Abstract

Objective

To investigate the acceptability and adequacy of a multicomponent exercise program via videoconferencing for the oldest-old in Porto Alegre, a city in southern Brazil.

Method

This is a quasi-experimental study. Fourteen participants were enrolled in the multicomponent exercise program Vivifrail® for 12 weeks, 5 days a week, with weekly video calls for assessment of acceptability and adequacy. The acceptability and adequacy questionnaire was based on 6 barriers that older adults face when engaging in physical exercise. Responses were measured using a 5-point Likert scale ranging from 0 to 4 points, with a maximum score of 24 points (maximum acceptability).

Results

Fourteen participants (89.07±6.30 years) concluded the protocol, with an acceptability rate of 70%. Internal consistency was moderate, with a Cronbach’s coefficient alpha of 0.7. Participants showed an overall increase in acceptability and adequacy (from 17.8±3.51 points in the first week to 22.0±2.94 in the 12th week). Four participants (28.6%) required some modification to the exercise protocol.

Conclusion

The Vivifrail® protocol, together with weekly follow-up via videoconferencing, was well accepted and adequate. It could be an important tool for promoting quality of life, especially in the oldest-old with difficulty leaving home. The acceptability questionnaire was able to detect exercise barriers and suggest possible modifications to the training program and could be presented as a suggestion for the evaluation of intervention protocols in the oldest-old population. Therefore, the Vivifrail® protocol, with weekly follow-up via videoconferencing, could be a new field of intervention for health professionals.

Keywords
Public Health; Aged; 80 and over; Exercise; Longevity; Covid-19

Resumo

Objetivo

Investigar a aceitação e adequação de um programa de exercícios multicomponentes por videoconferência para longevos em Porto Alegre (RS), Brasil.

Método

Estudo Quase experimental. Os participantes realizaram o protocolo de exercícios multicomponentes ViviFrail® durante 12 semanas, com a aceitação e adequação avaliadas semanalmente por videoconferência. O questionário de aceitação e adequação foi baseado em uma escala Likert (de 0 a 4) de seis barreiras que os participantes enfrentam ao fazer exercício físico, com pontuação máxima de 24 pontos (aceitação máxima).

Resultados

A aceitação foi de 70%, com 14 participantes concluindo o protocolo (89,07±6,30 anos). A consistência interna, (alfa de Cronbach) para o questionário, foi de 70%, considerada moderada. Os participantes mostraram um aumento geral na aceitação dos 17,8±3,51 pontos iniciais, para 22,0±2,94 pontos no final. Quatro (28.6%) necessitaram de adequação no protocolo de exercício.

Conclusão

O programa de exercícios multicomponente ViviFrail®, com acompanhamento através de videoconferência, foi bem aceito e adequado, podendo ser uma importante ferramenta para a promoção da qualidade de vida, principalmente em longevos com dificuldade de sair de casa, tanto por problemas de mobilidade, quanto por ambientes sociais desfavoráveis (violência urbana e situações sanitárias). O questionário de aceitação e adequação, que necessitou ser criado, foi capaz de detectar barreiras do

Palavras-Chave:
Saúde Pública; Idosos de 80 anos ou mais; Exercício Físico; Longevidade; Covid-19

INTRODUCTION

Aging is a natural, slow, and gradual process that induces biological changes throughout the body, manifested by a progressive reduction in functional capacity, which is particularly evident in the oldest-old¹1 World Health Organization. World report on ageing and health. WHO; 2015.,²2 Mello AC, Engstrom EM, Alves LC. Health-related and socio-demographic factors associated with frailty in the elderly: a systematic literature review. Cad Saude Publica 2014;30(6):1143–68. Disponível em: https://doi: 10.1590/0102-311x00148213.. Physical inactivity, combined with chronic conditions prevalent in this age group, can lead to a higher risk of adverse health outcomes. Studies show that inactive older adults have an increased risk of falls (39%), mortality (31%), loss of independence (50%), frailty (48%), hospitalization (15%), and institutionalization (21%) compared with physically active counterparts³3 Lins MM, Marques APO, Leal MCC Barros RL. Risco de fragilidade em idosos comunitários assistidos na atenção básica de saúde e fatores associados. Saúde Debate 2019; 43(121): 520-529. Disponível em: https://doi.org/10.1590/0103-1104201912118
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4 Bielemann RM, Silva BGC, Collic VN, Xavier MO, Silva SG. Impacto da inatividade física e custos de hospitalização por doenças crônicas. Rev Saúde Pública 2015;49(75):1-8. Disponível em: https://doi.org/10.1590/S0034-8910.2015049005650.
https://doi.org/10.1590/S0034-8910.20150... -⁵5 Unningham C, O' Sullivan R, Caserotti P, Tully MA. Consequences of physical inactivity in older adults: A systematic review of reviews and meta-analyses. Scand J Med Sci Sports. 2020 May;30(5):816-827. Disponível em: https://doi: 10.1111/sms.13616. Epub 2020 Feb 4. PMID: 32020713..Annually, physical inactivity is estimated to incur $53 million in public health expenses globally⁶6 Ding D, Lawson KD, Kolbe-Alexander TL, Finkelstein EA, Katzmarzyk PT, Mechelen WV. The economic burden of physical inactivity: a global analysis of major non-communicable diseases. Lancet 2016;388(10051):1311-1324. Disponível em: https://doi.org/10.1016/S0140-6736(16)30383-X
https://doi.org/10.1016/S0140-6736(... .

Physical exercise is crucial for the promotion of a healthy phenotype in older adults, and its main benefits include the improvement of functional capacity and the preservation of autonomy and independence for longer⁷7 World Health Organization. WHO Clinical Consortium on Healthy Ageing 2019. WHO; 2019.. Benefits have been reported for different exercise modalities, such as resistance training, aerobic training, pilates, among others⁸8 Ferraz SP, Batista MSS. A relevância de programas de exercícios resistidos no tratamento e prevenção da sarcopenia em idosos: uma revisão integrativa. Resar, Society and Develop 2021;10(15):1-10. Disponível em: http://dx.doi.org/10.33448/rsd-v10i15.23362
https://doi.org/10.33448/rsd-v10i15.2336...

9 Hou N, Sun X. Effect of aerobic exercise on neuromuscular quality in the elderly. Rev Bras Med Esporte 2022;28(5). Disponível em: http://dx.doi.org/10.33448/rsd-v10i15.23362
https://doi.org/10.33448/rsd-v10i15.2336... -¹⁰10 Carvalho CBO, Dias ALM, Caldas LRR, Carneiro-Júnior MA. O método Pilates e sua influência na capacidade funcional do idoso: uma revisão sistemática. Revista Kairós-Gerontologia 2017;20(3):223–235. Disponível em: https://doi.org/10.23925/2176-901X.2017v20i3p223-235
https://doi.org/10.23925/2176-901X.2017v... . However, choosing the right type of exercise is extremely important.

According to the World Health Organization (WHO) ¹¹11 World Health Organization. Recomendações globais sobre atividade física para a saúde. Genebra: WHO; 2010. Disponível em: http://apps.who.int/iris/bitstream/10665/44399/1/978924
http://apps.who.int/iris/bitstream/10665... , for older individuals to obtain significant gains, they should adhere to exercise programs that promote the development of physical fitness components such as aerobic capacity, muscular endurance, balance, and flexibility, that is, multicomponent training. However, physical exercise interventions in the oldest-old have not been reported as frequently as in the youngest-old¹²12 Krug RR, Lopes MA, Mazo GZ. Barreiras e facilitadores para a prática da atividade física de longevas inativas fisicamente. Revista Brasileira de Medicina do Esporte 2015;21(1):57–64. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1517-86922015000100057&lng=pt&tlng=pt. Likewise, little is known about the acceptability and adequacy of a multicomponent physical exercise program for the oldest-old. Biehl-Printes et al.¹³13 Biehl-Printes C, Brauner FDO, Rocha JDP, Oliveira G, Neris J, Rauber B, et al. Prática de exercício físico ou esporte dos idosos jovens e longevos e o conhecimento dos mesmos em programas públicos: Pesquisa Nacional de Saúde 2013. PAJAR 2017;4(2):47. Disponível em: http://revistaseletronicas.pucrs.br/ojs/index.php/pajar/article/view/25276 reported that lack of interest was the main reason for the oldest-old not participating in physical exercise programs. Krug Lopes & Mazo¹²12 Krug RR, Lopes MA, Mazo GZ. Barreiras e facilitadores para a prática da atividade física de longevas inativas fisicamente. Revista Brasileira de Medicina do Esporte 2015;21(1):57–64. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1517-86922015000100057&lng=pt&tlng=pt also mentioned reasons such as physical limitations, poor disposition, excessive care from family members, and inadequate exercises (insufficient or very intense).

Promoting healthy practices and behaviors among older individuals is crucial, especially during periods such as the Covid-19 pandemic, in which containment strategies such as the lockdown negatively impacted the health of the population¹⁴14- López-Sánchez GF, López-Bueno R, Gil-Salmerón A, Zauder R, Skalska M, Jastrzębska J, et al. Comparison of physical activity levels in Spanish adults with chronic conditions before and during COVID-19 quarantine. Eur J Public Health 2020;31(1):161-166. Disponível em: https://academic.oup.com/eurpub/advance-article/doi/10.1093/eurpub/ckaa159/5882018. On the other hand, the lockdown made older adults more familiar with technologies such as videoconferecing¹⁵15 Rocha MS, Longo PL, Montiel JM. Utilização de smartphones por idosos durante o distanciamento físico causado pelo covid-19. Tecnologias em projeção 2021;12(1):9–17.. Therefore, home-based exercise programs via videoconferencing can be an alternative to improve or maintain functional capacity in this population¹⁴14- López-Sánchez GF, López-Bueno R, Gil-Salmerón A, Zauder R, Skalska M, Jastrzębska J, et al. Comparison of physical activity levels in Spanish adults with chronic conditions before and during COVID-19 quarantine. Eur J Public Health 2020;31(1):161-166. Disponível em: https://academic.oup.com/eurpub/advance-article/doi/10.1093/eurpub/ckaa159/5882018, and may also be well received in periods other than the pandemic, as home exercises had already been proven to benefit older adults long before Covid-19¹⁶16 Chaabene H, Prieske O, Herz M, Moran J, Höhne J, Kliegl R, et al. Home-based exercise programmes improve physical fitness of healthy older adults: A PRISMA-compliant systematic review and meta-analysis with relevance for COVID-19. Ageing Research Reviews. 2021;67:101265. Disponível em: http:// doi: 10.1016/j.arr.2021.101265.,¹⁷17 Liu-Ambrose T, Davis JC, Best JR, Dian L, Madden K, Cook W, Hsu CL, Khan KM. Effect of a Home-Based Exercise Program on Subsequent Falls Among Community-Dwelling High-Risk Older Adults After a Fall: A Randomized Clinical Trial. JAMA. 2019;321(21):2092-2100. Disponível em: 10.1001/jama.2019.5795. Erratum in: JAMA. 2019 Jul 9;322(2):174. PMID: 31162569; PMCID: PMC6549299..

In this context, Vivifrail® was developed as a multicomponent home exercise program to improve the functional capacity of older adults¹⁸18 Izquierdo M, Casas-Herrero A, Zambom-Ferraresi F, Martínez-Velilla N, Alonso-Bouzón C, Rodríguez-Mañas L. ViviFrail - A Practical Guide for Prescribing a Multi-Component Physical Training Program to prevent weakness and falls in People over. ResearchGate. 2016 [Posted in Dez. 2016; Acesso em: 20 ago. 2020 ]. 70 p. 66.. The program proposes different exercise protocols based on the participant’s functional capacity, ranging from frail to robust states. However, to date, no study has investigated the acceptability and adequacy of this type of intervention in the oldest-old. Therefore, this study aims to investigate the acceptability and adequacy of a home-based multicomponent exercise program via videoconferencing among the oldest-old in Porto Alegre, a city in southern Brazil.

METHODS

This is a quasi-experimental study with a repeated measures design, involving weekly monitoring of exercise acceptability. Participants were recruited from follow-up studies of nonagenarians previously enrolled in home-based research and healthy volunteers who signed up for projects at the Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS). Participants were selected by convenience sampling through telephone calls in which the researcher explained the study to the participant, who agreed to participate or not.

The study was approved by the institutional Research Ethics Committee (number 21628419.9.0000.5336) and was conducted in accordance with the Declaration of Helsinki¹⁹19 World Medical Association. Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects. WMA; 2018. Disponível em: https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/
https://www.wma.net/policies-post/wma-de... .

The inclusion criteria were patients aged ≥ 80 years previously enrolled in PUCRS projects. The exclusion criteria were not having a smartphone for videoconferencing, not having a companion available during the evaluation and practice of the proposed exercises, and inability to respond to verbal commands, in addition to the exclusion criteria defined by the Vivifrail® protocol¹⁸18 Izquierdo M, Casas-Herrero A, Zambom-Ferraresi F, Martínez-Velilla N, Alonso-Bouzón C, Rodríguez-Mañas L. ViviFrail - A Practical Guide for Prescribing a Multi-Component Physical Training Program to prevent weakness and falls in People over. ResearchGate. 2016 [Posted in Dez. 2016; Acesso em: 20 ago. 2020 ]. 70 p. 66..

Initially, the study was presented to potential participants or their caregivers by phone, and a video call was schedule for the initial evaluation. The lead researcher emphasized the importance of a caregiver or family member being present during the assessment and explained about the Informed Consent Form (ICF), which was sent by mail for signature.

After the participant signed the ICF, the trained researcher conducted the physical assessment and administered the comprehensive questionnaire on sociodemographic and clinical conditions at the initial, intermediate (6 weeks), and final (12 weeks) assessments via videoconferencing. The instrument on sociodemographic and clinical conditions collected information on the presence of symptoms and illnesses related to exclusion criteria or that could interfere with the acceptance of exercise practices (joint pains, depression, or dizziness). It also inquired about physical exercise routines, falls, ease or difficulty in performing functional activities, cognition, and memory (Geriatric Depression Scale and Mini-Mental State Examination). Physical evaluation was conducted according to Vivifrail® recommendations to determine the best exercise passport based on the participant’s functional capacity and risk of falls¹⁸18 Izquierdo M, Casas-Herrero A, Zambom-Ferraresi F, Martínez-Velilla N, Alonso-Bouzón C, Rodríguez-Mañas L. ViviFrail - A Practical Guide for Prescribing a Multi-Component Physical Training Program to prevent weakness and falls in People over. ResearchGate. 2016 [Posted in Dez. 2016; Acesso em: 20 ago. 2020 ]. 70 p. 66.. Functional capacity was assessed using the Short Physical Performance Battery (SPPB) and the risk of falls was assessed using a 4-step protocol. The assessment was described in full by Izquierdo et al.¹⁸18 Izquierdo M, Casas-Herrero A, Zambom-Ferraresi F, Martínez-Velilla N, Alonso-Bouzón C, Rodríguez-Mañas L. ViviFrail - A Practical Guide for Prescribing a Multi-Component Physical Training Program to prevent weakness and falls in People over. ResearchGate. 2016 [Posted in Dez. 2016; Acesso em: 20 ago. 2020 ]. 70 p. 66.

Chart 1 shows the best exercise passport according to the functional assessment score (SPPB).

The exercise program took place from October to December 2020, 5 times a week, totaling 60 sessions over 12 weeks. Each participant received an exercise passport (protocol manual) by mail and performed the exercises at home with the presence of an adult caregiver. The researcher contacted the participants weekly via videoconferencing to monitor the exercises, clarify any potential questions or issues, and evaluate acceptability of exercises, as described below.

Each passport contains movement illustrations with descriptions of initial position, performance, final position, risks, and contraindications. All passports should be executed in a daily routine lasting 30 to 45 minutes, from Monday to Friday, over 12 weeks. In addition, each passport includes an activity diary for participants to track their progress. During “circuit” sessions, participants should perform all circuit exercises, and during “walking” sessions, participants should only walk. Patients considered at risk of falls received a passport marked with a plus (+) sign (B+ and C+). The exercise passports were published by Izquierdo et al.²⁰20 Izquierdo M, Casas-Herrero A, Martinez-Velilla N, Alonso-Bouzn C,Rodriguez-Manas L. Un ejemplo de cooperación para la implementación de programas relacionados con el desarrollo de ejercicio en ancianos frágiles: programa europeo Erasmus + «Vivifrail». Rev Esp Geriatr Gerontol 2017;52(2):110–1. Disponível em: https://www.elsevier.es/en-revista-revista-espanola-geriatria-gerontologia-124-articulo-un-ejemplo-cooperacion-implementacion-programas-S0211139X1630004X. and are available at: https://vivifrail.com.

The main outcomes measured were the acceptability and adequacy of the exercise program over 12 weeks. As there were no instruments available that could adequately assess patient progress in the setting of our study, we constructed a questionnaire to understand the difficulties and acceptability of the exercises by the participants. The questionnaire was not validated. Questions were based on the 6 barriers that older adults face when trying to engage in physical activity described by González et al.²¹21 González V, Lorig K, Holman H, Sobel D, Laurent D, Minor M. Assumindo o Controle de sua Saúde: autocuidado de doenças cardíacas, artrose, diabetes, depressão, asma, bronquite, enfisema e outras condições físicas e mentais. 4°. Porto Alegre: ediPUCRS; 2017. Cap 7. Exercício para flexibilidade, força e equilíbrio: facilitando a vida ;p.412 . The questionnaire was administered weekly by the researcher via videoconferencing over the 12 weeks of the exercise protocol, and responses were measured using a 5-point Likert scale.

Participants were asked about (1) the importance they attributed to engaging in physical exercise (none/very little [0 points] to extremely important [4 points]), (2) their acceptability and satisfaction of the exercises (none/very little [0 points] to very high [4 points]), (3) the discomfort they felt during the exercises (none/very little [4]; mild [3]; indifferent/moderate [2]; very bad [1]; severe [0]), (4) how challenging it was to perform the exercises (none/very little [4]; little [3]; indifferent/moderate [2]; very challenging [1]; extremely challenging [0]), (5) exercise duration (very little/none [0]; little [2]; indifferent/sufficient [4]; a lot/extremely high [2]; too much [0]), and (6) whether the exercises could assist in activities of daily living (very little/insignificant [0 points] to extremely important [4 points]). Participants had to justify all their answers, allowing the researcher to understand the difficulties and discomforts they experienced and, when necessary, adapt some exercises according to individual needs and limitations.

The score ranges from 0 to 24 points, with higher scores indicating greater acceptability. Internal consistency assessment was performed using Cronbach’s alpha, which estimates the reliability of a questionnaire constructed for research projects²²22 Rego Monteiro H, Monteiro GTR, Arica J. Confiabilidade em Questionários para Qualidade: Um Estudo com o Coeficiente Alfa de Cronbach. Produto & Produção 2010;11(2):85–103. Disponível em: https://seer.ufrgs.br/index.php/ProdutoProducao/article/viewFile/9321/8252]. Freitas and Rodrigues²³23 Freitas ALP, Rodrigues SG. A avaliação da confiabilidade de questionários: uma análise utilizando o coeficiente alfa de Cronbach. ResearchGate. 2005 [Posted in 2005; Access at 20 ago. 2020 ]. 16 p. 1-12. Disponível em: https://www.researchgate.net/publication/236036099_A_avaliacao_da_confiabilidade_de_questionarios_uma_analise_utilizando_o_coeficiente_alfa_de_Cronbach. suggest using the following ranges to rate reliability according to Cronbach’s alpha: (A) a £ 0.30 – Very low; (B) 0,30 < a £ 0.60 – Low; (C) 0.60 < a  0.75 – Moderate; (D) 0.75 < a £ 0.90 – High; and (E) a > 0.90 – Very high.

At the end of each session, an acceptability score was calculated for each participant. Pearson’s linear correlation was used to assess the correlation between the degree of acceptability in each assessment and the follow-up time. A p-value <0.05 was considered statistically significant.

DATA AVAILABILITY

The dataset supporting the results of this study is available upon request to the corresponding author Ana Paula Tiecker (ana.tiecker96@edu.pucrs.br).

RESULTS

Of 20 participants initially evaluated, 14 (70%), with a mean age of 89,07±6,30 years completed the study. Reasons for dropping out included osteoarticular disease in 2 (33%) and a lack of will to continue in 4 (67%). Five (83%) of those who dropped out were women and 1 (17%) was a man, with a mean age of 93.8±3.96 years. Figure 1 shows a progressive increase in exercise acceptability over the 12-week period. Pearson’s linear correlation showed, with a 95% correlation, a 0.323-point increase in acceptability per week. At the end of the 12-week period, participants had an increase of 4.2 points (from 17.8±3.51 to 22±2.94), with a statically significant correlation (p <0.001 and a sample power >0.99). Statistical power was calculated using the G*Power software, assuming an alpha of 0.001, a sample size of 14, and an effect size of 50 (the maximum allowed by the program).

Figure 1
Exercise acceptability over the 12-week intervention period, Porto Alegre/RS, 2021.

Acceptability was not improved in only 2 participants due to pain or lack of commitment. Four (28.6%) required some exercise modifications, including a participant suffering from pain and discomfort due to osteoarticular disease that required an almost complete passport change. Another participant required temporary modifications because of knee inflammation, with interruption of 2 exercises: sitting and standing, and climbing and descending stairs. Two participants needed to increase rest intervals during walking because of extreme fatigue.

Internal consistency analysis of the acceptability questionnaire yielded a consistency of 66% when including all questions. After removal of question 4, as all participants responded that exercise duration was adequate over the 12-week period, internal consistency increased to 70%. Both consistency levels are considered moderate.

Acceptability of the exercises proposed by Vivifrail® was improved in most participants, as shown in Figure 1. In the subjective assessment, participants were asked about the reasons behind their responses. The most representative responses are shown in Table 2.

Regarding the importance of performing the proposed exercises, 12 (85%) participants found it important or extremely important because exercise makes them more energetic, helps reduce pain, can help in the performance of daily activities, and because the body needs to stay healthy. Their perception did not change over the 12-week intervention period. The other 2 (15%) changed their perception from not important to little important and from not important to very important.

When asked about satisfaction with the proposed exercises, 13 (93%) participants were satisfied from the first week. Only 1 (7%) participant responded “indifferent” because they had difficulty performing the exercises. As the weeks passed, the satisfaction of the 13 participants further improved, while the other participant remained dissatisfied during the follow-up weeks because they only liked to walk and were more involved in a hobby (fixing furniture). After some adjustments, the participant became more motivated but remained dissatisfied. At the end of the 12-week period, participants, in general, were very satisfied with the exercises.

Regarding discomfort, 10 (71%) participants felt some discomfort in the first week, including fatigue and pain during or after exercise. At the beginning of the program, 2 participants felt pain during a specific upper limb stretch, and another developed knee pain. After some adjustments (interruption or reduction of exercises that could aggravate symptoms), pain reduced and acceptability increased in these patients. After 6 weeks, 6 (42%) participants still experienced fatigue, and pain was reduced in those who reported it at the beginning of the study. Only 1 participant started experiencing pain during the follow-up weeks as a result of osteoarticular disease, which was aggravated by the exercises. The rest of the participants no longer experienced any discomfort. At the end of the 12-week program, 2 (14%) participants continued to experience some discomfort: one due to fatigue from walking, which had significantly decreased since the beginning of the program, and the other due to pain from osteoarticular disease.

Seven (50%) participants found it very or extremely difficult to perform the proposed exercises in the first week, mainly due to the time they had been without exercising. The exercise that participants found most challenging was walking within the time proposed by the passport, and some experienced difficulty even after implementation of rest intervals. Upper limb stretching was also challenging for 2 participants. The difficulty decreased with exercise adjustments, longer rest intervals, and replacement of the stretching exercise. With each passing week, participants experienced less difficulty and improved physical condition. Ten (71%) participants reported feeling very little or little difficulty at the end of the 12 weeks.

Regarding duration, all participants found it adequate since the first week. Ten (71%) participants reported that exercise could help in daily activities. As the weeks passed, not only participants but also caregivers and family members reported physical improvements and greater ease for participants in performing their daily activities.

DISCUSSION

The main study findings demonstrate that a 12-week home-based multicomponent exercise program, supported by weekly follow=up via videoconferencing, was well-received by participants. Acceptability progressively increased over the 12-week period, with subjective reports of improvement by the participants. Weekly follow-up with application of the acceptability questionnaire via videoconferencing revealed a good acceptability rate of the exercises proposed by Vivifrail®. Moreover, the program proved to be adequate for this population of older individuals, especially during the Covid-19 pandemic, as it offered support during this challenging time.

Acceptability is crucial for treatment adherence and outcomes²⁴24 Costa MES, Braga LC, Cardoso LR, Mokfa GV, Santos FR dos. Principais fatores assinalados por pacientes hipertensos para não adesão ao tratamento e controle da pressão arterial. SciGen 2022;3(1):206-14. Disponível em: http://scientiageneralis.com.br/index.php/SG/article/view/390, particularly among the oldest-old, who are less inclined to engage in physical activity¹³13 Biehl-Printes C, Brauner FDO, Rocha JDP, Oliveira G, Neris J, Rauber B, et al. Prática de exercício físico ou esporte dos idosos jovens e longevos e o conhecimento dos mesmos em programas públicos: Pesquisa Nacional de Saúde 2013. PAJAR 2017;4(2):47. Disponível em: http://revistaseletronicas.pucrs.br/ojs/index.php/pajar/article/view/25276,²⁵25 Lopes MA, Krug RDR, Bonetti A, Mazo GZ. Barreiras que influenciaram a não adoção de atividade física por longevas. Revista Brasileira de Ciências do Esporte. 2016;38(1):76–83.. Lopes et al.²⁵25 Lopes MA, Krug RDR, Bonetti A, Mazo GZ. Barreiras que influenciaram a não adoção de atividade física por longevas. Revista Brasileira de Ciências do Esporte. 2016;38(1):76–83. showed that the place where physical activity is performed has a significant impact on acceptability by the oldest-old. Appropriate places facilitate engagement for both active and inactive older individuals, especially if closer to home, as they (especially women) find it more difficult to leave their homes²⁵25 Lopes MA, Krug RDR, Bonetti A, Mazo GZ. Barreiras que influenciaram a não adoção de atividade física por longevas. Revista Brasileira de Ciências do Esporte. 2016;38(1):76–83.,²⁶26 Wilcox S, Tudor-Locke CE, Ainsworth B. Physical activity patterns, assessment, and motivation in older adults. Physical Activity and Aging ResearchGate. 2001 [Posted in ago 2001; Access at 20 ago. 2020 ]. 13-39 Disponível em: https://asu.pure.elsevier.com/en/publications/physical-activity-patterns-assessment-and-motivation-in-older-adu. Additionally, participants were in lockdown due to the Covid-19 pandemic, consequently leading to a reduction in physical exercise despite health authorities’ encouragement¹⁴14- López-Sánchez GF, López-Bueno R, Gil-Salmerón A, Zauder R, Skalska M, Jastrzębska J, et al. Comparison of physical activity levels in Spanish adults with chronic conditions before and during COVID-19 quarantine. Eur J Public Health 2020;31(1):161-166. Disponível em: https://academic.oup.com/eurpub/advance-article/doi/10.1093/eurpub/ckaa159/5882018,²⁷27 Schuch FB, Bulzing RA, Meyer J, López-Sánchez GF, Grabovac I, Willeit P, et al. Moderate to vigorous physical activity and sedentary behavior change in self-isolating adults during the COVID-19 pandemic in Brazil: A cross-sectional survey exploring correlates. medRxiv 2020;1–21. Disponível em: https://doi.org/10.1101/2020.07.15.20154559
https://doi.org/10.1101/2020.07.15.20154... . Thus, home-based activities might be better suited for these individuals.

Other factors affecting acceptability are the belief that an intervention will be effective (ie, outcome expectation) and adherence to the intervention (ie, efficacy expectation) ²⁵25 Lopes MA, Krug RDR, Bonetti A, Mazo GZ. Barreiras que influenciaram a não adoção de atividade física por longevas. Revista Brasileira de Ciências do Esporte. 2016;38(1):76–83.,²⁸28 Flegal KE, Kishiyama S, Zajdel D, Haas M, Oken BS. Adherence to yoga and exercise interventions in a 6-month clinical trial. BMC Complement Altern Med 2007;9(7):37. Disponível em: https://doi.org/10.1186/1472-6882-7-37.
https://doi.org/10.1186/1472-6882-7-37... . By conducting weekly follow-up via videoconferencing, we allowed participants to self-evaluate and report difficulties and improvements, which in turn allowed us to better adapt the exercises when necessary, contributing to a better acceptability rate. The literature has also shown that, before initiating an exercise program, it is important that participants receive a detailed verbal and written description of the program that informs the frequency, intensity, duration, modality, load, and progression of the exercise²⁹29 Rivera-Torres S, Fahey TD, Rivera MA. Adherence to Exercise Programs in Older Adults: Informative Report. Gerontol Geriatr Med 2019;5:233372141882360. Disponível em: https://doi.org/10.1177/2333721418823604
https://doi.org/10.1177/2333721418823604... . A clear description of the program promotes motivation and adherence among participants, as was observed in this study. To the best of our knowledge, data on acceptability of exercise protocols among the oldest-old are scarce, making this the first study to evaluate such outcomes in this population.

Participants’ acceptability of the exercise program is crucial for achieving successful outcomes. Recent studies have suggested strategies to minimize the effects of social isolation in older people, considering the significant repercussions of physical inactivity in this population¹⁵15 Rocha MS, Longo PL, Montiel JM. Utilização de smartphones por idosos durante o distanciamento físico causado pelo covid-19. Tecnologias em projeção 2021;12(1):9–17.,³⁰30 Machado CLF, Pinto RS, Brusco CM, Cadore EL, Radaelli R. COVID-19 pandemic is an urgent time for older people to practice resistance exercise at home. Exp Gerontol. 2020;141:111101. Disponível em: https://doi/10.1016/j.exger.2020.111101.. Chaabene et al.¹⁶16 Chaabene H, Prieske O, Herz M, Moran J, Höhne J, Kliegl R, et al. Home-based exercise programmes improve physical fitness of healthy older adults: A PRISMA-compliant systematic review and meta-analysis with relevance for COVID-19. Ageing Research Reviews. 2021;67:101265. Disponível em: http:// doi: 10.1016/j.arr.2021.101265. conducted a meta-analysis to evaluate the effects of online home-based exercise programs on the physical fitness of healthy older people. They showed that home exercises can improve physical fitness and functional health aspects such as strength, muscular endurance, and balance. In Brazil, one of the few studies using an online intervention during the pandemic reported the experience of only one participant, an older adult. The online experience was positive both in terms of organization and execution, and the patient positively adhered to the program³¹31 Paulino AC, Vendruscolo R. Vó, sai do celular! Um relato da proposta de aulas remotas de educação física idosos durante a pandemia. Cadernos de Formação RBCE. 2021;12(1):102–17. Disponível em: https://doi/10.1016/j.exger.2020.111101. Therefore, physical exercise programs via videoconferencing, when well accepted by the participants, are an important alternative to reduce the effects of a sedentary lifestyle.

Given the paucity of studies investigating the acceptability of home-based physical exercise protocols, we sought to support our findings with different studies evaluating acceptability. Bower et al.³²32 Bower KJ, Louie J, Landesrocha Y et al. Clinical feasibility of interactive motion-controlled games for stroke rehabilitation. J NeuroEngineering Rehabil 2015;12 (63). Disponível em: https://doi.org/10.1186/s12984-015-0057-x
https://doi.org/10.1186/s12984-015-0057-... evaluated, among other outcomes, the acceptability of an exercise program based on interactive gaming technology. As in this study, the authors observed a good acceptability rate among most participants (92.5%), as well as increasing acceptability as modifications were made to the interactive games. This suggests that acceptability involves various aspects of human behavior and is directly linked to adherence and continued engagement in physical exercise programs. Bacha et al.³³33 Bacha JMR, Gomes GCV, de Freitas TB, Viveiro LAP, da Silva KG, Bueno GC, et al. Effects of Kinect Adventures Games Versus Conventional Physical Therapy on Postural Control in Elderly People: A Randomized Controlled Trial. Games Health 2018;7(1):24-36. Disponível em: https://doi:/10.1089/g4h.2017.0065. evaluated postural control in older patients using Kinect Adventures versus conventional physical therapy in a controlled randomized study, assessing treatment acceptability and adherence. In terms of acceptability, both groups were satisfied with the interventions, with a 91% adherence rate. This highlights that acceptability improves engagement in proposed activities.

In our study, multicomponent exercises were successfully administered via videoconferencing without in-person monitoring. The recent literature shows that exercises performed at home with minimal supervision produce significant health benefits for older patients³²32 Bower KJ, Louie J, Landesrocha Y et al. Clinical feasibility of interactive motion-controlled games for stroke rehabilitation. J NeuroEngineering Rehabil 2015;12 (63). Disponível em: https://doi.org/10.1186/s12984-015-0057-x
https://doi.org/10.1186/s12984-015-0057-... . A recent meta-analysis by Kis et al.³⁴34 Kis O, Buch A, Stern N, Moran DS. Minimally supervised home-based resistance training and muscle function in older adults: A meta-analysis. Arch Gerontol Geriatr. 2019 Sep 1;84:103909. showed that minimally supervised home-based physical training is a safe, effective, and cost-efficient option to increase lower body muscle strength in older individuals with different health conditions.

This study has some limitations. The small sample size, lack of randomization, absence of a control group, and mandatory smartphone use might limit the generalization of results with higher evidence levels. However, mandatory smartphone use was not a major restriction on participation in this study. Another limitation is the lack of a validated acceptability questionnaire, and the fact that the proposed questionnaire had a moderate internal consistency. In addition, the results may have been influenced by the fact that the researcher who applied the acceptability questionnaire was the same person who guided the proposed intervention. The research setting, in which participants had a prior and trusting relationship with the researcher, and the fact that they were contacted and monitored during a period of psychological vulnerability, may have favored the positive results.

Nevertheless, a trust-based relationship should exist between patients and all health care professionals, and we believe a similar environment could be reproduced in other health care settings. It is important to note that, to the best of our knowledge, this is the first Brazilian study to assess the acceptability of the multimodal exercise protocol Vivifrail® during lockdown via videoconferencing. Although the lack of in-person meetings with participants presented many challenges, we were able to overcome them. From a practical perspective, our findings suggest good acceptability and adequacy of a low-cost, easy-to-follow, and monitorable exercise intervention aiming to improve functional capacity in the oldest-old, particularly during lockdown.

Home-based programs like Vivifrail® seem to be a useful strategy to promote physical activity among older individuals, particularly the oldest-old, reducing adverse effects associated with sedentary behavior in this population.

CONCLUSION

In this study, a multicomponent and individualized home training program, with weekly monitoring via videoconferencing for 12 weeks, was well accepted and adequate for a population of oldest-old individuals during lockdown in Porto Alegre, Brazil. The acceptability questionnaire was effective in detecting barriers to exercises and suggesting possible modifications to the training program; less than a third of participants required adjustments to the initially proposed program. The questionnaire constructed for this study can be used to evaluate the acceptability of exercise programs by oldest-old individuals. However, it still requires validation in future studies.

This study was able to overcome challenges not presented in other studies, transforming an unusual situation (lockdown due to Covid-19) into a potential new field of intervention for health professionals. In fact, some study researchers, after observing the acceptability of the program, started to apply Vivifrail® to their patients during online care. Considering that the multicomponent exercise program can be performed efficiently via videoconferencing, future intervention projects with an adequate sample size and control group, using the same methodology, may provide the benefits suggested in this study.

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