An Online Version of Physical Exercise with Musical Accompaniment Might Facilitate Participation by Subjects Who Cannot Participate in Person: A Questionnaire-Based Study

The number of people with dementia is rising rapidly in conjunction with the increase in longevity. Currently, there are only a few disease-modifying therapies against most dementia-related diseases, so there is a great need for multifaceted efforts, including non-pharmacological interventions, to prevent dementia [1]. The positive effects of aerobic physical exercise regarding prevention of the occurrence and progression of dementia have been well established. Since 2010, we have carried out a program aimed at preventing and suppressing the progression of dementia using physical exercise combined with music (the Mihama-Kiho Project) and have reported its effectiveness in community-dwelling healthy older people (the Mihama-Kiho Project part 1) [2]. Neuroanatomical analysis using voxel-based morphometry revealed that the gray matter volume of the frontal lobe was better preserved/larger after a 1-year intervention (Mihama-Kiho Scan Project 1) [3]. These physical exercise classes with musical accompaniment have been ongoing through the present, and their long-term effects over 5 years were reported (the Mihama-Kiho Follow-up Project) [1]. In patients with dementia, we had previously reported improvements in cognitive function and activities of daily living after a 6-month intervention involving physical exercise with musical accompaniment (the Mihama-Kiho Project part 2) [4]. The relationship between the pattern of brain atrophy and the efficacy in cognitive function suggested that this type of intervention might result in cognitive improvements (the Mihama-Kiho Scan Project 2) [5].

Currently, in-person exercise poses a challenge due to the ongoing outbreak of the coronavirus disease 2019 (COVID-19). Thus, we decided to conduct the physical exercise classes with musical accompaniment online. The contents of the physical exercise with music accompaniment were quite the same as the previous in-person interventions [1‒3]. The only difference between them was the way of the physical exercise, that is, online or in person. Using the online conference system (Zoom™), the appearance of the trainer was projected on the screen of the personal computer (PC) or tablet. By setting the gallery view, the trainer and the participants can see each other, so the trainer can know to what degree each participant performs the exercise well and regulate the intensity of the exercise to avoid the occurrence of the unexpected impairments. If there are some questions, the participant can ask the trainer at the end of the exercise sessions through the online conference system. The close explanation will be shown in another paper (Tabei, in submission). The aim of the present study was to clarify the characteristics of the online participants compared to previous participants who attended the exercise classes in person [1‒3] by the surveillance via questionnaire several months after starting the online exercise classes.

The subjects were recruited voluntarily using internet flyers seeking participants. We announced the 6-month online physical exercise program with musical accompaniment by sending a direct e-mail to about 1 million elderly persons (≥65 years old), all of whom were members of SAISON Credit Card, which is the parent company of the Research Institute of Brain Activation. Ninety subjects were recruited on a first-come basis. The inclusion criteria for participants were as follows: (1) over 65 years old, (2) physically and psychologically healthy, (3) good eyesight, (4) able to hear instructions clearly, and (5) had independence in life [1, 2]. The applicants were not selected if they met any of the following exclusion criteria: (1) apparent history of cerebrovascular attack, (2) presence of chronic exhausting disease such as malignancy and infection, (3) presence of severe cardiac, respiratory, and/or orthopedic disabilities, (4) use of drugs that might adversely affect cognition (antidepressants and antipsychotics), and (5) previous diagnosis of dementia [1, 2]. Three months after beginning the exercise classes, which is half of the intended duration, questionnaires were administered over the internet. The questionnaires addressed the attributes of the participants, the perceived advantages of the classes, and the presence or absence of changes in cognitive and physical function after participating in the exercise classes (Table 1; online suppl. Table 1; for all online suppl. material, see https://doi.org/10.1159/000529192). The details of the physical exercise program with musical accompaniment were previously published [1‒3].

After the decision of the participants, two subjects declined. The total number of subjects was 88 (71.2 ± 4.9 years old; male:female = 42:46). The results from the questionnaires are shown in Figures 1-3 and Table 2. We identified some characteristic differences in the online cohort compared to previous participants who attended the exercise classes in person [1, 2]. The characteristics of the participants are shown in Figure 1. The male-to-female ratio was roughly 1:1 (Fig. 1a). In regard to family structure, about 60% of the participants lived with their elderly partner or alone (Fig. 1b). About 60% of the participants had graduated from college (Fig. 1c). According to the National Population Census in 2010 [6], the rate of persons over 60 years of age (who would now be over 70) who graduated from college is 13.7%. Thus, we can conclude that the educational history of the participants in the present study was relatively high. Over 90% of the participants could operate the PC by themselves (Fig. 1d). Eighty-five percent of the participants felt that the operation of the PC to access the exercise classes was easy, very easy, or of average difficulty (Fig. 1e). Most of the participants reported being satisfied with the contents of the exercise (Fig. 1f).

Figure 2 shows the changes in cognitive and physical function and our daily lives. About 42% of the participants felt that their sense of the day of the week and volition were improved after beginning the exercise classes (Fig. 2a, b). The frequency of physical movements increased in almost 34% of the participants (Fig. 2c). The participants thought that their activities of daily living had improved after starting the exercise class (Fig. 2d). About 36% of the participants answered that their health condition had improved by attending the exercise classes for 3 months (Fig. 2e).

The reasons cited for participating in the online physical exercise classes with musical accompaniment are shown in Figure 3. The most frequent answer to the reason for participation was because it was free (81.8%; Fig. 3a). The second most frequent answer was because the classes were held online (75.0%). It is noteworthy that 22.7% of the participants answered that they participated in the online exercise classes because there were no troublesome human relationships to consider. Figure 2b graphs the answers to the question, “If the exercise classes were held in person, would you wish to participate?” Almost half of the participants answered that they would not participate if it was held in person; in other words, they participated because it was online. Figure 3c illustrates the reasons for their answers to the previous question (Fig. 3b); subjects did not wish to participate in the exercise classes if they were held in person due to the risk of COVID-19 infection (75.0%) and trouble getting to the site where the exercise classes were held (59.1%). Almost 11% of the participants answered that, if held in person, they would have felt troubled by having to interact with others.

We conducted a survey of participants of an online version of physical exercise classes with musical accompaniment after 3 months of attendance; the effectiveness of this exercise program was demonstrated in our previous studies of in-person classes (the Mihama-Kiho project) [1‒5]. The results of the present study can be summarized as follows. (i) The male-to-female ratio was nearly equal. (ii) The educational history of the participants was relatively high, and they were able to set up the online devices by themselves. (iii) Most of the participants were satisfied with the contents of the physical exercise with musical accompaniment. (iv) The participants felt that their orientation and volition were improved. (v) Regarding their daily lives, the participants thought that their exercise habits, activities, and health conditions had improved. (vi) The reason for participation in 75% of the subjects was that the classes were held online, and 23% cited the absence of troublesome human relationships. (vii) Half of the participants would not have participated if the exercise classes were held in person; only 23% would have participated in person. (viii) The reasons why they would not have participated in person included the risk of COVID-19 infection (75%) and the trouble of getting to the exercise site (60%).

From this, we can conclude that the use of the internet does not represent a barrier for today’s elderly population to participate in our exercise classes. According to the Annual Report on the Ageing Society 2021 published by the Cabinet Office in Japan [7], about 74% and 58% of septuagenarians and octogenarians, respectively, utilize the internet, and the rates have increased almost 2–3 fold compared with the results from 2010 [8] (septuagenarians 39.2%, octogenarians 20.3%). The Communication Usage Trend Survey 2020 performed by the Japanese Ministry of Internal Affairs and Communications [9] showed that 53.9% of people over 65 years old use the internet (males 64.4%, females 45.7%). It is assumed that persons with good information technology (IT) literacy participated in our online exercise program, which is reflected in the higher degree of educational history of the present participants compared with the population average. Because utilization of the internet by elderly people is increasing yearly, we expect that more elderly people will be able to participate in online exercise classes more easily in the future.

It is noteworthy that the rate of male participation in the present study was higher than for classes held in person [2]. In our Mihama-Kiho project, in which the physical exercise classes with musical accompaniment were held in person, the male-to-female ratio of the participants was 1:8 (male 6, female 48) [2]. As mentioned above, the male-to-female ratio of elderly people over 65 years of age who utilize the internet is almost 4:3 (male 64.4%, female 45.7%). However, the male-to-female ratio of the population over 65 years old in Japan in 2019 was almost 3:4 (male 1.560 million, female 2.029 million) [10]. Thus, we can reasonably conclude that the male-to-female ratio of the population of elderly people over 65 years of age who utilize the internet is almost 1:1.

We predict that online exercise could stimulate greater potential demand for physical exercise. Most of the participants (86.3%) were satisfied with the contents of the physical exercise classes with musical accompaniment, rating them greater than average. However, most of the participants (80.7%) replied that they would not have participated if this program was held in person. The main reasons cited for this were the risk of COVID-19 infection and the trouble getting to the exercise site. The reasons cited as to why they participated in this program were that, first, it was free, and second, it was held online. Namely, the persons who did not or could not participate in person became able to participate when the classes were held online.

Currently, the online physical interventions are being utilized, especially after the outbreak of COVID-19. The subjects include physically inactive adults [11] and low-active elderly people [12], patients with diabetes mellitus [13], Parkinson’s disease [14], and multiple sclerosis [15]. These studies concluded that, similar to the present study, the online interventions were characterized by their convenience, physical and mental health benefits, sustainability, and affordability. The safety was ensured by narrating and showing in writing the instructions as follows [15]: discuss with your family and healthcare providers before beginning any exercise program; perform the exercise in the room with the appropriate temperature and good ventilation; stay hydrated by drinking water before, during, and after the exercise; plan flexible rest breaks to avoid excessive fatigue; listen to your body and adjust the frequency, intensity, and duration of the exercise; and, if the activity aggravates an existing symptom, stop, rest, or modify the activity. Some programs included the opportunity to connect the participants at the end of the classes [12].

This study has several limitations. First, the effectiveness of the online physical exercise classes with musical accompaniment has not been established. We are currently investigating its effects and will be able to report these results in the near future (Tabei, in submission). Second, the persons who could participate in this program were limited to those who could operate a PC or tablet and use the internet. Research conducted by the ministries and agencies of Japan has revealed that almost three-quarters of septuagenarians can use the internet, and the rate is increasing yearly. We predict that most elderly people will be able to participate in this program in the near future. Lastly, the study was performed via an internet questionnaire. If we had been able to interview participants directly, we could have obtained more details such as their primary professions, how they spend their days, and their residential conditions. Despite these limitations, we expect that online exercise classes will facilitate the participation of elderly males and persons who are responsible for the care of their spouses, as well as broaden their use in remote areas suffering from depopulation and aging.

Due to the impact of the COVID-19 outbreak, we started offering online exercise classes and carried out a survey of the participants. The rate of male participation was higher than in our previous classes held in person. Orientation, volition, activity, exercise habits, and health condition were improved in 30–40% of the participants. The utilization of the internet by elderly people is increasing yearly, and thus online physical exercise classes with musical accompaniment will be useful not only as a countermeasure to spreading infection but also in promoting access in remote areas suffering from depopulation and loss of the labor force.

This study received approval from the Advanced Institute of Industrial Technology Research Ethics Committee (Approval No.: 18007) and was conducted in accordance with the Helsinki Declaration of 1975. All of the participants provided informed consent in writing or online on the site used to run the assessment and collect data. The latter process was also approved by the Advanced Institute of Industrial Technology Research Ethics Committee (Approval No.: 18007).

The Department of Dementia and Neuropsychology, Master Program of Innovation for Design and Engineering, Advanced Institute of Industrial Technology, was established using donations provided by the Research Institute of Brain Activation.

The study was conducted without any funding sources.

Masayuki Satoh: design of the study, interpretation of data, and writing the manuscript. Ken-ichi Tabei: interpretation of data and revision for important intellectual content. Jun-ichi Ogawa: carrying out the class of physical exercise with music. Makiko Abe, Chiaki Kamikawa, and Yoshinori Ota: acquisition and interpretation of data.

All data analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.