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[Table 1].

Pre-screening, baseline measures[Table 2] 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).
 * 1) Warm-Up phase (~20 min): Focusing on mobilisation and light cardiovascular work.
 * 2) Strengthening phase. (20 min): Initially for 20 min, increased progressively as the participant adapts.
 * 3) Relaxation phase (10 min): Focusing on addressing flexibility and balance.

After completion of 12 weeks (24 sessions), the baseline tests[Table 2] were repeated and statistical analysis performed.

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)