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.