Discussion
In this study, it was observed that sedentary elderly people who perform a regular physical exercise program at home show a significant improvement in functional mobility and quality of life, which corroborates our hypothesis. The natural aging process causes morphological and functional deteriorations that progressively compromise the functional mobility and QOL of the elderly1,5,6, but these physiological changes can be minimized by regular physical exercise.5,6,25-28 In this study, the elderly was submitted to a semi-supervised exercise program performed at home. Every two weeks of training, home visits were carried out by the researchers with the purpose of controlling activities, general assessments, checking the occurrence of possible injuries related to training, increasing the load, and adhering to the protocol. A considerable average was observed in the practice of the exercises (± 0.6 days per week) and a reduced loss of follow-up (4.5%). The results are consistent with previous researches that have demonstrated the efficacy of physical exercise programs in functional mobility10,25-28 and in the QOL of the elderly.5,11,12,28 Most of these studies have analyzed the effect of supervised exercise programs performed at training and / or rehabilitation centers, others have conducted a comparative analysis of the benefits of supervised versus unsupervised exercise and they have observed trends indicating supervised exercise is most effective;29-31 however, recent studies have shown the elderly have a preference for home-based programs,10,32,33 providing more satisfaction and as a consequence, greater adherence and continuity after the end of the program which may have a positive impact on the results in the medium and long term.11,25,34 Whereas, the knowledge regarding the effects of home exercises on the elderly is still incipient.
The subjects who performed the home exercise program in our study during the period of 12 consecutive weeks showed a significant improvement in the primary endpoint, functional mobility, constituting an important evolution of the functional capacity, being consistent with previous studies10,11,13,25 which, through similar methodologies, obtained equivalent results. In the study conducted by Nelson et al.10, 72 elderly (mean age of 77.8 ± 5.3) were randomly assigned to a group that performed physical exercise at home or to a control group with nutritional education at home.
The exercise group performed the program for 6 months where each participant received a booklet with exercises guidelines, adjustable weight anklets, training at the beginning of the program on proper exercise performance and periodic follow-up visits. They concluded that minimally supervised home-based exercises can be safe and improve the functional performance of the elderly, like the results found in this study. In a similar research to our study, Youssef and Shanb (2016)35 evaluated the effects of supervised exercise programs versus home exercises on muscle strength, balance, and functional activities in the elderly.
The authors involved 40 elderly people divided into a group that practiced the supervised exercise program and another that practiced at home. The subjects performed an exercise program of 35 to 45 minutes twice a week for four months consisting of muscle strength training, coordination and functional and balance training. At the end of the study, the authors concluded that the two training modalities improve balance performance. It was also observed that the supervised program showed superior results in relation to functional activities and isometric muscle strength.
The reduced muscle mass and muscle function and / or reduced physical performance is known as sarcopenia36, which represents a considerable highlight in public health worldwide37,38 with numerous physiological complications such as functional deficits, fragility, fatigue, increased risk falls, fractures, hospitalizations, multiple comorbidities (osteoporosis, diabetes mellitus)39, increased mortality and impaired quality of life.38,40,41 In view of this scenario, several physical training protocols associated or not with nutritional support have been highly recommended in the therapeutic approach to sarcopenia.42
Tsekoura and coworkers43 involved 54 elderly people (47 women) with sarcopenia in a study comparing the effect on muscle, functional / physical performance, and QOL of home and supervised three-month exercise programs. The subjects were randomized into a supervised group, a home group, and a control group. Three functional evaluations were carried out, before the beginning, at the end and three months after the conclusion of the training protocol. Assessments included four-meter (4 m), Timed-Up and Go (TUG) and chair support (CS) tests. Qol was assessed using the Greek questionnaire Sarcopenia Quality of Life (SarQol_GR).
The handgrip strength and knee muscle strength were also checked using portable and isokinetic dynamometers and the body composition by bioelectrical impedance. At the end of the study, the authors presented significant results on the effects of physical exercise in elderly people with sarcopenia in both training groups when compared to the control group in all measured variables. It was also observed that the effects of the training were maintained for at least three months after the end of the protocol. Both exercise programs were effective, however the supervised program showed superior results. These data corroborate the findings of our study that showed significant results regarding the efficiency of a semi-supervised home exercise program in improving the functional mobility and the QOL of sedentary elderly in the community.
In another recent study conducted by Kota et al. (2019)44, the effects of a regular home exercise program on the elderly’s locomotion syndrome were evaluated. The training program was carried out three times a week for a period of two months, including balance exercises, muscle strength, nutritional education, and incentives to social participation. Pre- and post-intervention assessments were performed on all participants. The intervention was performed three times a week. The authors used a balance test in the orthostatic position and a scale for assessing geriatric locomotive function. The researchers concluded that a low-frequency home program of physical and educational activities was effective in improving the physical and locomotor function of the elderly.
As seen in the scientific literature, the practice of physical exercise improves the functional mobility of the elderly, increasing their level of physical activity10,46 and, improve functional and cognitive performances,47 improve balance and muscle strength,48 giving them the ability to safely carry out ADL‘s such as bathing, dressing and performing household activities, minimizing the risk of falls and increasing autonomy10,11,45 which provides a higher QOL for this population.5,12,28,49
Degenerative diseases are common in the elderly population, especially degeneration of the knee joint cartilage with a prevalence of 47% in men and 70.2% in women in the Japanese population over 60 years.50 The evolution of osteoarthritis of the knees leads to a limitation of ADL‘s compromising the QOL of the elderly.51
In 2019, Suzuki and coworkers52 verified the effects of two home exercise programs on muscle strength and joint flexibility in 100 elderly people in the community with knee osteoarthritis, confirmed by radiological examination. One group of patients performed different exercises and stretched the knee and hip muscles and the other group strengthened the quadriceps muscles. The authors assessed pain self-reported physical function, maximum isometric strength of knee extension and radiological control after four weeks of training and observed a significant reduction in knee pain in the strength of the knee extensor muscles and in radiographic indexes. They also highlighted the important improvements in the performance of ADL‘s and general health conditions. Another important outcome assessed was the high rate of adherence to the home exercise program.52
According to several studies, hip fractures are the most important cause of morbidity and mortality and health spending by the government with the elderly population,53-56 and consequent impairment of health-related quality of life (HRQOL).57,58Renerts et al. (2019)59 carried out a study involving elderly people after hip fracture with the objective of verifying the effect of a home exercise program associated or not with vitamin D supplementation. Patients, after hospital discharge, received a pocketbook with the guidelines of a balance exercise program, muscle strength and functional mobility, consisting of 30 minutes daily according to a protocol previously published by the authors.60 At the end of the study, the authors observed that hip fractures really have a negative impact on the HRQOL of the elderly regardless of the variables age, gender, body mass index and interventions used in the study. With this study, it can be concluded that a home exercise program associated or not with vitamin D supplementation has a positive effect on maintaining HRQOL for up to one year.59
Aas and coworkers (2020)61 evaluated occupational balance compared to QOL in 46 institutionalized elderly (69 to 101 years old) of both genders. The authors observed a normal distribution of occupational balance scores in the sample, for both genders. Occupational balance was positively and significantly associated with the QOL of men, but not among women. These findings confirm a balance deficit in institutionalized elderly and reinforce the need to adopt a regular program of physical activities for this population. A recent systematic review,62 demonstrated an evidence of a strong association between physical exercise and the QOL of the elderly, but it was not possible to sustain the existence of the causal relationship since most of the studies presented significant associations used transversal designs making inferences impossible about causality. It was verified semi-supervised home physical exercise resulted in a statistically significant improvement in overall QOL when compared to CG, converging with results from previous studies obtained similar results, but with the use of supervised exercises.28 It was also observed a significant improvement in the QOL in the IG, in four of the six facets of the WHOQOL-OLD, corroborating with previous study.63 It is important to highlight the great improvement obtained in the autonomy facet which may be related to a relevant improvement in functional mobility, identified by the reduction. The analysis of variance performed in the age extracts showed no statistically significant difference between the subgroups studied demonstrating the home exercise program is effective in improving the functional mobility and the QOL of the elderly in different age groups, obtaining equivalent results between elderly and very old.
We would like to draw attention to some of the strengths of this clinical randomized, controlled and blind trial. Both groups of subjects were followed up individually with home visits by the researchers every two weeks with the purpose of controlling the execution of the proposed activities. Another strength of this study was that the training program proposed was composed of dynamic exercises easy to perform, without the need for specialized assistance at home weekly control through the personal diary and the intense participation of family members contributing to high adherence to the protocol and low rate of complications. Another detail to consider was the reduced sample loss which did not interfere with the results as they did not exceed ten percent of the sample calculation.
On the other hand we can consider the predominance of the female gender as a limitation of this study. However the randomization process avoided this bias and it is also justified that among the elderly population there is a predominance of women.64-66 The participants filled in the diary with the exercise routine but to increase the reliability of the data, family members were asked to assist them. According to the state of the art new studies need to be carried out to confirm the effects of semi-supervised home exercise programs on the QOL of the elderly.