Multiuser Exercise-Based Telerehabilitation Intervention for Older Adults with Frailty

1. Introduction

Following the COVID-19 pandemic, methods such as telerehabilitation have been studied in recent years as an alternative to traditional face-to-face rehabilitation. Telerehabilitation involves the use of communication devices such as smartphones, tablets, personal computers, and telerehabilitation resource guides to facilitate communication and exercise when caregivers and users are physically separated. This type of therapy was designed according to the recommendations of the physiotherapists.

Although there are obvious cost advantages to providing telerehabilitation, whether this method is as effective as traditional methods for improving both clinical and quality-of-life (QoL)-related outcomes needs to be examined. Japan is considered a 'super-aging society'; by 2025, 6.8 million baby boomers will be aged over 65 years, and the number of single-person households and baby boomers requiring care is expected to increase according to the reports from the Ministry of Health, Labour and Welfare. Elderly people in Japan generally have a strong desire to live independently, and it is likely that their future care needs will differ from those currently addressed by conventional nursing care services. According to a report published by the Ministry of Economy, Trade, and Industry in April 2018, by 2035, the number of people requiring nursing care will reach 10 million, and the gap between the supply and demand for nursing care personnel will grow to approximately 680,000 people in Japan. As a result, a substantial number of 'nursing care refugees' will be unable to access nursing care services. Given this context, it is crucial to construct social infrastructure that addresses the physical, cognitive, and emotional needs of the elderly and ensures that they are not socially isolated. Such infrastructure must also incorporate technologies that are currently not covered by Japan's long-term care insurance (LTCI) system. The LTCI system includes seven levels of care: two levels of supportive care and five levels of nursing care. An individual can receive nursing care services if their certification results fall under one of the seven levels.

Exercise instructions for older adults using mobile technology have been suggested to improve physical activity, and older adults who have received telecare interventions have been reported to experience improvements in their QoL. Although many general systematic and scope reviews of telerehabilitation have focused on elderly people, none have focused on the effectiveness of exercise-based mHealth or telerehabilitation for frail older adults. Therefore, in this study, we aimed to investigate the QoL-related outcomes of simultaneous telerehabilitation in multiple users and conduct a literature search of the current state of the research on telerehabilitation.

1.1. Development of Interventions

In response to the increased need for telerehabilitation, a nursing care rehabilitation technology company developed Rehab Studio, an exercise-based remote rehabilitation service that can be used by many frail elderly people simultaneously (Figure 1). Rehab Studio uses a customised version of an online web-conferencing system.

This service allows the type and timing of exercises to be adjusted according to the user's physical condition and preferences. The training videos can be viewed at any time and are selected by rehabilitation specialists according to the users' current goals and physical condition so that the users can exercise daily (Figure 2).

The training videos include several exercises such as upper and lower limb and trunk muscle strengthening exercises, stretching, sitting, and standing balance exercises. A short video of approximately 5 min consists of three different exercises, while a video of 15–20 min consists of approximately 10 different exercises. More than 100 training videos and more than 2,000 different exercises are available in this resource. Training videos can be selected according to different objectives such as 'fall prevention', 'improving activity levels', and 'dementia prevention'.

Eligible persons receive weekly telerehabilitation and may also use a separate day service or other LTCI services. The training videos have no time constraints, and daily exercise opportunities can be created by using them as independent training on days when telerehabilitation and LTCI services are not scheduled. The effectiveness of this intervention was analysed in this study.

1.2. Pilot Test of Rehab Studio

Prior to the current study, short-term pilot tests of the service were conducted (first: May 2020, second: August 2020, third: November–December 2020, fourth: February 2021, fifth: August–September 2022). Although the pilot sample sizes ranged from a few to over 100 people, testing allowed the intervention to be refined and improved. A care provider supplied the tablet terminals, online videos, and live viewing tools to frail elderly individuals and physical and occupational therapists directly conducted exercise programs for the participants. This system allowed the users to perform exercises while watching an exercise program. Physical and occupational therapists provided individual feedback to the users and communicated interactively online.

For the fifth pilot test, in August 2022, four frail elderly individuals (two men and two women) who used a daycare service were provided with online exercise instructions and communication opportunities for 1 month. These users were certified as requiring long-term care under Japan's LTCI system (two required long-term care level 1 and two required support level 2). Two of the four users expressed a desire to continue using the service even if they had to pay for it. They also shared the following comments about the service: 'The instruction was very detailed and informative', 'I feel more positive mentally', and 'It is good to be able to interact with other people without going outside'.

2. Methods

2.1. Evaluation of the Intervention

To determine the effectiveness of Rehab Studio, we selected 7 subjects. Inclusion criteria were: those attending day care with support levels 1 or 2, and care level 1; absence of dementia; ability to walk alone with a cane or walker; and agreement to participate within the study timeframe. Exclusion criteria included history of dementia or psychiatric disorders. Seven people agreed to participate, but one left due to ill health, resulting in six subjects who received 1-hour live online rehabilitation sessions with multiple participants. The participants engaged with the sessions in a sitting position with real-time communication with rehabilitation specialists, using Rehab Studio (Figure 3).

Rehab Studio has the following advantages: After participating in the exercise program, users can enter their satisfaction levels on a five-point scale, and physical and occupational therapists can check the results; the system is based on participant experiments and designed such that even elderly people who are not comfortable with technology can easily participate in the program; and this system has been tested for several years. In addition, the service is continually updated based on feedback (on pricing, exercise program design, and safety considerations) from users who participated in the intervention over the last several years (Table 1). Rehab Studio uses a customized version of the online web conferencing system, 'Whereby' (Norway), which is specifically designed to allow older adults to participate without the need for email addresses or passwords (Figure 4).

To assess the effectiveness and safety of the service, the EuroQol 5 dimensions 5-level (EQ-5D-5L) questionnaire was administered twice: before the intervention and 1 month after the intervention (Table 1). The EQ-5D-5L is a questionnaire with five items (walking, dressing, usual activities, pain/discomfort, and anxiety/blocked up) that are scored by the respondents on a five-point scale. We converted the responses obtained into a QoL score (maximum 1 point; minimum 0 points) using the conversion table of the Japanese version of the EQ-5D-5L.

3. Results

All six users exhibited improved EQ-5D-5L scores and self-rated health scores. The mean EQ-5D-5L score increased from 0.63±0.13 before the intervention to 0.77±0.14 after the intervention (p=0.010), while the mean self-rated health score increased from 66.0±18.0 to 83.3±10.3 (p=0.019). All statistical tests were two-sided. Data were analysed using paired t-tests. Significant differences were found in the total EQ-5D-5L and self-rated health scores (p<0.05). The significance level was set at p <0.05. Data were analysed using JMP pro ver18 (SAS Institute, Cary, NC, USA).

4. Discussion

4.1. Main Findings and Clinical Significance

In this pilot study, we found that a one-month multiuser exercise-based telerehabilitation intervention led to statistically significant improvements in both EQ-5D-5L scores and self-rated health scores among all six frail older adult participants. The mean EQ-5D-5L score increased from 0.63±0.13 to 0.77±0.14 (p=0.010), representing a 0.14-point improvement that exceeds the minimal clinically important difference (MCID) of 0.07-0.10 for the EQ-5D-5L in older populations [31,32]. The mean self-rated health score increased from 66.0±18.0 to 83.3±10.3 (p=0.019), indicating a 26% improvement in participants' subjective health perception. The EQ-5D-5L assesses five dimensions—mobility, self-care, usual activities, pain/discomfort, and anxiety/depression—capturing both physical and psychological components of health [33]. The improvements observed across these domains suggest that the intervention contributed to multidimensional well-being rather than isolated physical gains, which is particularly relevant for frail older adults whose health status is characterized by multisystem decline [34,35].

4.2. Social Engagement and Multiuser Format

The multiuser, group-based format represents a key distinguishing feature that may have contributed to the observed improvements. Social isolation has been identified as a significant risk factor for mortality and functional deterioration in older adults, with effect sizes comparable to established risk factors such as smoking [36,37]. In the context of frailty, social isolation can create a vicious cycle where physical limitations reduce opportunities for social engagement, which in turn accelerates functional decline [38,39]. The real-time video conferencing format employed in our study allowed participants to see and interact with both therapists and other participants, creating a virtual community. Research has demonstrated that group-based exercise interventions for frail older adults not only improve physical function but also enhance social networks and reduce depressive symptoms [40,41]. Our multiuser telerehabilitation format may disrupt the isolation-frailty cycle by providing both physical benefits through structured exercise and psychosocial benefits through shared online engagement.

4.3. Technological Accessibility

A critical success factor for telerehabilitation is technological accessibility for older adults, many of whom have limited digital literacy [42,43]. The Rehab Studio platform was specifically designed to address these barriers by eliminating the need for email addresses or passwords and providing pre-configured tablet devices that automatically connected to scheduled sessions. These design considerations align with principles of age-friendly technology design [44] and address usability barriers that have been identified as major obstacles to telehealth adoption among older adults [45,46].

4.4. Exercise and Frailty Management

The exercise component aligns with evidence that structured physical activity can prevent and potentially reverse frailty in older adults [47,48]. Frailty is increasingly recognized as a dynamic state that can be modified through appropriate interventions [49]. Multicomponent exercise programs addressing strength, balance, and endurance have emerged as effective interventions for frailty prevention and management [50,51]. Our platform incorporated all three components through a library of exercises covering strengthening, stretching, and balance activities, with personalization critical for the heterogeneous frail older adult population [52].

4.5. Healthcare Delivery Context

Telerehabilitation gained unprecedented attention during the COVID-19 pandemic [53,54], but its value extends beyond pandemic-related necessity. Many older adults face barriers to accessing traditional rehabilitation services, including transportation difficulties, geographical remoteness, and physical limitations [55]. The multiuser format leverages the scalability advantages of telehealth while maintaining social engagement benefits. This model is particularly relevant in Japan's healthcare system, which faces projected shortages of rehabilitation professionals due to population aging [56].

4.6. Study Limitations

This study has several important limitations. First, the small sample size (n=6) substantially limited statistical power and generalizability [57,58]. While we observed statistically significant improvements, these findings should be considered preliminary and hypothesis-generating. Second, the non-randomized design and absence of a control group limit causal inference [59,60]. Without a control group, we cannot definitively attribute improvements to the intervention rather than to placebo effects or temporal trends. Future studies should employ randomized controlled designs [61]. Third, the short intervention duration (one month) limited our ability to assess sustainability of benefits [62]. Long-term follow-up assessments are needed to evaluate durability of effects [63]. Fourth, reliance on self-reported measures introduces potential response bias [64]. Future studies should include objective measures such as gait speed, grip strength, or accelerometer-measured physical activity [65,66]. Fifth, we did not systematically assess intervention adherence, which is critical for understanding effectiveness [67]. Finally, our study was conducted in a single urban area in Japan with participants recruited from established day care services. Findings may not generalize to rural populations, other countries, or individuals not engaged with formal care services [68,69]. Cultural factors may influence both acceptability and effectiveness of telerehabilitation [70].

4.7. Future Research and Clinical Implications

Large-scale randomized controlled trials with adequate statistical power are needed to definitively establish effectiveness of multiuser exercise-based telerehabilitation for frail older adults [71,72]. These trials should include appropriate control groups and comprehensive outcome assessments including quality of life, physical function, cognitive function, and healthcare utilization [73]. Research should also examine dose-response relationships to identify optimal intervention parameters [74], investigate subpopulation differences [75], and assess cost-effectiveness [76,77]. Despite limitations, this pilot study provides preliminary evidence supporting feasibility, safety, and potential efficacy of multiuser exercise-based telerehabilitation for frail older adults. The positive outcomes add to evidence supporting policy reforms to expand insurance coverage for telerehabilitation services [78,79]. The multiuser format offers a scalable model that could help address workforce shortages and improve access to rehabilitation services [80].

Table 2. Overview of the literature search.

Study	Country	Subject No.	older adult, frail/ other	telehealth/ mHealth	multiuser/ group	QOL outcome
Tsai et al., 20177	Australia	36	yes, with COPD	Yes	Yes	Yes
Bernocchi et al., 201821	Italy	112	yes, with heart failure and COPD	Yes	No	Yes
Lin et al., 201414	Taiwan	43	yes, stroke	Yes	Yes	not evident
Kwan et al., 202016	China	99	yes, cognitive frailty	Yes	Yes	not evident
Murukesu et al., 202122	Malaysia	42	yes, cognitive frailty	No	Yes	Yes
Oursler et al., 202215	USA	80	yes, with HIV	Yes	Yes	Yes
Daniel, 201223	USA	23	yes, prefrail	No	Yes	not evident
Cabrita et al., 201724	the Netherlands	10	yes (not frail-specific, but frailty assessed)	Yes	Yes	Yes
Zengin Alpozgen et al., 202217	Turkey	30	yes (not frail-specific, with no other conditions specified)	Yes	No	Yes
Geraedts et al., 202125	the Netherlands	40	yes, prefrail	Yes	Yes	not evident
Dekker-van Weering et al., 201726	the Netherlands	37	yes, prefrail	Yes	Yes	Yes
Li et al., 202027	USA	8	yes, cognitively intact	Yes	Yes	not evident
Osuka et al., 202228	Japan	58	yes, frail	Partly	Yes	Yes
Tekin, 202229	Turkey	255	Yes	Yes	No	Yes
Tosi et al., 202130	Brazil	43	yes, frail	Partly	No	not evident

COPD: chronic obstructive pulmonary disease, QOL: quality of life.

Table 2. Overview of the literature search.

Study	Country	Subject No.	older adult, frail/ other	telehealth/ mHealth	multiuser/ group	QOL outcome
Tsai et al., 20177	Australia	36	yes, with COPD	Yes	Yes	Yes
Bernocchi et al., 201821	Italy	112	yes, with heart failure and COPD	Yes	No	Yes
Lin et al., 201414	Taiwan	43	yes, stroke	Yes	Yes	not evident
Kwan et al., 202016	China	99	yes, cognitive frailty	Yes	Yes	not evident
Murukesu et al., 202122	Malaysia	42	yes, cognitive frailty	No	Yes	Yes
Oursler et al., 202215	USA	80	yes, with HIV	Yes	Yes	Yes
Daniel, 201223	USA	23	yes, prefrail	No	Yes	not evident
Cabrita et al., 201724	the Netherlands	10	yes (not frail-specific, but frailty assessed)	Yes	Yes	Yes
Zengin Alpozgen et al., 202217	Turkey	30	yes (not frail-specific, with no other conditions specified)	Yes	No	Yes
Geraedts et al., 202125	the Netherlands	40	yes, prefrail	Yes	Yes	not evident
Dekker-van Weering et al., 201726	the Netherlands	37	yes, prefrail	Yes	Yes	Yes
Li et al., 202027	USA	8	yes, cognitively intact	Yes	Yes	not evident
Osuka et al., 202228	Japan	58	yes, frail	Partly	Yes	Yes
Tekin, 202229	Turkey	255	Yes	Yes	No	Yes
Tosi et al., 202130	Brazil	43	yes, frail	Partly	No	not evident

COPD: chronic obstructive pulmonary disease, QOL: quality of life.

5. Conclusions

This pilot study provides preliminary evidence that a one-month multiuser exercise-based telerehabilitation intervention can improve quality of life in frail older adults. All six participants showed improvements in EQ-5D-5L and self-rated health scores, and the intervention was safe with no reported adverse events. However, the small sample size, absence of a control group, short intervention duration, and reliance on self-reported outcomes limit conclusions regarding causality and generalizability. Multiuser telerehabilitation could help address challenges such as limited healthcare resources, workforce shortages, and increased demand for rehabilitation services in aging societies. By enabling healthcare providers and older adults to collaborate in virtual spaces, these technologies have potential to improve health outcomes, enhance access to care, reduce isolation, and provide continuous support. With continued research, refinement, and policy support, multiuser exercise-based telerehabilitation may become an important component of comprehensive care for frail older adults, complementing traditional in-person services and helping older adults maintain independence, function, and quality of life as they age. New telemedicine, telerehabilitation, and mHealth technologies for elderly people can improve their QoL. Multiuser telerehabilitation could address problems such as limited healthcare resources and increased demand for rehabilitation services. By allowing healthcare providers, caregivers, and older adults to collaborate in real or virtual spaces, these new technologies can improve health outcomes and provide continuous support to users.