.com/watch?v=emhl_ePbdfs
an SPPB score of 4 to 6 (level A), the second was for the pre-frail To start the intervention, a message was sent a few days before-
adults with an SPPB score of 7 to 9 (level B) and the third for robust hand to remind about the appointment and the materials for the cor-
adults with an SPPB of 10 to 12 (level C). responding session. The intervention for each of the participants was
The exercise sessions designated for each participant were carried out individually through the Zoom app or by WhatsApp video
divided into: 1) 10 min warm-up exercises as walking and head, call three times a week with the supervision of health professionals
shoulder, articular of lower limbs movements, 2) 30 min of the with a duration of 45-60 min per session. In addition, the partici-
general part of the exercises: upper and lower body strength pant’s physical fitness and physical activity status were monitored
86 D.L.V.-C. Edna Mayela et al. / Geriatric Nursing 54 (2023) 83 93

Table 1
Design of multicomponent physical exercise online intervention according to physical performance level.

Multicomponent exercise program for older adults

Group Phase Exercises Series / repetitions Time

Level 1 (frail) Warm-up Walking with assistance 1 5 min

3 head movement exercises 1/10 6 min
4 shoulder movement exercises 1/10 8 min
6 articular movements of lower 1/10 12 min
limbs exercises
General 3 upper muscle strength exercises 1/10 5 min
3 lower muscle strength exercises 1/10 5 min
Back to normal 4 stretching exercises 1/3 10 min
Neck flexion movements
Shoulder and arms stretches
Limbs stretches
Level 2 (pre-frail) Warm-up Brisk walking 1 10 min
8 articular movements of upper 1/10 10 min
and lower extremities exercises
General 3 upper body strength exercises 1/10 5 min
3 lower body strength exercises 1/10 5 min
Back to normal 4 stretching exercises 1/3 8 min
Neck flexion movements
Shoulder and arms stretches
Limbs stretches
Level 3 (robust) Warm-up Walking with arm movements 1 2 min
Slow jogging 1 1 min
Knee elevation 1 1 min
Walking with knees semi-flexion 1 1 min
5 joint movements of upper and 1/10 5min
lower extremities exercises
General 6 balance exercises 2/10-12 15 min
Endurance exercise (walk or 1/2 4-8 min
zumba song)
6 upper and lower body strength 2/15 15 min
and endurance exercises
Back to normal 4 stretching exercises 2/15 15 min
Neck flexion movements
Shoulder and arms stretches
Limbs stretches

through a series of questions at the beginning of each week of inter- on the YouTube channel https://www.youtube.com/watch?
vention to ensure the older adult was able to continue with the v=rSeEbayj43M
intervention.29
The intensity of the exercise was considered using the OMNI- RES Data collection
scale (exertion scale for resistance), which was shown to each partici-
pant in the end of the session, which sets a score from 0 to 10, rank- All data from the baseline and final evaluations were collected
ing 0 for extremely easy and 10 for extremely hard. Furthermore, in through the Zoom app or by WhatsApp video calls and by using Sur-
the live sessions with the instructor, the aim was to maintain a work- veyMonkey.
out intensity ranging from light to moderate (4-6 on the intensity
scale), changes in exercise volume and intensity were also made Primary response variable: Physical performance
every 2 weeks.
The MEP was developed with the support of a physical training The physical performance was assessed with an SPPB scale which
specialist, a medical rehabilitator, gerontological nutritionists, and is an instrument that evaluates three domains of physical perfor-
geriatricians. mance: balance, gait speed, and lower limb strength for rising from a
chair. Every test has a maximum score of 4, obtaining a single score
Control group on a 0 (worst) to 12 (best scale). 24,30

This group was invited to remote meetings every 15 days in which Covariates
education on exercise-related health prevention was provided.
Topics such as the benefits of multicomponent exercise for older Sociodemographic: Age (years), sex, and schooling (<10;
10 years)
adults, recommendations for physical exercise training in older Health Conditions: depressive symptoms were evaluated by
adults, recommendations for active aging, healthy eating for older the Depression Scale of the Center for Epidemiological Studies
adults, and MyPlate for older adults. The physical rehabilitator and (CESD-7)31, cognitive status was assessed using the MMSE test26,
gerontological nutritionists were in charge of providing the recom- comorbidity through the Charlson comorbidity index23,32, frailty was
mendations. In addition, the participants were instructed not to par- measured using the FRAIL scale33, and sarcopenia using the SARC-F
ticipate in any physical exercise program during the study period and scale; in addition, the use of medication (number, dose, and time of
to continue with their usual activities. This information is available consumption) was recorded34. Functional disability (FD) was also
 D.L.V.-C. Edna Mayela et al. / Geriatric Nursing 54 (2023) 83 93 87

evaluated, using the Barthel scale for BADL25, and the Lawton scale Post hoc sensitivity analyses for missing data were performed to
for IADL (Lawton & Brody, 1969) 35. calculate beta coefficients and corresponding confidence intervals;
Nutrition variables: malnutrition was assessed through the Mini the hypothesis tests were performed with the use of linear mixed-
Nutritional Assessment (MNA) test 36, anthropometric measurements regression multiple imputation, under the assumption of a monotone
such as weight (kg), height (mts), BMI (body mass index), calf, waist, pattern of missing data. All MI analyses were performed using 22
hip and mild-arm circumferences, and body composition as fat mass dataset imputations. 38
(%) and free fat mass (%). These measurements were evaluated with All results of comparisons with p0,05 were considered statisti-
an OMRON HBF-514CÒ portable scale capable of assessing a total cally significant and were performed with STATA 16.1 for Windows
weight of 150 kg. Level of physical activity: physical activity was (StataCorp., Texas).
measured using the Physical Activity Survey (YPAS) questionnaire,
obtaining weekly METs as a result (De Abajo et al., 2001). 37
Results

Statistical analysis A total sample of 88 participants was obtained, 46 belonging to

the intervention group and 42 to the 4.5 § 4.12 control group, of
We used the intention-to-treat methodology. Descriptive statis- whom 69.32% were women, with a mean age of 68.52§5.72 years
tics were presented for the total sample and categorized by interven- and 11.10 § 4.42 years of schooling. In relation to health conditions
tion group, utilizing means and standard deviations (SD) for at the beginning of the study, the total following means were
continuous variables, and absolute/relative frequencies for categori- obtained in the tests: 27.92§2.49 on the MMSE test, 27.92§2.49 on
cal variables. To compare final measurements between groups, we the CESD-7 scale, 3.39§2.59 on the Goldberg scale, 1.60 § 1.33,
used an independent t-test for continuous variables and a chi- 26.49§ 2.28 on the MNA test and 4.20§3.29 in the medication use.
squared test for categorical variables. For baseline measurements In functionality, 10.14 § 1.31 on the SPPB scale, 98.69§2.88 on the
within groups, a paired t-test was used for continuous variables, and Barthel index, and 7.70§0.81 on the Lawton scale were obtained.
a Chi-squared test was applied for categorical variables. Table 2 shows the comparisons of the means § SD or N (%) of the
Also, linear mixed effect models were used to compare the differ- baseline characteristics between both groups; it can be observed that
ence in mean SPPB score at 3 months follow-up between groups, con- there was no significant difference in any of the study variables.
trolling for baseline SPPB, age, sex, comorbidity index, score, and frail, Table 3 shows the comparison of the means § SD or N (%) of the
score. Secondary analysis of the three component parts of the pri- follow-up characteristics of both groups. Three months after the
mary outcome (balance, gait speed, and chair stand data) using the beginning of the exercise program, the intervention group showed a
same model. The covariates included in this analysis were those vari- statistically significant higher score in the SPPB (11.57 § 0.61) com-
ables that had a p 0.20 in the association with physical performance pared to the control group (10.75§1.56, mean difference (0.81, 95%
in a simple regression analysis. CI (0.23-1.40), p=0.006) and in the total time in Tandem Balance test

Table 2
Baseline characteristics of study participants

Characteristics Total (n=88) Intervention (n=46) Control (n= 42)

Mean § SD o n (%) Mean § SD o n(%) Mean § SD o n (%)

Demographic data
Age, years 68.52§5.72 68.17§6.25 68.90§5.14
Women 61 (69.32) 30 (65.22) 31 (73.81)
Education, years, 11.10§4.42 11.04§4.01 11.16§4.88
Living status
Married/common law 55 (62.5) 29 (63.04) 26 (61.90)
Single, separated, divorced, widowed 33 (37.5) 17 (36.96) 16 (38.10)
Clinical data
MMSE scale, score 27.92§2.49 28.00§2.33 27.83§2.68
CESD-7 scale, score 4.67§4.55 4.02§4.13 5.38§4.91
Goldberg scale, score 3.39§2.59 3.10§2.40 3.71§2.78
Charlson index, score 1.63§1.36 1.73§1.43 1.52§1.29
FRAIL scale, score 0.63§0.83 0.60§0.77 0.66§0.90
SARC-F scale, score 0.78§1.25 0.71§0.98 0.85§1.50
MNA scale, score 26.49§ 2.28 26.95§1.82 26.05§2.59
Drugs, score 4.20§3.29 4.82§3.97 3.52§2.20
Physical performance and functional dependence
SPPB scale, score 10.14§1.31 10.24§1.25 10.05§1.39
Tandem balance test, seg 10.69§2.06 10.57§1.72 10.81§2.36
4 mt walking speed, seg 6.36§2.98 6.34§3.46 6.39§2.39
5 times sit/stand test, seg 11.19§3.87 11.68§3.56 10.66§4.16
Barthel index, score 98.69§2.88 98.69§2.67 98.69§3.13
Lawton scale, score 7.70§0.81 7.60§ 1.02 7.80§0.50
Nutrition
Weight, kg 69.87§11.80 71.66 § 11.33 68.26§12.17
BMI, kg/m2 28.16§4.22 28.26 § 4.11 28.07§4.40
Waist circumference, cm 95.3§10.28 95.09 § 11.80 95.48 § 8.95
Calf circumference, cm 35.60§3.32 35.92 § 3.48 35.31§3.21
Mets per week (YALE) 57.24§57.34 63.66§67.07 51.18§46.56
Notes: Data are presented as means § standard deviation or n (%). There were no significant differences between groups in baseline characteristics (p>0.05). Abbreviations: MMSE=
Mini-Mental State Examination; CES-D7= Center for Epidemiological Studies Depression Scale (7 items); SPPB= Short Physical Performance Test; MNA: Mini Nutritional Assessment
FRAIL: a simple frailty questionnaire; SARC-F: a screening questionnaire for sarcopenia; Goldberg scale: anxiety symptoms.
88 D.L.V.-C. Edna Mayela et al. / Geriatric Nursing 54 (2023) 83 93

Table 3
Changes in the variables after the interventions between groups.

Intervention Control Mean 95% CI p-value

Mean§SD o n(%) Mean§SD o n(%) difference

Clinical data
MMSE, score 28.57§3.37 27.97§ 3.14 0.60 0.97-2.18 0.447
CESD-7, score 3.30 § 3.52 2.20§3.47 1.10 0.59-2.79 0.198
Goldberg, score 3.12§2.43 2.08§2.10 1.03 0.06-2.13 0.064
Charlson index, score 1.09§1.33 1.28§1.12 0.19 0.40-0.79 0.516
Drugs, score 4.36§2.82 3.54§2.72 0.82 0.52-2.16 0.227
Physical performance and functional dependence
SPPB, score 11.57§0.61 10.75§1.56 0.81 0.23-1.40 0.006
Tandem balance test, seg 11.66§2.18 10.39§2.08 1.26 0.21-2.31 0.019
4 mt walking speed, seg 4.75§2.06 5.32 § 2.34 0.57 0.51-1.65 0.296
5 times sit/stand test, seg 10.01§1.99 10.39§ 2.65 0.38 0.77-1.53 0.509
FRAIL, score 0.36§0.69 0.71§0.95 0.35 0.57-0.75 0.090
Barthel scale, score 99.84§0.87 99.71§1.17 0.13 0.36-0.63 0.596
Lawton scale, score 7.96 § 0.17 8.0 § 0 0.03 0.02-0.08 0.306
Nutrition
Weight, kg 68.44 § 9.95 65.51§11.68 2.92 2.82-8.68 0.312
BMI, kg/m2 27.98 § 4.43 26.60 § 4.69 1.37 1.03-3.79 0.257
Waist circumference, cm 94.21 § 8.35 94.06§14.03 0.14 5.98-6.27 0.961
Calf circumference, cm 35.32§2.26 35.1 § 4.11 0.22 1.54-1.98 0.802
Malnutrition risk, total score 12.72§1.28 12§1.96 0.05 1.0-1.15 0.078
Mets per week (YALE) 73.93 § 49.61 90.85 § 69.23 16.92 12.39-46.24 0.253
Notes: Data are presented as means § standard deviation or n (%). There were no significant differences between groups in baseline characteristics. Abbreviations: MMSE= Mini-
Mental State Examination; CES-D7= Center for Epidemiological Studies Depression Scale (7 items); SPPB= Short Physical Performance Test; MNA: Mini Nutritional Assessment
FRAIL: a simple frailty questionnaire; SARC-F: a screening questionnaire for sarcopenia; Goldberg scale: anxiety symptoms.

(11.66 § 2.18 vs 10.39 § 2.08 seg, mean difference (1.26, 95% CI Lawton-Brody index total score (7.77 § 0.54 vs 8.0 § 0.0, mean differ-
(0.23-1.40), p=0.019). Also, in the comparison of the baseline and fol- ence 0.22, 95% CI 0.04-0.41, p=0.01) (Figs. 2 and 3).
low-up characteristics of both groups, it was found improvement In the linear mixed effects model, the intervention group showed
between baseline versus final values in the SPPB total score (10.24 an increase in SPPB score compared to the control group with a beta
§1.25 vs 11.57§0.61, mean difference: 1.33, 95% CI 0.81-1.84, coefficient of 0.81 (95% CI 0.25 to 1.36, p < 0.004), after adjusting for
p=0.000), in the tandem balance test (10.57 § 1.72 vs 11.66§2.18, age, sex, comorbidity index, score, frail scale, score and SPPB scale
mean difference: 1.08, CI 95% 0.06-2.11, p=0.037), Barthel index total (baseline measurements). Also, the intervention group had higher
score (98. 78 § 2.50 vs 99.84 § 0.87, mean difference: 1. 06, 95% CI values of time tandem balance test (95% CI.180 to 2.14, p= 0.020 and
0.09-2.02, p=0.032) and in the Lawton-Brody index total score (7.75§ time sit/stand test (95% CI 0.04 to 2.07, p=0.040) after adjusting for
0.66 vs 7.96§0.17, mean difference 0.21, 95% CI 0.03-0.45, p=0.04). In the same covariables Table 4.
turn, the control group showed statistically significant improvements We conducted an analysis to compare the baseline and follow-up
after the intervention in SPPB total score (9.93 § 1.34 vs 10.75 § physical performance characteristics between two intervention
1.56, mean difference 0.81, 95% CI 0.22-1.41, P=0.008) and the groups: the first group (n=20) engaged in the intervention with a

Fig. 2. SPPB (Short Physical Performance Battery), total score before and after the three-month intervention. 0=Control group, 1=Intervention group. The bars represent the mean §
SD. The statistical analysis was performed with the Student’s t-test for paired samples.
 D.L.V.-C. Edna Mayela et al. / Geriatric Nursing 54 (2023) 83 93 89

Fig. 3. Mean time in the Tandem Balance Test, before and after the three-month intervention. 0=Control group, 1=Intervention group. The bars represent the mean § SD. The statis-
tical analysis was performed with the student’s t-test for paired samples.

frequency of
3 sessions per week, while the second group partici- intervention group had statistically higher SPPB scores (mean differ-
pated with a frequency of 2 sessions per week (n=20). Significant ence: 0.81; 95% CI 0.23 to 1.40, p=0.006) compared to the control
differences were observed in the total SPPB (means § SD) scores in group, and had higher tandem balancing test (seg) scores (mean dif-
both groups, although slightly more pronounced in first group: ference: 1.26; 95% CI 0.21 to 2.31, p=0.019), p=0.019). In the mixed-
(11.45 § 0.68 vs 10.10 § 1.44, mean difference: 1.35) and (11.76 § effects linear regression analysis, the same effect was observed after
0.43 vs 10.46 § 0.87, mean difference: 1.30) in the second group adjusting for baseline variables: age, sex, frailty, and SPPB score.
Fig. 4. While the assessment of performance change over time has been
Concerning adherence within the intervention group, 60.61% documented in previous studies, there are few published studies
reported performing the session three times or more per week, while about magnitude of change in physical performance that holds clini-
39.39% reported two times or less. A total of 78.78% reported having cal significance in the older adults. Perera et al., 2006 through sec-
completed 100% of their exercise routine, 12.27% completed 90%, and ondary analysis estimate the magnitude of small meaningful and
9.09% completed 70%. And only 18% reported experiencing any dis- substantial individual change in physical performance measures and
comfort after completing the session. Also, Table 5 mentions the evaluate their responsiveness. 27 The results showed that a small
strategies for ensuring treatment fidelity in the interventions. 39 meaningful change is approximately 0.5 points for SPPB a substantial
change is estimated to be around 1.0 point. Also showed, what to
Discussion detect small meaningful effects, are required sample sizes ranged
from 71 to 161 individuals per group for meaningful effects and 13 to
In this study, we assessed the impact of an online multicompo- 42 participants per group for detecting substantial effects. Moreover,
nent physical exercise (MPE) intervention on PP in older persons liv- recommendations for interpreting effect sizes are as delineated: an
ing in the community. After three months, it was shown that the effect size of 0.2 for small, a range of 0.5 to 0.6 for moderate, and

Table 4
The impact of the intervention on physical performance scores between baseline and 3 months follow-up for the intervention group compared to the control group.

SPPB, score Tandem balance test, seg 4 mt walking speed, seg 5 times sit/stand test, seg

Coefficient Coefficient Coefficient Coefficient

(95% CI, P-value) (95% CI, P-value) (95% CI, P-value) (95% CI, P-value)
Intervention Group 0.81 1.16 0.374 1.06
(0.25 to 1.36,0.004) (0.180 to 2.14,0.020) ( 1.36 to 0.620,0.461) (0.04 to 2.07, 0.040)
Age, years 0.004 0.029 0.036 0.037
( 0.050 to 0.053,0.955) ( 0.061 to 0.120,0.523) ( 0.128 to 0.051,0.432) ( 0.132 to 0.056,0.232)
Female .310 0.214 0.883 1.20
( 0.933 to 0.313,0.330) ( 1.30 to 0.879,0.701), ( 0.227 to 1.99,0.119) (0.082 to 2.33, 0.035)
Comorbidity index, score 0. 163 0.024 0.108 0.377
( 0.383 to 0.055,0.144) ( 0.357 to 0.407,0.899) ( 0.497 to 0.279,0.587) ( 0.244 to 1.00,0.234)
Frail scale, score 0.060 0.323 0.169 0.296
( 0.303 to 0.423,0.745) ( 0.325 to 0.972,0.329) ( 0.828-0.490,0.615) ( 0.331 to 0.923, 0.355)
SPPB scale, score* 0.187 0.589 0.573 0.187
( .032 to 0.408,0.095) (0.202-0.976,0.003) ( 0.965 to -0.180, 0.004) ( 0.212 to 0.58, 0.358)

Notes: Linear mixed effect model (beta coefficient) for the mean difference adjusted for age, sex, comorbidity index, score, frail scale, score and SPPB= Short Physical Perfor-
mance Test, scale score.
90 D.L.V.-C. Edna Mayela et al. / Geriatric Nursing 54 (2023) 83 93

Fig. 4. SPPB (Short Physical Performance Battery), before and after the three-month intervention in the intervention group. 0 = 2 session
s week, 1=
3 session
s week. The bars
represent the mean § SD. The statistical analysis was performed with the student’s t-test for paired samples. *MD (Mean difference)

0.8 to 1.0 denotes a large change.40 As previously mentioned, we week 12 we can already obtain significant changes in physical
obtained an average difference of 0.81 with a range of 0.21 to 2.31 performance.41
between the groups in the SPPB test, which signifies a moderate sub- These findings demonstrate the positive effects that a structured
stantial meaningful change. Continuing research is crucial to ascer- MEP can have on older adults’ physical function and performance.
tain the clinically meaningful magnitude of change in performance The minimum period of the training program should be three
metrics, which can significantly enhance the needs of clinical practice months, and it should include endurance, strength, coordination, bal-
and research field. ance, and flexibility exercises that last 30 to 40 minutes each time. If
Comparing our findings with studies that implemented the MPE older persons are pre-frail or frail, these findings may represent a
online intervention. Chang et al. (2023) analyzed the efficacy of an stronger impact. In our study, we only had a prevalence of 13.24%
MPE intervention in community-dwelling older adults during the with low PP and only 15% had frailty; however, we can see that this
COVID-19 pandemic and showed that the intervention group had type of program could improve their PP and prevent them from pre-
better SPPB (intervention, +0.2; control, -0.45; h2p = 0.113) in addi- senting frailty in the future. Also, in our study, it was possible to
tion to an improvement in the tandem stand (intervention, +0.16; show the feasibility and safety of performing these exercises at home
control, -2.11; h2p=0.140). However, this study was divided into two for community-dwelling older adults with adequate online supervi-
intervention stages: weeks 1-8 and weeks 9-16 (home exercise pro- sion by specialized health professionals such as physical training spe-
gram).21 As a consequence of the COVID-19 pandemic, they could cialists, medical rehabilitators, geriatricians, and gerontological
only assess the participants at baseline and at week 16, so they could nutritionists.
not distinguish the effects of the two intervention stages. Among the Another strength of this study was the study design, which was a
advantages reported by most of the participants, there is that they randomized controlled clinical trial. On the other hand, despite the
discovered the benefits of online learning, including the ability to loss of participants in the follow-up stage, the sample remained ade-
exercise with other family members. It is recommended that in the quate (80% statistical power). Regarding adherence, participant losses
future the participants become familiar with the videos before start- were higher than expected (19.54%); however, it is known that when
ing the exercise program. an exercise program is home-based, adherence decreases. This was
Chaabene et al. (2021) showed through a meta-analysis the effec- evidenced by Sadjapong et al. (2020) with adherence of 57.5%. Other
tiveness of MPE with home-based training for improving PP in possible limitations were the absence of external motivational factors
healthy older adults. The results indicated small effects of home- to encourage participants to continue with the intervention, as well
based training on muscle strength, muscle power (SMD = 0.43), mus- as the COVID-19 pandemic factor, the limited access to technology,
cular endurance (SMD= 0.28), and balance (SMD = 0.28). The results and the failure of the internet connection during the exercise
of this study are similar concerning the size of the effect on PP after session.41
the intervention. It also agrees with the program of minimum dura- Another obstacle was that the evaluations were also carried out
tion (12 weeks) with a frequency of three times a week.21 online and the staff equipment was standardized for each of the tests.
Likewise, a study by Sadjapong et al. (2020) performed a random- This may represent a measurement bias, so it is suggested for the
ized controlled clinical trial, which included 64 older adults with future to compare the evaluation of the SPPB online test vs face-to-
frailty (77.78 § 7.4 years), who were divided into two parallel face in addition to working on the development of apps that assess
groups: an intervention group (n = 32) and a control group (n = 32). physical performance components at home with greater confidence.
The intervention group included a combined center- and home-based Currently, scientific evidence of telehealth interventions in Latin
multicomponent exercise training program consisting of aerobic, American and Mexican populations is limited. This study contributes
resistance, and balance exercises, which was carried out three days to documenting the feasibility of a multicomponent physical exercise
per week for 24 weeks. They found similar results in the effects of online intervention based on a home exercise program in commu-
physical performance (berg balance scale, TUG) and frailty scores nity-dwelling older adults and its effectiveness in improving physical
(p < 0.01), at both 12 and 24 weeks. This study also shows that since performance and functionality.
 D.L.V.-C. Edna Mayela et al. / Geriatric Nursing 54 (2023) 83 93 91

Table 5
Treatment fidelity strategies for the intervention.

Treatment Fidelity Goals Strategies Evidences

1. Design of Study
1.1 Comparable treatment:  Standardized Protocol:  Registered protocol
Ensuring accurate and uniform A detailed intervention protocol was established, outlining the interven-  Pilot study ‘results
treatment application across tion components and standardized methodology, including session fre-  Supervisor’s registration of all
subjects within specific treat- quency, duration, and intensity. providers-reported events
ment conditions.  Blinding and Bias Control: during sessions.
Participants were randomly assigned to each group, and the participants
were unaware of which group they belonged to.
 Pilot Testing:
A preliminary phase was initiated to assess the viability of the treatment
fidelity measures.
 Balanced allocation of participants:
Both groups had the same number of participants and duration. The con-
trol group received uniform information, while the intervention group
the same physical exercise methodology.
1.2 Plan for implementation set-  Potential intervention providers:
backs: A group of potential intervention providers received training and stan-
Mitigate potential dardization at the study’s outset to handle potential dropouts or over-
implementation load scenarios during the intervention.
2. Provider Training
2.1 Standardize training: Providers training:  Manual detailing the inter-
Ensure that training is con-  Intervention providers received a detailed manual and instructional vention methodology.
ducted similarly for different videos for guidance.  Videos available on a YouTube
providers.  The intervention team had multiple training workshops for protocol channel
adherence.  Document with the checklist
s
 Weekly collaboration meetings with project supervisor, principal inves- evaluation.
tigator, and medical consultant guided intervention development and  Recorded data in
decision-making. SurveyMonkey
2.2 Accommodate supplier dif-  Experience of the intervention team:  Recording
s training courses
ferences: Guaranteeing suffi- Experienced geriatrics and exercise experts were chosen for the interven-  Pilot study ‘results
cient training for diverse tion team and trained to standardize exercises for older adults.
provider skill levels and  Pilot Testing:
backgrounds To validate their skills, pilot tests were conducted.
 Guidance and Collaboration:
Weekly advisory sessions were conducted, with the project supervisor,
principal investigator and medical specialist’s advisers.
3. Treatment Delivery
3.1 Control for provider  Participant interviews: Database
interview responses.
differences: During the intervention, participants were interviewed regarding their
Monitor and manage nonspecific adherence:
treatment effects perceived by How many days per week did you perform your exercise routine?
participants. Each time you completed your exercise routine, what percentage of it did
you fulfill?
During or after your exercise routine, did you experience any injuries or
discomfort?
In cases where you did not follow the physical activator’s instructions,
what factors contributed to your decision not to do so?
 Monitoring and Feedback:  Document with the checklist
s
1.%2 Ensure adherence to Expert external observers evaluated treatment sessions randomly, provid- evaluation.
treatment protocol. ing unbiased assessments.
Providers self-supervised by recording session details like duration, symp-
toms, and internet issues.
3.3 Minimize contamination Distinct intervention teams were assigned to each group, ensuring that
between conditions different intervention methods did not cross-contaminate.
4. Receipt of Treatment
4.1 Ensure participant compre-  Participants training:  Manual
guidelines for
hension: In the initial week, participants received personalized training including participants.
To guarantee understanding of exercise session demonstrations, guidelines in a manual, and perfor-  Database
answers of the
intervention information. mance evaluations during sessions. interviews.
 Participants interviews:
Qualitative interviews were held with participants to assess their under-
standing and the barriers to attending live sessions.
 Data on the adherence of the participants were collected:  Database ‘adherence
1.%2 Control for provider Data on weekly session frequency, session duration, and telephone follow-
differences. ups were gathered from participants.
5. Treatment Skills
5.1 Ensure participant use of Participants received supportive materials (videos, messages) to aid inter-  Material, videos, and
cognitive and behavioral skills. vention implementation, with ongoing monitoring of their engagement messages
capabilities.
Notes. Framework for process evaluation strategies adapted from: Bellg et al. 2004.39
92 D.L.V.-C. Edna Mayela et al. / Geriatric Nursing 54 (2023) 83 93

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https://doi.org/10.1093/ageing/afac028. afac028.
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The authors declare that the research was conducted in the intervention in functionally impaired older people with type 2 diabetes
absence of any commercial or financial relationships that could be mellitus. J Cachexia Sarcopenia Muscle. 2019;10(4):721–733. https://doi.org/
construed as a potential conflict of interest. 10.1002/jcsm.12432.
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muscle endurance and balance of frail older adults: a meta-analysis of randomised
Funding Statement controlled trials. J Clin Nurs. 2023;32(9-10):1795–1805. https://doi.org/10.1111/
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Through the Health Department of the Iberoamerican University ticomponent training on physical performance in older adults: a systematic review
in Mexico City, this project was supported by a grant from the and meta-analysis. Arch Gerontol Geriatr. 2023;104: 104838. https://doi.org/
10.1016/j.archger.2022.104838.
Research Direction 14th Grant Funding for the Scientific Research
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