Study Design and Setting
This study was a 12-week randomized controlled trial conducted among community-dwelling older adults. This study aimed to determine the feasibility and acceptability of an education-exercise program called Permanento and to evaluate its effect on determinants of physical functioning components. The study was conducted between February and May 2023 in Prague, Czech Republic. The exercise intervention was delivered online via a platform developed specifically for this study. All participants were briefed and instructed on how to access the videos and follow the exercise sessions. Pretest and posttest data were collected in person at the Department of Physiotherapy, Faculty of Physical Education and Sport, Charles University. The research assistants who collected the data were blinded to the group assignments. Informal consent was granted by the Ethical Committee of the Faculty of Humanities, Charles University, and all participants provided written informed consent. The trial was retrospectively registered at ClinicalTrials.gov (NCT06133894) on November 14th 2023.
Participants and Recruitment
Statulator software (available at https://statulator.com/about.html) was used to estimate the sample size. The effect size was set at 0.20, and the α error was set at 0.05. A statistical power of 0.95 could be achieved with 72 subjects. To account for expected withdrawals during the trial, a total of 98 community-dwelling volunteers aged between 70 and 82 years were recruited. Information about the opportunity to participate in the study was disseminated through organizations providing activities for older adults in Prague from September to December 2022 (Život 90, Senior Fitness, Elpida, Právě teď, Inbaze, and Universities of the Third Age). All participants met the eligibility criteria, which included (1) being 70 years or older, (2) having online access and a device to play and follow exercise videos, (3) living independently at home, and (4) not having any chronic or acute health conditions that would prevent participation in very simple exercises. Screening was performed over a phone call with one of the research assistants during the application process. A total of 104 older adults were screened, resulting in six exclusions due to low age (1) or lack of online access (5), as shown in Fig. 1 (29). All eligible participants (N = 98) were invited to participate in pretests; however, only 84 successfully completed the baseline test. Nine of the invited participants withdrew due to illness or a change of mind, and five did not appear without notice. The 84 tested participants were randomized into equal intervention and control groups. Group randomization was performed electronically using Microsoft Excel by an independent person not involved in the study. However, three participants did not respect the results of the randomization and relocated themselves from the control group to the intervention group. The intervention group (n = 45) underwent the introductory and educational parts of the intervention and initiated the exercise plan. The control group (N = 37) continued with their everyday activities as usual for 12 weeks and was instructed not to start any new activities. After the research trial, all participants in the control group followed the same program, including both the educational and exercise components, to ensure that they received the same procedures and benefits as the intervention group.
Education and Exercise Intervention
The program consists of educational and exercise components to provide comprehensive information and trigger enthusiasm and intrinsic motivation to exercise. The educational section includes relevant topics necessary to understand the wider context of aging in the current world with the aim of (1) providing clear reasons for being physically active and (2) offering simple guidelines for maintaining functional fitness through minimalistic daily exercise. The goal is to change the traditional “I should exercise” mindset to “I want to exercise”. For the purposes of the study, this educational component was delivered to the intervention group during a 3-hour workshop, but the same information was available on the online platform in the first 10 chapters. Each chapter includes text, audio, and introductory videos, allowing participants to refresh their memory at any time during or after the trial.
The exercise component of the platform is divided into nine chapters, each containing one video routine ranging from 12 to 17 minutes. Each routine consists of a few welcoming words and explanations of the most important issues to be aware of during the exercise, such as correct positioning, various modifications of range of motion or intensity, and the importance of perceiving and listening to one's body during the exercise. Each exercise routine results in approximately 10 minutes of continuous physical activity. The program consists of nine simple exercise routines (1–9) that can be performed while sitting on a chair (#1, 2, 3), standing by a chair (#5, 6), or lying on a mat (#4) or bed (#7, 8, 9).
The exercises are inspired by developmental kinesiology and follow completely natural principles that are simple but effective, especially when applied daily. The main principles include activation of the diaphragm through breathing, activation of the vestibular apparatus through head movements, and contralateral movements (18). These principles are performed in a set of varying movements enriched by other gentle motions supporting proper posture and functional components necessary for the safe and confident performance of daily activities, such as strengthening phasic muscles, stretching postural muscles, and joint movements. All principles can be applied while sitting, standing, or lying down and are easy to perform, modify, and enjoy daily.
The exercise plan was to exercise at least six days a week. Participants had flexibility in selecting a routine according to their current state of mind, but they had to follow certain rules to avoid performing the same routine the entire week. The weekly routine selection rules included performing only one bed exercise (#7, 8, 9) and at least three different routines from #1 to #6. The time of day for daily exercise was unrestricted, and participants were free to exercise more than the minimum. Participants maintained a diary to log their daily exercise routines, mood before and after exercising, and any additional comments.
Adverse Events
An adverse event was defined as any event or occasion that prevented the participant from performing the day's exercise. Such events were expected given the length of the intervention and the time of year when minor health complications such as flu are common. Adverse events also included vacations or other commitments that prevented following the exercise plan, such as babysitting grandchildren. Successful completion of the program was considered when a participant completed at least 10 out of the 12 weeks of the intervention period.
Assessment
All assessments were performed at the Faculty of Physical Education and Sport, Charles University, Prague, Czech Republic. Physiotherapy students served as research assistants and collected all the data before and after the trial. All research assistants were blinded.
Actual and Perceived Physical Functioning:
The multidimensional timed up-and-go (TUG) test was used to measure mobility skills, combining gait speed, balance, and overall functional capacity (30). The single-leg stance test was used to assess static postural and balance control (31). Grip strength was measured using a hand-grip dynamometer (Takei TKK A5401 Digital Hand-Grip Dynamometer). Standardized protocols were followed to test grip strength separately for the right and left hands, with the elbow extended to 90 degrees and the humerus positioned beside the body (Fess & Moran, 1981). The subjects were instructed to push the dynamometer for two to three seconds at their maximum effort for each trial. Each hand was tested in three consecutive trials, with short rests in between trials, and the strongest recording was noted for both hands. The cut-off points by sex were < 30 kg for men and < 20 kg for women (32). Perceived physical functioning was assessed using a single item: “How is your functional status in general? Would you say your functional status is …”, with response categories on a 5-point Likert scale.
Acceptability of the Intervention
Acceptability was assessed using a custom-designed questionnaire completed by each participant postintervention to evaluate their perception of the program. Participants were asked to rate the clarity, meaningfulness, and manageability of the program on a 5-point Likert scale (from 1 being the most negative to 5 being the most positive). Participants were also asked if they would recommend the program to family or friends. The questionnaire included open-ended questions to provide more detailed feedback regarding likes and dislikes during the intervention period.
Perceived and Actual Sustainability of Home Exercising
The main mission of this program is to create a sustainable, long-term exercise routine that becomes a permanent and welcome part of older adults’ daily lives. Expected sustainability was assessed at the end of the intervention with a simple question: “Do you plan to continue daily exercise according to the program?” followed by the open-ended question “Why?”
Data Analysis
The data were analysed using SPSS for Windows, Version 24 (Armonk, NY, United States: IBM Corp.). The descriptive statistics for continuous data are presented as the means and standard deviations, and those for categorical data are presented as counts and percentages. The data regarding adherence, acceptance, and sustainability were descriptive in nature and were presented as counts and percentages for the intervention group and where possible for the complete sample. Within-group changes were considered explanatory; thus, sample t tests or chi-square tests, depending on the data type, were calculated. The effect size (Cohen's d) for within-group changes pre- and postintervention was calculated as the mean posttest score minus the mean pretest score divided by the pretest standard deviation. Effect sizes were categorized as follows: <0.2 trivial, 0.2 to < 0.5 small, 0.5 to 0.8 moderate, and ≥ 0.8 large (Cohen, 1988).