# Exercise as it relates to Disease/Impact of an exercise intervention on wellbeing in older adults

This is a critique of the research article "Physical exercise impact on variables related to emotional and functional well-being in older adults", completed by Belmonte Darraz S, González-Roldán AM, de María Arrebola J and Montoro-Aguilar CI, and published in Revista Espanola de Geriatria y Gerontologia (Spanish Journal of Geriatrics and Gerontology), March 2021.

## What is the background to this research?

This paper observes the impact of a European Union funded exercise intervention, the Erasmus 'Vivifrail' project on selected functional health markers of a cohort of (n)49 >60 yr old individuals from the Balearic Islands, Spain. The 'Vivifrail' project provides a framework on the promotion and prescription of strength, balance and gait exercise to older adults, to improve independence and quality of life.
There is increased global political awareness of the looming costs and strain on medical systems of an ageing population. Subsequently, there is a need to identify the efficacy of large scale interventions to inform future development and identify best practices.

## Where is the research from?

The ‘Vivifrail’ program is currently being promoted in Germany, Spain, France, Italy and the United Kingdom. The research, on individuals from the Balearic Islands, Spain, was performed in partnership with the University of the Balearic Islands, University of Jaén and Majorca city council Department of health on a cohort of Balearic Island residents.
The authors have no prior experience in exercise intervention research or assessment of large scale government initiatives.
There is no presented conflict of interest or bias. But it is of note, that an employee of the city council reviewing a government-backed initiative, does open up the possibility for inherent bias.

## What kind of research was this?

The study is a Cross-Sectional variation of an observational design study. With participants recruited or excluded based on selection criteria, all participants were exposed to the same fundamental exercise intervention and the researchers analysing the outcome of the intervention.
Cross-Sectional studies are considered the weakest observational design, as they only capture data on a single cohort, with no control, for a given window of time. Due to this, they cannot provide a strong causal relationship between the intervention and the outcome.

## What did the research involve?

The study observed residents from the Autonomous Community of the Balearic Islands, Spain, who volunteered to participate.
A final cohort of (n)49 participants (1 male, 48 female) over 60 years old met the inclusion criteria$^{[Table1]}$.
Pre-screening, baseline measures$^{[Table2]}$ and an informed consent were administered to selected participants.
The cohort underwent a 12-week exercise intervention, consisting of 2x 60 min exercises sessions per week delivered by a qualified physiotherapist.
The 'Vivifrail' program consists of three phases, with each variable of the fundamental session plan tailored to the identified functional capacity and falls risk of the participant (Type A-D).
* Warm-Up phase (~20 min): Focusing on mobilisation and light cardiovascular work.
* Strengthening phase. (20 min): Initially for 20 min, increased progressively as the participant adapts.
* Relaxation phase (10 min): Focusing on addressing flexibility and balance.
After completion of 12 weeks (24 sessions), the baseline tests$^{[Table2]}$ were repeated and statistical analysis performed.
Table 1: Inclusion Criteria :
| Inclusion criteria | Method |
| Age | Participants over 60 years old. |
| Medical approval | Written approval from the participants doctor. |
| No absolute contraindications. | Participants presented with no absolute contraindications to exercise: Cognitive impairment. Cardiovascular conditions: Severe heart disease, congestive heart failure, unstable angina, recent myocardial infarction, pulmonary embolism, uncontrolled cardiac arrhythmias, acute infectious disease, uncontrolled hypertension (> 180 /> 110 mmHg), myocarditis, pericarditis, active or recent endocarditis, aortic dissection, malignant ventricular arrhythmias (ventricular tachycardia, ventricular multifocal activity, etc.). Uncontrolled diabetes. |
| Physically capable. | Participants identified with limited function were excluded. Reason sited: recent surgical operation (<12 weeks prior), infection or pathology that severely limited function. |
| ≥80% participation. | Participants are retrospectively excluded if they participate in less than 80% of the scheduled exercise sessions. |
| Pre / post-intervention data collection. | Participants are retrospectively excluded if they failed to provide all key information at both pre and post data collection. |
Table 2: Baseline/Post-Intervention Measures :
| Test | Method |
| Blood pressure | Digital blood pressure monitor (Omron). The study followed the provided guidelines for blood pressure collection. |
| Abdominal girth | Measurement (cm) around the circumference of the waist. |
| Glucose levels | Digital blood glucose monitor (Abbott Diabetes Care Ltd). The study followed the provided guidelines for glucose collection. |
| Pressure Pain Threshold (PPT) | A digital algometer (Wagner Instruments) was used to monitor applied pressure (N) at the 'slightest perception of pain' to the upper trapezius and tip of the index finger. |
| Short Physical Performance Battery (SPPB) | Physical tests Balance test. 10s in each pose: Feet together side by side. The heel of 1 foot against the big toe of the other foot. Feet aligned heel to toe. Gait speed test. Timed 4m walk. Chair stand test. Timed 5 reps standing out of a chair without the use of arms. |
| Falls Risk Test | Physical tests and review of medical history. History of recent falls. ≥2 falls in the last year or 1 fall requiring medical attention. Timed Up and Go. Timed walking speed test (6 m). Previously diagnosed with cognitive deterioration. |
| Frail Questionnaire | A questionnaire covering 5 elements related to frailty (fatigability, endurance, mobility, comorbidity and weight loss). |
| Oviedo Sleep Quality Questionnaire (OQSQ) | A questionnaire related to sleep satisfaction to identify insomnia or hypersomnia. |
| GENCAT Quality Of Life Questionnaire | A questionnaire covering 8 elements related to the quality of life (self-determination, emotional well-being, personal development, rights, and interpersonal relationships, including social, material well-being and physical well-being). |
| Barthel Index (BI) | A questionnaire covering 10 elements related to functional independence (eating, bathing, dressing, grooming, stool, urination, toilet, transfer chair/bed, mobility and going up/downstairs.) |

## What were the basic results?

The study reported significant (p <0.05) differences in:
* Diastolic blood pressure.
* Frail test.
* Gait speed.
* PPT.
* BI.
* 6 of 8 GENCAT elements.
* OQSQ hypersomnia and quality of sleep.
No significant differences were reported in:
* Systolic blood pressure.
* Blood glucose level.
* Abdominal circumference.
* 2 of 8 GENCAT elements.
* No differences were reported in insomnia.
The researchers interpret the results as "a significant improvement after the intervention ... in emotional well-being, personal development, physical well-being, self-determination, rights and social inclusion. No differences were observed regarding the interpersonal relationships and material well-being."
Given the Cross-Sectional design of the study, and lack of a control group, additional research is warranted before stating outright that the exercise intervention is the sole cause for the outcome.

## What conclusions can we take from this research?

The methodology selected is relatively an inexpensive and efficient method of assessing the selected cohort, but relies heavily on self-assessment tools, which impacts the validity of the results due to the known limitations of self-reported data. But with the lack of a control group, the potential for pre-existing bias and the potential for unrecorded variables influencing the final result, there's an inability to derive a causal relationship between the intervention and the outcome.
There is recent research on higher-risk segments of the older population such as post-14-week COVID-19 lockdown, and post hospitalisation, that all cite the VIvifrail program as safe and produces some positive outcomes.

## Practical advice

The 'Vivifrail' program provides a simple, low barrier to entry system for safely implementing functional exercise to an older population of varied risk (Type A-D), once approved by their doctor. The program combines strengthen exercises, balance and gait training effectively to improve markers of independence and reduce the risk of falls. It also provides a framework for the delivery of exercise, monitoring and progression within this population.
It's worthwhile to consider, that consultation with a doctor before commencing the 'Vivifrail' program is essential to minimise risks.

## Further information/resources

Link: Sample Vivifrail exercise program
Provided resources based on identified functional level and falls risk:
* Link: Type A "People with disabilities".
* Link: Type B "People with fragility".
* LInk: Type B + "People with fragility and risk of falls".
* Link: Type C "People with pre-frailty".
* Link: Type C + "People with pre-fragility and risk of falls".
* Link: Type D "Robust people".
Link: Erasmus Vivifrail project.
Link: World report on ageing and health (Summary), (Full Text)

## References

* ↑ González-Roldán AM, de María Arrebola J, Montoro-Aguilar CI. Physical exercise impact on variables related to emotional and functional well-being in older adults. Revista Espanola de Geriatria y Gerontologia. 2021 Mar 25.
* ↑ Instituto de Investigación en Ciencias de la Salud (IUNICS) e Instituto de Investigación en Salud de las Islas Baleares (IdISBa), Universidad de las Islas Baleares (UIB), Palma, España; Área de Sanidad del Ayuntamiento de Palma de Mallorca, Palma, España.
* ↑ Instituto de Investigación en Ciencias de la Salud (IUNICS) e Instituto de Investigación en Salud de las Islas Baleares (IdISBa), Universidad de las Islas Baleares (UIB), Palma, España.
* ↑ Área de Sanidad del Ayuntamiento de Palma de Mallorca, Palma, España.
* ↑ Departamento de Psicología, Universidad de Jaén, Jaén, España.
* 1 2 Izquierdo M. Multicomponent physical exercise program: Vivifrail. Nutricion hospitalaria. 2019 Jul 1;36(Spec No2):50-6.
* ↑ World Health Organization. World report on ageing and health. World Health Organization; 2015 Oct 22.
* ↑ Remón ÁL, Díaz-Benito VJ, Beatty JE, Lozano JA. Levels of Physical Activity Among Older Adults in the European Union. Journal of Aging and Physical Activity. 2020 Oct 7;29(2):242-9.
* ↑ Setia MS. Methodology series module 3: Cross-sectional studies. Indian journal of dermatology. 2016 May;61(3):261.
* ↑ Munnangi S, Boktor SW. Epidemiology of study design.
* ↑ O’Brien E, Atkins N, Stergiou G, Karpettas N, Parati G, Asmar R, et al. European Society of Hypertension International Protocol revision for the validation of blood pressure measuring devices in adults. Blood Press Monit. 2010;15:23–38.
* ↑ Schrock LE. Miscoding and other user errors: importance of ongoing education for proper blood glucose monitoring procedures. Journal of diabetes science and technology. 2008 Jul;2(4):563-7.
* ↑ Melia M, Schmidt M, Geissler B, König J, Krahn U, Ottersbach HJ, Letzel S, Muttray A. Measuring mechanical pain: the refinement and standardization of pressure pain threshold measurements. Behavior research methods. 2015 Mar;47(1):216-27.
* ↑ Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG, Scherr PA, Wallace RB. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. Journal of gerontology. 1994 Mar 1;49(2):M85-94.
* ↑ Gleason LJ, Benton EA, Alvarez-Nebreda ML, Weaver MJ, Harris MB, Javedan H. FRAIL questionnaire screening tool and short-term outcomes in geriatric fracture patients. Journal of the American Medical Directors Association. 2017 Dec 1;18(12):1082-6.
* ↑ Bobes J, García-Portilla González MP, Saiz Martínez PA, Bascarán Fernández MT, Iglesias Álvarez C, Fernández Domínguez JM. Propiedades psicométricas del cuestionario Oviedo de sueño. Psicothema, 12 (1). 2000.
* ↑ Verdugo MÁ, Gómez LE, Arias B, Schalock RL. The Integral quality of life scale: development, validation, and use. InEnhancing the quality of life of people with intellectual disabilities 2010 (pp. 47-60). Springer, Dordrecht.
* ↑ Mahoney FI. Functional evaluation: the Barthel index. Maryland state medical journal. 1965 Feb;14(2):61-5.
* ↑ Rabbitt P, Abson V. ‘Lost and Found’: Some logical and methodological limitations of self‐report questionnaires as tools to study cognitive ageing. British Journal of Psychology. 1990 Feb;81(1):1-6.
* ↑ Sallis JF, Saelens BE. Assessment of physical activity by self-report: status, limitations, and future directions. Research quarterly for exercise and sport. 2000 Jun 1;71(sup2):1-4.
* ↑ Courel-Ibáñez J, Pallarés JG, García-Conesa S, Buendía-Romero Á, Martínez-Cava A, Izquierdo M. Supervised exercise (Vivifrail) protects institutionalized older adults against severe functional decline after 14 weeks of COVID confinement. Journal of the American Medical Directors Association. 2021 Jan;22(1):217.
* ↑ Martínez-Velilla N, Valenzuela PL, Zambom-Ferraresi F, de Asteasu ML, Ramírez-Vélez R, García-Hermoso A, Lucia A, Izquierdo M. Tailored exercise is safe and beneficial for acutely hospitalised older adults with COPD. European Respiratory Journal. 2020 Dec 1;56(6).
* ↑ Martínez-Velilla N, Sáez de Asteasu ML, Ramírez-Vélez R, Zambom-Ferraresi F, García-Hermoso A, Izquierdo M. Recovery of the Decline in Activities of Daily Living After Hospitalization Through an Individualized Exercise Program: Secondary Analysis of a Randomized Clinical Trial. The Journals of Gerontology: Series A. 2021 Feb 1.
* ↑ Martínez Velilla N, Valenzuela Ruiz PL, Sáez de Asteasu ML, Zambom Ferraresi F, Ramírez Vélez R, García Hermoso A, Librero López J, Gorricho J, Lucía Mulas A, Izquierdo Gabarren M. Effects of a tailored exercise intervention in acutely hospitalized diabetic oldest old adults: An ancillary analysis.