Effects of Virtual-Group Exercise at Home (V-GEAH) on Adherence and Fall Risks in Older Adults with a History of Falling

Special Article - Fall Prevention

Gerontol Geriatr Res. 2016; 2(3): 1018.

Effects of Virtual-Group Exercise at Home (V-GEAH) on Adherence and Fall Risks in Older Adults with a History of Falling

Machiko R. Tomita¹*, Fisher NA¹, Ramsey D², Stanton K¹, Bierdeman L¹, Kocher L³, Saharan S¹, Sridhar R4, Naughton BJ5 and Wilding G6

¹Department of Rehabilitation Science, University at Buffalo, USA

²Department of Health Professions Education, D’Youville College, USA

³Department of Industrial and Systems Engineering, University at Buffalo, USA

4Department of Computer Science and Engineering, University at Buffalo, USA

5Department of Medicine, University at Buffalo, USA

6Department of Biostatistics, University at Buffalo, USA

*Corresponding author: Tomita MR, Department of Rehabilitation Science, University at Buffalo, 505 Kimball Tower, 3435 Main Street, Buffalo, NY 14214, USA

Received: June 03, 2016; Accepted: June 27, 2016; Published: June 28, 2016


The objective of this study was to investigate the adherence to and effectiveness of a Virtual-Group Exercise at Home (V-GEAH) program on reducing fall risks in community dwelling older adults, through a randomized controlled trial. Participants were 51 people aged 60-89 years with no cognitive deficits and had a fall within the past year. The intervention was solitary home exercise converted to group exercise at home, utilizing videoconference technology. The program offered progressive resistance and balance exercise 3 times a week for 24 weeks. Participants joined online group sessions using their computer with Internet, interacted with the health research team and exercise peers. Then, they followed an exercise instructor while being monitored for their safety. For72 V-GEAH sessions offered, adherence was excellent (84.0-93.3%) and no one dropped out. The treatment group improved in balance confidence, lower extremity strength (knee extension and flexion, ankle plantarflexion and dorsiflexion, and hip adduction), knee extension (quadriceps) endurance, and basic activities of daily living, more than the control group who were encouraged to walk. The number of falls reported by the treatment group was half of that of the control group. We conclude this video-conference exercise program was instrumental in raising motivation and accountability for continuing exercise, which were attributed to visual contacts with exercise peers and health care providers, easy and clear exercise instruction, gradual progressive exercise program, and participants’ learned computer skills enough to solve problems.

Keywords: Fall risks; Web conference technology; Adherence; Home exercise; Strength; Fear of falling


V-GEAH: Virtual Group Exercise At Home; RCT: Randomized Controlled Trial; ADL: Activities of Daily Living; ABC: Activity- Specific Balance Confidence; ICC: Intratater Correlation Coefficient; FIM: Functional Independence Measure; GEE: Generalized Estimating Equations


One in three community-dwelling older adults fall [1], of whom 22% incur additional falls within a year [2]. Fall related injuries are currently one of the most expensive medical conditions, accounting for 6% of medical expenditures for people 65 years of age and older [3]. Fall injury related health care costs are estimated to increase to $54.9 billion by 2023 in the U.S. alone [4]. Exercise is considered one of the most effective interventions to prevent further falls for older adults who have sustained a fall [5]. However, committing to regular exercise is known to be difficult. Reportedly, 25 to 50% of people who begin an exercise program typically drop out within 6 months and those who complete the programs have low to moderate adherence rates of approximately 66% [6]. Home-based exercise, especially demonstrates poorer adherence rates (≈25%) when compared to gym or a community-based group exercise [7,8], despite the advantages of not having to travel, privacy, flexibility to exercise at one’s convenience, and not being dependent on weather. Yet, poor adherence is primarily attributable to performing exercises alone, the lack of motivation, boredom, and safety concerns [9,10].

One way to improve home exercise adherence is the use of a supportive environment. Advancement in telecommunication systems enable people at home to interact with an exercise instructor in real time via their television screen. A study reported that a group of older adults who participated in a 15-week home-based Tai chi exercise program using DocBox [a] achieved higher adherence rates (69% vs. 38% for home-based exercise without the technology), reduced their number of falls, and improved balance and health measures, all of which were similar to the effects of Tai chi conducted in a community center [8]. Therefore, a virtual, home-based exercise program specifically tailored to older adults will improve adherence to group exercise program. Based on this rationale, the purpose of our study was to utilize commercially available, free of charge videoconference technology to convert long term home-based solitary exercise to group exercise, allowing peer interaction and the monitoring of participants for safety during home exercise. We named this virtual-group exercise at home (V-GEAH) program.

The specific hypotheses were:

1. Participants in the V-GEAH program would show a lower attrition rate (<25%) and a higher adherence rate (>66%) compared to the average of group exercise in past studies.

2. Participants in the V-GEAH program would reduce the number of falls and fall risks such as depression, weakness in lower extremity, and poor gait and balance, and increase balance confidence and function more than the control group.

At the posttest interview, participants evaluated the V-GEAH program using open-ended questions.

Materials and Methods

Development of V-GEAH program

We developed a Virtual-Group Exercise At Home (V-GEAH) program utilizing the internet and videoconferencing technologies. Participants used a desktop or laptop computer with a minimum dual core processor, a high speed connection (download speed =30 mbps), a large monitor (=17”) or a 32” TV screen as a monitor, and a Logitech HD webcam [b]. Each participant exercised at home alone, but was connected with up to six peers and a healthcare research group. A medical doctor’s segmented window was reserved for emergency use so that the participants in need of care and the physician could communicate during an exercise session. We used a video communication service called ooVoo [c] that provides free of charge video chats over the Internet. To use the webcam with multiple chat applications simultaneously, we installed a freeware program called ManyCam [d], and to record all sessions, we used Bandicam [e]. Training on how to use the system was provided in person to each participant, and then all participated in a beta testing (mock exercise session). During the session, if trouble occurred, they could contact ITs in the research group by phones to solve the problem.

Prior to the intervention, a 24-session progressive exercise program was developed and videotaped. The program exercise was for all lower extremity muscle groups, and was designed to allow for rest and recovery of the different muscle groups during each session so as to prevent fatigue. It intended to gradually improve strength and endurance of ankle, knee, and hip muscles, and also improve balance. The instructor was a certified fitness trainer and was familiar with older adults. The exercise program was developed by an exercise physiologist who developed a quantitative progressive exercise method [11], and a geriatric researcher who is knowledgeable about function of older adults with chronic conditions.

The program progressed on several levels: by adding exercise types (flexibility to balance), by intensifying exercises (different levels of Theraband ® [f] to ankle weights), and by increasing the number of repetitions/sets. New exercise types were added every 4 weeks. Within the 4-week interval, the program progressed by increasing repetitions (reps)/sets (1 set of 5 reps, 2 sets of 5, 1 set of 10 and 1 set of 12 reps). Examples of instructions are: (a) In an early stage, “Stand with your hands supported on a steady chair, push up on your toes and hold for 10 seconds and lean back on your heels, raising toes off the floor and hold for 10 seconds”; (2) In a midway stage, “Put appropriate weight directed by the exercise physiologist on each ankle, stand straight holding on to a stable chair, lift your right leg sideways and hold for 5 seconds, then relax, and switch to the other leg. Bring your right leg backwards while keeping knee straight, lift foot slightly off the floor, and do not lean forward and hold for 5 seconds. Switch to the other leg”; (3) in an early to advance stage, “Sit on a chair that is not too low. Keep your feet on the floor slightly apart. Lean forward over your knees; push off with both hands to stand up (for more advanced state, without using hands). When you sit down, don’t flop down; sit in a controlled manner”; and (4) In an advanced stage, “Put your hands on your hips, stand with one leg in front of you as if taking a big step or lunge. Take a giant step with an exaggerated knee bend such that the heel of your back foot comes off of the floor. Then, push back to the starting position with your front foot. Switch legs.”Each session lasted approximately 25 to 40 minutes, depending on the progression. We expected that this program design and progression would result in high compliance and culminate in reducing fall risk factors.

Study design

Human experimentation has been approved by a university Institutional Review Board (#426053-8). The research design was a Randomized Controlled Trial (RCT) with a 24-week intervention period. For the treatment group, four V-GEAH groups consisting of 6 to 7 participants per group started a V-GEAH program in October, January, April, and July to compensate for a seasonal effect. The control group was encouraged to walk inside or outside the home, in accordance with a federal recommendation [12]. Both groups were provided with a pedometer. The assessments were conducted at university labs 3 times: baseline, 12 and 24 weeks.


The original sample size needed was 50, 25 in each group, based on a power analysis of our previous study with an effect size (d) of .71 [14]. Expecting 20% attrition for the control group and 5% for the treatment group, 74 participants were recruited by a convenience sampling method using newspaper advertisements (Figure 1). Inclusion criteria were community-dwelling people aged 60 to 90 years, who fell in their home environment or a work place within the past year, resulting in a visit to a primary care physician or an emergency department. Exclusion criteria were having neurological disorders including Alzheimer’s disease and Parkinson’s diseases, cognitive impairment and, terminal illness, receiving physical and/or occupational therapy, non-ambulatory, and being scheduled to have any kind of surgery. All participants were required to obtain written permission from their primary care physicians to be in this study. Both groups were equivalent in all baseline variables of demographic characteristics, health status, and exercise behaviors (Table 1).