**5.1 Voluntary exercise efforts and behavior modification**

Behavior modification is one of the most important perspectives in implementing rehabilitation for patients with frailty and those at risk of needing care. Even if high-quality exercise regimens are provided by professionals such as physical therapists or HEPOP®, simply providing it to the individual does not prevent caregiving. *Overarching Goal and Intervention for Healthy Aging in Older People… DOI: http://dx.doi.org/10.5772/intechopen.106787*


#### **Table 1.**

*Cutoff values for usual walking speed and the SPPB.*

**Figure 6.**

*Transtheoretical model flowchart some modified quotations from Prochaska JO (1997) and Marcus BH (1998) [37, 38].*

In our clinic, we use the transtheoretical model of health behavior change (TTM) [37, 38], a stage classification based on behavioral modification, preparation for exercise, and duration of practice, to assess exercise awareness and provide stageappropriate interventions when conducting rehabilitation and exercise interventions for people with frailty (**Figure 6**). Some people have always been regular exercisers, whereas others have always wanted to exercise, but have not been able to do so regularly. The method of involvement varies depending on the stage, and one of the goals is to get patients to progress to further stages. A meta-analysis of practice reports for people with diabetes found that introducing practices, setting up step-by-step exercise, working toward habituation, and providing feedback on assessment results significantly improved HbA1c levels in people with diabetes after the intervention [39].

Further study is needed to determine the effectiveness of this model for older patients with frailty. However, those in stages 2 and 3 may share a schedule and specific targets to make it easier for them to continue exercising. In stages 4 and 5, we instruct patients on the appropriate amount of exercise, the selection of an exercise program, and the correct posture so that they do not exercise incorrectly or overuse

the exercise program. In stage 1, which involves the initial explanation of the benefits of exercise, followed by family participation, an immediate effect may be seen.

#### **5.2 Changes in motor function and behavior modification stage after exercise**

This section presents the findings of our clinical study on outpatient rehabilitation for older individuals who were referred from the locomotive-frailty outpatient clinic at our hospital because of declines in muscle strength and balance. Rehabilitation consisted mainly of exercise instruction at home by a physical therapist using HEPOP®. The following points were tried and tested: (1) regular evaluations were conducted to provide feedback to the patients, (2) the amount and frequency of exercise were gradually increased based on the evaluation results, (3) the importance of voluntary exercise at home was explained and the patients were asked to record their daily exercise status, (4) low-intensity, high-frequency strength exercises were performed at home, whereas high-intensity, high-difficulty balance exercises were performed at the hospital under the supervision of a physical therapist, and (5) the frequency of visits to the hospital was reduced from once a week to once a week or longer as the exercise habits became more firmly established. After 3 months of outpatient rehabilitation among 36 older individuals aged 65 years and over, we found significant improvements in walking time, on the Timed Up and Go test (TUG), and on the five times sit-tostand test (paired *t* test, p < 0.05). In addition, 75% of the participants improved their TTM stage by one stage or more (McNemar's test, p < 0.05). Based on these findings, we believe that home exercise instruction using HEPOP® may be effective for improving physical function and promoting behavioral modification in older individuals.

### **5.3 A Case in which frailty improved with appropriate exercise guidance despite the COVID-19 pandemic**

We present a case in which physical function was improved by exercise instruction in a homebound older adult who had originally established an exercise habit, but whose activity was restricted during the COVID-19 pandemic. An older man in his 70s with a history of a classic lumbar vertebral compression fracture had subjective symptoms of stumbling when walking after refraining from activity due to the ongoing pandemic. Prior to visiting our institution, he was attending a gym for training five to six times a week. He mainly performed aerobic exercises using an ergometer and treadmill, and his behavioral modification stage was 5. However, he was not performing muscle strengthening exercises or balance training. When COVID-19 began to spread, it limited his access to the training gym and thus reduced his activity levels. Therefore, exercise instruction from a physical therapist was started once a week at an outpatient rehabilitation center. At the time of his initial examination, he had a J-CHS score of 1 (Pre-frailty), a walking speed of 1.1 m/s, a TUG time of 7.7 s, knee extension muscle strength of 42.3 kgf on the right and 36.9 kgf on the left, and a one-leg standing time of 8.7 s. Outpatient rehabilitation included exercise instruction using HEPOP®, routine home exercise checks using a notebook, standing balance exercises, and resistance training instruction for 3 months (**Figure 7**). After the intervention, he started to perform machine training in addition to aerobic exercise at the gym, which he resumed, and was also able to perform HEPOP exercises daily at home. As a result, 3 months after the intervention, his complaint of stumbling when walking disappeared and his physical functions improved (walking speed 1.3 m/s, TUG time 6.2 s, and one-leg standing time 17.1 s). His knee extension muscle strength improved to 43.3 kgf on the right and 40.8 kgf on the left. Although this patient was in behavioral modification

*Overarching Goal and Intervention for Healthy Aging in Older People… DOI: http://dx.doi.org/10.5772/intechopen.106787*

**Figure 7.** *Actual exercise instruction for older people using HEPOP®︎.*

stage 5, we found that his exercise content was skewed, his balance ability had declined, and he had no exercise routine other than those performed at the gym. Therefore, even in patients with apparently good exercise habits and motivation, a specialized evaluation may reveal decreased or declining function, and a review of exercise content and improvement of function may be achieved by taking a more targeted approach. It is assumed that many older people are at risk for such functional decline as a result of the COVID-19 pandemic, so assessment and intervention in outpatient frailty clinics may play an important social role during this prolonged situation.
