28 January 2025: Clinical Research
Effects of Remote Exercise on Physical Function in Pre-Frail Older Adults: A Randomized Controlled Trial
Kyeongjin Lee1ABCDEFG*DOI: 10.12659/MSM.947105
Med Sci Monit 2025; 31:e947105
Abstract
BACKGROUND: Remote exercise have emerged as a promising solution to overcome barriers to physical activity participation in pre-frail older adults, such as limited mobility and accessibility issues. Pre-frail older adults often face barriers to physical activity due to limited mobility and accessibility, underscoring the need for remote exercise alternatives. This study aimed to evaluate and compare the efficacy of remote versus in-person exercise in improving physical function in pre-frail older adults.
MATERIAL AND METHODS: Ninety pre-frail older adults aged 65 years and above were recruited, and randomly assigned to 3 groups: the remote exercise group (REG, n=30), the in-person exercise group (IPEG, n=30), and the control group (CG, n=30). The REG and IPEG groups underwent identical exercise, including balance, strength, and gait training, conducted twice weekly for 8 weeks. The REG received live, real-time instructions via video conferencing, while the IPEG participated in identical sessions conducted at a local facility. Outcome measures included assessments of balance, lower-limb strength, gait ability, and fall efficacy.
RESULTS: Both the REG and IPEG groups demonstrated significant improvements in balance, gait ability, lower-limb strength, and fall efficacy compared to the CG (P<0.05). No significant differences were found between the REG and IPEG groups across all outcome measures, indicating that remote exercise were as effective as in-person sessions.
CONCLUSIONS: Remote exercise effectively enhanced balance, strength, gait, and fall efficacy in pre-frail older adults, providing a viable alternative to traditional in-person programs and addressing healthcare disparities.
Keywords: Frail Elderly, Gait, postural balance, telerehabilitation
Introduction
With advances in global healthcare and rising life expectancy, the world is witnessing unprecedented growth in the elderly population. By 2050, approximately 22% of the global population is projected to be over 60 years old, according to the World Health Organization [1]. This demographic shift presents significant challenges to healthcare systems, social structures, and economies worldwide. A substantial portion of this population falls into the “pre-frail” category – a critical transitional phase characterized by a decline in physical function, increased vulnerability, and an elevated risk of progressing into frailty. Frailty is defined as a clinical syndrome involving decreased strength, endurance, and reduced physiological function, which makes individuals more susceptible to dependency and mortality [2,3]. Pre-frailty, in contrast, is an earlier stage in the frailty continuum, characterized by 1 or 2 indicators of physical decline, such as reduced grip strength, or slower gait speed, but not yet severe enough to be classified as frailty [2,4]. This stage offers a critical window for intervention, as it is often reversible with appropriate measures. Unlike frailty, which involves a more pronounced functional decline, pre-frailty is a reversible condition if addressed through timely interventions [5].
Pre-frail older adults commonly experience symptoms such as reduced grip strength, slower walking speed, low physical activity, and an increased risk of falls [6]. Pre-frail older adults are at a significantly higher risk of falling compared to their robust counterparts [7]. According to a meta-analysis, frail older adults have a higher risk of falls than robust individuals, followed by pre-frail older adults, who also demonstrated a notably elevated risk [8]. These findings indicate that the risk of falling increases with the degree of frailty, underscoring the importance of timely interventions. Importantly, their functional decline is not yet severe enough to be classified as frailty, creating a crucial window of opportunity for intervention. Effective preventive measures can halt or even reverse progression to frailty, making this population a key target for fall prevention programs [9]. Despite the potential benefits, the pre-frail stage has often been overlooked in research, with most studies focusing on either frail individuals or the general elderly population [10]. Despite its importance, few studies have specifically targeted interventions for pre-frail older adults, leaving a gap in evidence-based practices for this transitional stage. Early intervention for pre-frail older adults is crucial to maintaining functional independence, improving quality of life, and reducing healthcare costs related to falls and frailty progression.
Given the elevated risk of falls among pre-frail older adults, targeted interventions aimed at improving muscle strength, balance, and gait are essential [11]. Exercise interventions – including strength training, balance exercises, and flexibility routines – have been shown to effectively reduce fall risk in pre-frail populations [12]. These exercises address key factors contributing to falls, such as impaired postural stability and muscle weakness, and are crucial for maintaining independence and reducing fall-related risks [13]. Systematic reviews have also highlighted the psychosocial benefits of exercise, emphasizing its role in enhancing both physical function and psychological confidence [14, 15].
However, traditional in-person exercise programs present several barriers for pre-frail older adults, including difficulties in traveling long distances, limited access to facilities, reliance on public transportation, economic burdens, and lack of caregiver support [16]. These barriers underscore the need for more accessible intervention methods that can overcome logistical and physical challenges.
Remote exercise has emerged as a viable alternative, offering unique advantages in terms of accessibility and flexibility compared to traditional in-person exercise [17]. Remote exercise allows pre-frail older adults to participate in physical activity from home, addressing barriers such as limited mobility, lack of caregiver support, and pandemic-related concerns. This mode of exercise has the potential to enhance adherence and provide safer, more convenient access. These programs enable older adults to exercise in a safe, familiar environment, which is especially valuable given the challenges of physical travel and potential exposure to health risks. Interest in remote exercise solutions has increased substantially since the COVID-19 pandemic, as video conferencing platforms enable real-time interaction, individualized feedback, and posture correction, enhancing both the efficacy of and adherence to exercise programs [18,19].
Despite the growing evidence supporting the effectiveness of remote exercise programs in improving physical function among older adults, comparative studies evaluating their relative effectiveness against in-person programs remain limited [18–20]. Some studies have highlighted the accessibility benefits of remote programs but often lack rigorous experimental designs to directly compare outcomes such as balance, muscle strength, and walking ability between the 2 methods [18,19]. This underscores the need for further research to experimentally verify whether remote programs can match or surpass the effectiveness of in-person interventions while addressing these challenges.
In addition, while remote exercise has been shown to significantly improve physical function among older adults, technical difficulties remain a barrier to widespread success [18–20]. A previous study using a Facebook live-based remote exercise program as an intervention led to notable improvements in lower-limb strength and cardiorespiratory function [19]. However, participants encountered challenges such as unstable internet connections that disrupted exercise sessions, difficulties in managing equipment without direct supervision, and software-related errors that hindered full engagement. These barriers not only affected participant satisfaction but also reduced adherence, highlighting the need for better technical support and user-friendly solutions to maximize the benefits of remote exercise [19]. Similarly, a previous study on Zoom-based remote exercise reported that participants faced initial adaptation challenges due to unfamiliarity with the technology [18]. These findings underscore the necessity of improved technical accessibility and user education to ensure the success of remote exercise programs for older adults.
Despite the promising potential of remote exercise, there is still a lack of empirical studies specifically focusing on pre-frail older adults. While previous studies have focused primarily on either general elderly populations or frail individuals, this study specifically targeted pre-frail older adults to evaluate the unique benefits of remote exercise interventions in a high-risk group. This study aims to evaluate the effectiveness of remote exercise in improving physical function and reducing fall risk among pre-frail older adults at high risk of falls, and to determine whether remote exercise is as effective as in-person exercise for pre-frail older adults.
Material and Methods
STUDY PARTICIPANTS:
This study targeted pre-frail older adults aged 65 years and above residing in the Seoul and Gyeonggi regions of South Korea. Participants were recruited from a senior welfare center in Seoul through an open enrollment process. Recruitment was facilitated by posting recruitment materials on the welfare center’s bulletin board and conducting informational sessions to elucidate the study’s objectives and procedures.
Eligible participants included those who had fallen within the last 6 months or exhibited impaired gait and balance, with timed up and go test (TUG) scores ≥13.5 seconds and Berg balance scale (BBS) scores ≤45, indicating an elevated fall risk. Inclusion criteria further stipulated that participants possess a cognitive function score of 24 or higher on the mini-mental state examination, demonstrate the physical capacity to engage in a remote exercise (eg, ability to perform basic mobility tasks such as standing from a seated position and walking short distances), and provide informed consent voluntarily. Additionally, participants were classified as pre-frail based on Fried’s frailty criteria [2], meeting at least 2 out of 5 specified indicators.
Exclusion criteria encompassed individuals with neurological or musculoskeletal conditions that impeded their ability to engage in physical activity, those with a recent history (within 3 months) of severe cardiovascular disease, and individuals unable to commit to continuous participation throughout the study period.
All participants received comprehensive verbal and written explanations regarding the study’s objectives, procedures, risks, and potential benefits, provided by a trained researcher. Informed consent was obtained in writing from all participants, who were also informed of their right to withdraw from the study at any point. Confidentiality of all personal information was strictly maintained throughout the study. Ethical approval for this study was obtained from the Institutional Review Board (2024-05-014-001), and the study was conducted in accordance with the Declaration of Helsinki. Measures were taken to minimize any ethical concerns throughout the research process. Written informed consent was obtained from all participants before enrollment in the study. Participants were informed of their right to withdraw from the study at any time without consequence.
SAMPLE SIZE CALCULATION:
Sample size calculation was performed using G*Power software (version 3.1.9.7), chosen for its robustness in handling power analysis for various statistical tests and its relevance to the study design, with the following primary parameters. The significance level (α) was set at 0.05, allowing for a 5% risk of Type I error. The statistical power (1-β) was set at 0.80, ensuring an 80% probability of detecting a true effect if one exists. Based on Cohen’s criteria, the effect size was set to medium (η2=0.06).
A minimum of 26 participants per group was required to detect differences between groups. However, considering potential drop-outs during the intervention, an 15% larger sample was recruited, based on dropout rates reported in similar studies, resulting in a final target of 30 participants per group. This approach ensured sufficient statistical power to detect significant intervention effects while accounting for unforeseen participant attrition. Similar studies reported in the literature informed the sample size calculation, ensuring that the study retained adequate power to explore improvements in balance and gait function in each group.
STUDY PROCEDURES:
A total of 108 participants were initially recruited for the study, of which 14 were excluded for not meeting the eligibility criteria, resulting in 94 participants. The participants were randomly assigned into 3 groups using a computer-generated randomization process: remote exercise group (REG, n=33), an in-person exercise group (IPEG, n=30), and a control group (CG, n=31). Block randomization was implemented with a block size of 6 to ensure balanced allocation across groups. Randomization was conducted after baseline assessments were completed to avoid allocation bias and ensure that baseline characteristics did not influence group assignment.
Remote exercises were conducted via the Zoom video conferencing platform, with participants provided an initial tutorial on how to set up and use the platform. A technical support team was available before and during sessions to assist with troubleshooting and ensure smooth participation. The REG participated in exercise sessions conducted twice a week for 8 weeks through the video conferencing software, each session lasting 50 minutes. The remote exercises were supervised by a licensed physical therapist via the video conferencing application, with participants exercising at home under the supervision of caregivers and assistants. Attendance and engagement were tracked using digital attendance logs, supplemented by text messages and follow-up calls to maintain motivation. The IPEG exercised at the senior welfare center under the direct supervision of a physical therapist and assistants, with sessions conducted twice a week for 8 weeks, each lasting 50 minutes. The CG received an informational booklet on exercise and a single educational session, after which they self-reported their physical activity, which was periodically monitored by the research team. The CG were provided with general health education on fall prevention and physical activity but did not engage in structured exercise sessions.
The primary aim of the exercise was to improve balance and gait function to reduce the risk of falls. Baseline assessments were conducted to evaluate various physical and cognitive parameters. Balance was assessed using the TUG, BBS, and activities-specific balance confidence (ABC) scale. Lower-limb strength was measured using the 5 times sit-to-stand test (FTSTS) and the 30-second chair stand test (30SCS). Gait function was assessed through the dynamic gait index (DGI) and the 10-meter walk test (10MWT), while fall-related self-efficacy was measured using the modified falls efficacy scale (MFES).
After 8 weeks, all participants underwent post-intervention assessments using the same measures, conducted within 1 week following completion of the intervention period. Participants who discontinued due to health-related changes or participated in less than 80% of the intervention sessions were excluded from the final analysis. Data from participants excluded from post-analysis were reported through attrition analysis, detailing the reasons for and patterns of dropout. Ultimately, 30 participants from the REG, 30 from the IPEG, and 30 from the CG completed the study, and their pre- and post-intervention data were analyzed. To enhance the study’s reliability, assessors were blinded to group allocation during both pre- and post-intervention assessments (Figure 1).
INTERVENTION:
In this study, both the REG and IPEG followed an identical 8-week exercise program designed to enhance balance, gait function, and lower-limb strength, ultimately aimed at preventing falls. The identical program was chosen to ensure that any observed differences between groups could be attributed to the mode of delivery (remote vs in-person) rather than differences in the intervention content, thereby improving the comparability of results. The exercise was conducted twice weekly, with each session lasting 50 minutes, and the intensity was progressively increased throughout the program.
EXERCISE SETTING AND EQUIPMENT:
The IPEG and the REG conducted their exercise sessions simultaneously through a video conferencing application. The IPEG exercised at the senior welfare center, while the REG exercised at their respective homes. The program room at the senior welfare center was equipped with a camera (Logitech C920 HD Pro, Lausanne, Switzerland) to film the physical therapist, a computer for the video conferencing application (Zoom Video Conferencing Software, San Jose, CA, USA), and a large monitor (LG Electronics, Seoul, South Korea) to display the REG participants exercising from home. Each participant’s home was similarly set up to create an environment comparable to the senior welfare center, allowing them to follow along using a TV monitor.
REAL-TIME MONITORING: Real-time monitoring was ensured through high-quality video resolution, stable internet connection requirements, and ongoing communication to verify participants’ exercise performance. Any technical difficulties, such as internet instability or video quality issues, were addressed promptly by providing technical support or rescheduling sessions if necessary. The physical therapist monitored participants’ exercise postures and performance in real-time, providing individualized feedback. To ensure effective communication and safety, the sessions were divided into 3 smaller subgroups to allow for better supervision and minimize technical challenges, with each session consisting of 11 participants from the IPEG and 10 participants from the REG, totaling 21 participants per session (Figure 2).
EXERCISE PROGRAM:
Each session consisted of warm-up, main exercise, and cool-down phases, lasting 50 minutes. The warm-up phase lasted 10 minutes, the main exercise phase lasted 30 minutes, and the cool-down phase lasted 10 minutes. The warm-up phase was designed to gradually increase participants’ heart rate and relax muscles and joints in preparation for the main exercise. The main exercise focused on improving balance, enhancing lower-limb strength, and gait function, with intensity progressively increased according to each participant’s physical capacity. The cool-down phase included exercises to stabilize the heart rate and relax muscles.
Balance exercises included one-leg stands, lateral walking, and T-walking. Initially, participants used stable support, but as the weeks progressed, exercises were performed without support to increase intensity. Lower-limb strengthening exercises included chair sit-to-stand and squats, with repetitions and depth progressively increased each week to add difficulty. Gait improvement exercises consisted of marching in place, figure-eight walking, and brisk walking, with speed and duration progressively increased over the course of the intervention.
The eight-week program was designed to gradually increase in intensity and difficulty according to participants’ physical abilities and adaptation. The first 1 to 2 weeks focused on familiarizing participants with the exercises, including one-leg stands, chair sit-to-stand, and walking exercises. Intensity was adjusted by increasing the duration and repetitions of each exercise every week, with a particular focus on gradually reducing the use of support during balance exercise. In the REG, exercise outcomes were recorded each session through the video conferencing application, and participants received real-time feedback on their performance. Compliance was continuously monitored by tracking attendance at each session using digital attendance logs, and motivational feedback and encouragement messages were provided via text messages and follow-up calls to maintain engagement.
OUTCOME MEASURE:
Physical function was assessed through evaluations of balance, gait ability, and lower-limb strength, while fall efficacy was also measured to determine the participants’ confidence in their ability to avoid falling during daily activities.
BALANCE: Balance was measured using the TUG, BBS, and ABC. The TUG was used to assess balance [22]. Participants were instructed to stand up from a chair, walk 3 meters, turn around, walk back to the chair, and sit down. The TUG has been shown to have excellent reliability (intra-rater reliability ICC=0.98, inter-rater reliability ICC=0.99) and good validity for assessing functional mobility in older adults [23,24]. The total time taken to complete the task was measured using a stopwatch. A shorter time indicates better balance and functional mobility. The BBS was used to assess participants’ static and dynamic balance abilities [25]. This 14-item scale was used to assess participants’ static and dynamic balance abilities. The BBS is a reliable tool for assessing balance, with high intra-rater (ICC=0.97) and inter-rater reliability (ICC=0.98) and strong validity for predicting fall risk in older adults [26]. Each item was scored on a 5-point scale (0–4), where 0 indicates ‘unable’ and 4 indicates ‘independent,’ with a maximum possible score of 56. Higher scores indicate better balance. The ABC was used to measure participants’ confidence in maintaining balance during daily activities [27]. Participants rated their confidence in maintaining balance during 16 daily activities. The ABC has demonstrated excellent test-retest reliability (ICC=0.92) and good construct validity for measuring balance confidence in community-dwelling older adults (eg, walking around the house, reaching for objects, standing on tiptoe) on a scale from 0% (no confidence) to 100% (completely confident) [23,28]. Higher scores reflect greater balance confidence.
LOWER-LIMB STRENGTH: Lower-limb strength was assessed using the FTSTS and the 30SCS. The FTSTS was used to assess lower-limb strength. Participants were asked to rise from a chair and sit down 5 times as quickly as possible without using their hands. The FTSTS has high reliability (ICC=0.95) and good validity as a measure of lower-limb strength and functional mobility in older adults [29,30]. This test measures functional lower-limb strength related to daily activities. The total time taken was recorded using a stopwatch. Shorter times indicate better lower-limb strength. The 30SCS was used to measure lower-limb strength. Participants performed as many sit-to-stand repetitions as possible in 30 seconds without using their arms for support. The 30SCS has demonstrated good reliability (inter-rater reliability ICC=0.92, intra-rater reliability ICC=0.95) and validity in assessing lower-limb strength related to functional tasks in older adults [31,32]. The total number of repetitions was recorded. Higher numbers indicate better lower-limb strength.
GAIT ABILITY: Gait ability was assessed using the DGI and 10MWT. The DGI was used to evaluate gait ability. This 8-item scale was used to evaluate participants’ ability to modify their gait under varying demands. The DGI has good reliability (intra-rater reliability ICC=0.90, inter-rater reliability ICC=0.92) and validity for assessing dynamic balance and gait performance, particularly in older adults [33]. Each item was scored on a scale of 0–3, with a maximum score of 24. Higher scores reflect better dynamic balance and gait stability. The 10MWT was used to assess gait ability. Participants walked 10 meters at a comfortable but brisk pace to ensure consistency in gait speed measurement. The 10MWT has excellent reliability (ICC=0.98) and is a valid measure for assessing gait speed, which is a key indicator of functional mobility [34]. The time taken to complete the distance was recorded using a stopwatch, and gait speed (m/s) was calculated. Faster speeds indicate better gait ability.
FALL EFFICACY: The MFES was used to assess fall efficacy. This scale was used to assess participants’ confidence in performing 14 daily activities without falling. The MFES has strong test-retest reliability (ICC=0.92–0.98) and good validity for evaluating fall-related self-efficacy in older adults [35]. Each item was rated on a 10-point Likert scale (1=no confidence to 10=complete confidence). Higher scores indicate greater confidence in avoiding falls.
STATISTICAL ANALYSIS:
Descriptive statistics, including means and standard deviations, were calculated for all outcome variables at baseline and after the intervention for each group. The Shapiro-Wilk test was used to check the normal distribution of the data, and the normality assumption was satisfied. To verify homogeneity between groups, one-way ANOVA was used for all continuous variables to assess variance consistency, and the chi-square test was used to compare gender to ensure categorical balance. A paired
Results
Table 1 summarizes the baseline characteristics of the study participants. The groups were homogeneous with no significant differences in demographic and baseline characteristics across the 3 groups.
Table 2 presents the changes in balance ability, lower-limb strength, gait ability, and fall efficacy before and after the intervention. For balance ability, significant improvements were observed across all 3 groups for the TUG following the intervention (
For lower-limb strength, significant improvements were observed in both the FTSTS and 30SCS tests for REG and IPEG following the intervention (
For gait ability, significant improvements were exhibited in all 3 groups for the DGI following the intervention (
For fall efficacy, significant improvements were observed in REG and IPEG following the intervention (
Discussion
This study evaluated the effectiveness of both remote and in-person exercise in improving physical functions among pre-frail older adults at high risk of falls. Given the rapid growth of the elderly population and the associated increase in pre-frailty, it is crucial to develop effective and accessible strategies to enhance physical function and reduce fall risk [11,12]. Our findings demonstrated that both remote and in-person exercise significantly improved balance, gait ability, lower-limb strength, and fall efficacy compared to the CG. These results have important implications for designing effective fall prevention programs for pre-frail older adults, especially in terms of expanding accessibility to those unable to participate in traditional, in-person settings.
Significant improvements in balance were observed in both the REG and the IPEG, as assessed by the TUG, BBS, and ABC Scale. The absence of significant differences between REG and IPEG suggests that remote delivery is as effective as in-person supervision for these types of exercises, indicating that remote programs can be a feasible alternative without compromising efficacy. These findings are consistent with previous research that emphasizes the efficacy of exercise – both remote and in-person – in improving balance in pre-frail older adults [18,36,37]. Yi D and Yim J [18] reported significant improvements in TUG among older adults following a remote, home-based fall prevention program during the COVID-19 pandemic, highlighting the value of remote interventions in maintaining physical function under restricted conditions. Similarly, Hong J, et al [36] found that telepresence-based exercise programs effectively improved BBS scores, reinforcing the effectiveness of remotely supervised interventions in enhancing postural stability and balance control. The comparable improvements seen in both intervention groups in our study suggest that remote exercise can serve as an effective alternative to traditional, in-person programs for improving balance among pre-frail populations.
The significant reduction in TUG times observed in both intervention groups aligns with the findings of Ferreira CB, et al [37], who reported marked improvements in functional mobility among frail older adults following a structured exercise program. Importantly, our study also showed significant improvements in BBS and ABC scores for both REG and IPEG, while the CG exhibited no significant changes. These results indicate that both intervention methods are effective in enhancing balance and confidence, which are crucial factors for fall prevention in pre-frail populations. Including both remote and in-person interventions, along with a CG, allowed comprehensive comparisons of different exercise modalities. The finding that remote interventions are comparable to in-person programs underscores the potential scalability and accessibility of remote exercise solutions, particularly for individuals with limited mobility or those in rural areas with reduced access to health facilities.
The ABC scale assesses an individual’s confidence in performing daily activities without losing balance [27]. In this study, both the REG and the IPEG demonstrated significant improvements in ABC scores, reflecting increased confidence in performing activities of daily living. Enhanced balance confidence is critical for fall prevention, as it helps reduce the fear of falling – a major barrier that often limits physical activity and contributes to further functional decline. Our findings are consistent with previous studies that emphasize the importance of improving balance confidence to promote greater activity levels and maintain independence in older adults [38].
Both the DGI and the 10MWT demonstrated significant improvements in both REG and IPEG, indicating enhanced gait ability. These findings are consistent with those reported by Yi D and Yim J [18], who found that remote exercise programs with virtual supervision significantly improved gait speed and dynamic balance in older adults. The improvements in gait ability observed in the present study underscore the importance of targeted gait training as a core component of interventions aimed at reducing fall risk in pre-frail older adults. Additionally, the findings of Chittrakul J, et al [39] corroborate our results, as their study of a multi-system physical exercise program incorporating balance, proprioception, and strength training led to significant enhancements in gait stability and reduced fall risk. The present study found significant improvements in both DGI and 10MWT for REG and IPEG, while no significant changes were seen in the CG, demonstrating the potential of remote exercise as a viable alternative to face-to-face training. This is particularly important for addressing access barriers faced by older adults, such as transportation limitations and geographical isolation, thereby contributing to more equitable healthcare.
Lower-limb strength, assessed via the FTSTS and the 30SCS, significantly improved in both REG and IPEG. These results are consistent with previous findings, including those by Yi D and Yim J [18], who showed that remote resistance training effectively increased lower-limb strength among pre-frail older adults. Furthermore, Belleville S, et al [12] demonstrated that progressive resistance training was associated with significant improvements in FTSTS performance, underscoring the role of enhanced lower-limb strength in maintaining functional independence and mitigating fall risk in older adults. The inclusion of both remote and in-person exercise modalities in the present study provided an opportunity to rigorously evaluate the efficacy of different exercise delivery methods. The results suggest that remote exercise can be just as effective as in-person programs in increasing muscle strength, with significant implications for expanding the reach of strength-building interventions to individuals who face barriers to accessing facility-based programs, particularly those with mobility issues or residing in remote areas.
Fall efficacy, measured using the MFES, also showed significant improvements in both REG and IPEG. These findings align with those of Hsieh TJ, et al [40], who reported that individualized home-based exercise and nutrition interventions led to significant gains in fall efficacy and reduced fear of falling among older adults. Chittrakul J, et al [39] similarly found that multi-component exercise programs resulted in enhanced fall efficacy, an important factor in encouraging continued participation in physical activity and reducing the psychological burden of fall risk in pre-frail older adults. Enhanced fall efficacy leads to increased confidence in performing daily activities and may facilitate greater overall engagement in physical exercise, contributing to improved quality of life and independence.
The success of the REG in achieving significant improvements across all outcome measures highlights the well-designed and carefully supervised nature of the intervention. Participants in the REG exercised at home under real-time supervision from a licensed physical therapist via video conferencing software, ensuring both safety and effective execution of the exercises. Caregivers and assistants provided additional support, which enhanced participant engagement and safety during each session. This level of oversight allowed REG participants to receive personalized feedback comparable to in-person training, which is critical for maximizing exercise effectiveness and minimizing the risk of injury.
One of the key features that contributed to the success of the REG intervention was the simultaneous exercise sessions for REG and IPEG participants, which promoted uniformity in exercise delivery. The structured use of technology, including high-quality video streaming and a large monitor display, facilitated clear communication between participants and therapists, creating an experience that closely mimicked in-person group exercises. Moreover, the inclusion of smaller subgroup sessions, each comprising around 10 to 11 participants, allowed for focused supervision, reducing the likelihood of technical issues, and enabling tailored guidance for individual participants.
The progressive nature of the exercise program, with intensity and difficulty increasing over time according to participants’ physical capabilities, was instrumental in ensuring sustained improvements in physical function. REG participants adapted well to the technological aspects of the intervention, as evidenced by their high adherence rates, demonstrating both the feasibility and acceptability of remote exercise among pre-frail older adults. This finding shows that well-implemented remote exercise programs can overcome typical barriers to participation, such as transportation limitations, while providing an effective means to enhance physical and psychological health. In the REG, participants engaged in supervised exercise sessions via video conferencing, allowing them to participate from the safety and comfort of their homes. This method provides greater flexibility and accessibility, especially for individuals who face barriers to attending in-person sessions, such as limited mobility, transportation issues, or caregiving constraints. On the other hand, the IPEG involved direct, face-to-face supervision by a licensed physical therapist at a senior welfare center. This modality offers more immediate, hands-on feedback and allows therapists to adjust exercises in real-time to ensure proper technique and safety. Additionally, the in-person approach provides participants with social interaction, which can be an important factor in motivation and adherence to exercise programs. Despite these differences, the present study found that both remote and in-person exercise interventions were effective in improving physical function and fall efficacy. These results suggest that remote exercise can serve as a feasible and effective alternative to traditional in-person interventions, offering flexibility without compromising the quality of care.
However, several limitations should be acknowledged. Firstly, some participants in the REG experienced technical difficulties, such as internet connectivity issues and unfamiliarity with video conferencing software. These challenges were mitigated through technical support and ongoing assistance from caregivers and research staff. Secondly, the intervention duration was relatively short (8 weeks), which may limit the generalizability of long-term effects. Future research should include extended follow-up periods to evaluate the sustainability of the improvements observed in this study.
Conclusions
This study provides strong evidence that both remote and in-person exercises are effective in improving physical function and fall efficacy in pre-frail older adults. These findings demonstrate that remote exercise can be a viable alternative to traditional in-person methods, especially for individuals facing barriers to accessing facility-based programs. Remote physical therapy increases accessibility for individuals with mobility issues, those in rural areas, and those with limited caregiver support. Future research should focus on the long-term sustainability of these improvements and strategies to enhance adherence to remote exercise to maximize its public health benefits.
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