Virtual Programming for Physical Activity Interventions: Integration of Behavioral Components

Abstract

The SARS-Cov-2 pandemic changed many contemporary experiences, including how healthcare and exercise programming are delivered. As a result of the pandemic, there was an increase in virtual services and programming and there continues to be a demand for virtual options. The results from Desir et al support the use of virtual visits to successfully change lifestyle factors, specifically nutrition and physical activity. The use of individualized dietary and exercise goals were important to the success of the intervention, and should not be disregarded. As virtual healthcare and exercise continues to evolve, to maximize behavior change, we should also consider how to include the social and community aspects of exercise. Regardless, it is encouraging to see that significant advances are being made in virtual programming and that the needed engagement can occur in a virtual setting.

“One population that has substantial potential for benefits of regular exercise and physical activity is adults with frailty or prefrailty.”

The SARS-Cov-2 pandemic has wide-reaching health implications, many of which are still being described and will take years to fully realize. In addition to the forefront effects on respiratory function, the effects of the pandemic have reached into other aspects of health. Due to the pandemic, elective surgeries were postponed, regular preventative care appointments were canceled, and fitness facilities were closed. There were, and continue to be, changes in mental health due in large part to these shifts. ¹ All of these factors will undoubtedly have a long-term impact on diseases impacted by lifestyle behaviors and transitioning away from relatively unhealthy “pandemic behaviors” will be difficult for many.

Despite these undesirable outcomes, multiple changes occurred due to the pandemic that are beneficial. One of these changes is increases in remote healthcare delivery. ² Virtual visits with a healthcare provider increases access service and reduces barriers (e.g., transportation, lack of availability of local providers).^3,4 One specific example of this benefit is highlighted in this issue by Desir and colleagues. ⁵ As discussed, the SARS-Cov-2 pandemic increased remote delivery of physical activity and fitness programming, in both research and community settings.^6-8 Although there are currently fewer in-person visit restrictions with the SARS-Cov-2 pandemic, there is still a high demand for virtual healthcare.

Virtual Fitness Programming

The best methods and delivery of virtual physical activity programs are rapidly being refined. However, the virtual delivery of exercise programs is not a recent innovation. In 1951, Jack LaLanne first aired his exercise program show that is credited as the first exercise program on television. When VHS was introduced into people’s homes, it expanded availability of home exercise programs and that these programs could now be done “on demand” at the time of the viewer’s choosing. Behaviorally, ease of access to health promoting interventions is important especially when someone is ready for change. For example, in the smoking cessation literature, abundant evidence supports that it is difficult to determine when someone is ready to quit smoking, but once someone is ready, the appropriate supports are critical. ⁹ Conceptually, this is true for most behavior change. Barriers to making change when someone is ready significantly reduces the likelihood of long-term change. Access to virtual physical activity programming helps to meet this need of having access to exercise immediately available when the person is ready for change.

One of the most significant issues with providing virtual programming in terms of physical activity is the likelihood of limited engagement. In this issue, Desir and colleagues ⁵ used available technologies to their advantage by providing regular virtual meetings with a health coach. This allowed participants to set goals with and receive feedback from a trained professional. These modifications to “typical” virtual delivery programs are two important aspects that are often overlooked in exercise interventions of this type. It is likely that several of the findings from this study were significantly impacted by these modifications. Specifically, all participants met at least one exercise and one dietary goal; 75% of the participants met 65% of dietary goals and 75% met 50% of exercise goals. In our exercise training interventions with older adults, we frequently receive comments from the research participants that they enjoy the social aspect of the exercise sessions. This extends from the interaction with their peers in the program, as well as the relationship they build with the research team. At the conclusion of the training intervention, even though the participants indicate that they feel fitter and would like to continue exercising, few participants continue to exercise on their own once the social aspect is removed.

Virtual programs still remain limited in some areas compared to face-to-face modalities, specifically in the social factors area. Some of the factors that have been shown to enhance adherence to physical activity include performing physical activity with others, having encouragement with peers, and having a partner with whom to engage in physical activity. ¹⁰ Unsurprisingly, work is being done in the area of providing virtual physical activity programs that include the above-mentioned social aspects. For example, older adults provided feedback on an exergame training program and reported that one feature that needed to be included was interactions with co-players. ¹¹ Interestingly, they also reported that they needed to be able trust their health coach even though all of these interactions occurred remotely. Although it is unlikely that we will ever be able to state that face-to-face or virtual programs have a greater benefit in terms of the overall health of a population, advances are being made to provide critical components of care through virtual programming. ⁸

Considerations for Older Adults

One population that has substantial potential for benefits of regular exercise and physical activity is adults with frailty or prefrailty. Relationships between frailty and health outcomes in older adults have been well established,^12,13 specifically that frail older adults have poorer health outcomes.^13,14 Older adults are also a group that has significant barriers to regular exercise and physical activity, such as lack of transportation to community centers and fitness facilities, lack of knowledge for exercise training and a limited budget for personal training, and barriers to mobility that may make travel outside the home difficult. Together, this makes an at-home program to increase physical fitness and decrease frailty desirable.

Physical activity is a particularly impactful intervention for older adults. One of the benefits of exercise programs outside the home for older adults is the social support aspect.^15,16 For this group, the social aspects of physical activity have been shown to improve mental health as well. Additionally, increased physical activity has been linked to improvements in cognition,^17,18 independent functioning, ¹⁹ and decreased risk for dementia. ²⁰ The benefits for physical activity in this group are substantial and clear.

Despite these benefits, older adults receive contradictory information about the need to engage in physical activity. ¹⁰ For example, in a study on older adults with osteoporosis, many patients felt that their physician was encouraging them to be less active or restrictive in their activities. Examples of suggesting that older patients not ride a bike or spending more time sitting in the sun were indicators to patients that they should decrease their activity levels. Although this may not have been the intention of the physician, it is likely that older patients, especially older adults with frailty or other health conditions, interpret these statements through information that is provided by peers and family members of being more cautious and less active. In our settings, we have observed concerned family members telling their older adult relative that they need to rest more or not push themselves as much when exercising. The challenge faced by many is finding ways of being cautious while increasing activity. Physicians are often viewed as a person of authority on all things health-related, but receive very little—if any—training in exercise prescription and lack confidence in prescribing exercise for their patients. ²¹ We need to work on physicians and other primary care providers being comfortable prescribing and encouraging exercise for their patients. This starts with the healthcare provider asking the patient about their physical activity, which is why the Physical Activity as a Vital Sign initiative^22,23 is important to encouraging exercise for everyone.

Conclusion

It is promising that a quality lifestyle intervention has the potential to be delivered in a population that needs increases in exercise and physical activity, as discussed by Desir et al. ⁵ The individualized dietary and exercise goals, as well as regular visits with the same health coach, are important aspects that should not be overlooked with any exercise intervention, but especially one that is delivered virtually. As we continue to assess remote delivery of healthcare, the social and community aspects of exercise programming and interaction should be considered in the design of exercise and lifestyle interventions. Virtual programming with physical activity has come a long way from the initial LaLanne exercise programs on television, but we still have a low percentage of the US population meeting exercise recommendations. Although some of us will likely continue to argue for the “intangible qualities” that face-to-face interactions provide in promoting healthy lifestyles, it is encouraging to see that significant advances are being made in virtual programming and that the needed engagement can occur in a virtual setting.