Digitally Delivered, Group-Based Exercise Interventions for Older Adults: Scoping Review

Introduction

Background

Falls represent a significant cause of preventable injury, contributing to premature mortality and morbidity. Fall-related injuries are the major cause of accidental death and disability among older adults, with approximately one-quarter of community-residing men and women over 65 years of age, and almost half of those over age 80, falling annually [1]. Alarmingly, the rate of fall-related mortality increased by more than 30% between 2007 and 2016 [2]. In the last decade, digitally delivered basic medical care has increased substantially [3,4] and has been adopted as a key modality of care by many medical centers. While most older adults appear to prefer in-person visits for their medical care, many believe that telemedicine is useful and should continue to be available, particularly for more routine appointments [5,6], reflecting an increased awareness of the importance and acceptance of this modality. In addition to delivering medical care, there are opportunities for providing preventive care through digital technologies, including fall-risk screening with follow-up participation in evidence-based exercise programs. However, given that many older adults have expressed difficulty with technology [5,6], improving our understanding of how technology-driven approaches can be organized to support older adults is critical. These methods may further enhance telemedicine’s ability to provide care, including real-time interventions to reduce fall risk safely and effectively in older adults.

Types of Programs That Have Proven Efficacious for Improving Physical Function and Preventing Falls

While fall risk is multifactorial, exercise targeting a combination of dynamic balance and functional strength appears to be the most efficacious in reducing fall incidence and improving physical function in adults aged 60 years and older [1]. In particular, structured exercise programs such as Tai Chi [7] and the Otago program [8] have been effective in reducing both fall risk and the rate of falls in older adults. While successful programs differ somewhat in their areas of emphasis and rate of progression, the most effective programs typically emphasize progressive balance training and lower limb strengthening [1]. Indeed, in a comprehensive systematic review and meta-analysis published in 2020, Sherrington et al [9] reported a 34% reduction in fall rate among older adults participating in more than 3 hours per week of total exercise that incorporated systematic balance and strength training. Although specific analyses incorporating dose-response based on attendance are relatively sparse, it appears that interventions prescribing a greater number of practice days (either directly instructed or at home) yield greater improvements in both fall risk and number of falls [10]. More specific descriptions of some exercise interventions identified as effective for reducing fall risk can be found in the Centers for Disease Control and Prevention Compendium of Effective Fall Interventions [1].

Digitally Delivered Fall Prevention Programs

Digital delivery of fall prevention programs may provide an opportunity to improve dissemination and help balance risks and benefits. Such programs may also serve communities lacking appropriate facilities or trained personnel for in-person programs. Similarly, digital programming can reduce barriers for individuals who are unlikely or unable to attend in-person classes due to disease [11], disability [11,12], or geographic remoteness [13,14].

While hundreds of exercise videos are available on the internet—many of which are likely appropriate for older adults—most feature an instructor leading a routine alone in front of the camera, or with a small group of participants in a studio setting. Given the recorded nature of this format, feedback from the instructor is not tailored to the individual performing the exercises and is typically limited to group “cheerleading” in the form of generalized encouragement or nonspecific instruction regarding safety, technique, or progression. Even for classes taught live but with a single instructor, it is likely very difficult for the instructor to provide individualized and targeted feedback to a specific participant who clearly needs form correction in real time. Given the evidence suggesting that video-based instruction has limited (ie, not statistically significant) impact on fear of falling [15] and rate of falls [16], that engagement in a video-based exercise intervention decreases rapidly [16], and that improper technique is a key contributor to exercise-based injury [17], classes that are either video-based or involve large groups taught by a single instructor likely have limited utility.

Significance and Aims of This Review

This scoping review of real-time, virtually delivered, instructor-led exercise trials aims to summarize the growing body of research addressing the efficacy, usability, and safety of this type of program for older adults. In particular, we aim to summarize instruction methodologies and intervention outcomes, as well as identify gaps within the existing literature.

Methods

Overview

Following the standards established in 2018 to guide scoping reviews [18], we defined the review objectives, developed a protocol for data extraction and inclusion, and conducted independent, blinded data analysis by 2 investigators, followed by discussion among investigators to resolve conflicting interpretations. These processes are detailed more thoroughly below. The review was preregistered with INPLASY (registration number 3773).

Search Strategy

A systematic search of MEDLINE via PubMed, the Cochrane Controlled Register of Trials (CENTRAL), and Embase was conducted for peer-reviewed (nonpreprint) publications available in English through July 2024, with no limit on start date. Combined, these 3 databases maximize international reach, covering countries in North America, much of Latin America, and most of Europe, Africa, and Asia. See Multimedia Appendix 1 for the search terms used. Additionally, the bibliographies of systematic reviews identified by the primary search strategy were searched to identify potentially eligible studies.

Study Inclusion Criteria

Interventional study designs, including randomized controlled trials, nonrandomized trials, and single-arm pilot studies, were included in the search. Interventions were eligible only if they were digitally delivered (eg, via Zoom or another similar platform), provided instruction in real time to a group of more than 3 individuals, and lasted a minimum of 6 weeks. We did not require assessments to be digital; therefore, many interventions that included physical measurement conducted these assessments in person. Classes had to include primarily balance and strength training, or other modes of exercise focused on fall prevention, such as Tai Chi, Yoga, or Pilates. This criterion was based on the understanding that, while not necessarily recommended as first-line interventions to reduce fall risk [19], these modalities do appear to contribute to improvements in balance and strength [20,21].

Participant Inclusion/Exclusion Criteria

As a first step in evaluating the scope of group-based, digitally delivered exercise programming for geriatric populations, we chose to focus on apparently healthy older adults. Substantial details regarding inclusion and exclusion criteria are provided in Textbox 1.

Given the older adult population, many of the studies included participants with minor or controlled conditions, such as hypertension, sarcopenia, and mild cognitive impairment. However, in this context, the apparently healthy sample excludes patient populations with severe cardiac, endocrine, or neuropsychological disease, or severe cognitive impairment. These individuals were excluded due to the likelihood of needing additional support in the form of specialized facilities, safety equipment, or clinical training, which would make remote delivery increasingly challenging, particularly in a group-based setting. Additional requirements were being 60 years of age or older; living independently or semi-independently (eg, residing in an assisted living facility without dependency on any care other than meals); being ambulatory without any assistive device; and being able to participate in exercise according to the primary study author’s criteria.

Specific subpopulations excluded from selection were patients with cardiac problems or those with diagnosed cardiovascular disease, individuals with uncontrolled hypertension, diagnosed neuromuscular or musculoskeletal disorders (including Parkinson disease), other conditions requiring ongoing medical treatment, and individuals diagnosed with severe cognitive impairment or deemed unable to follow the instructions of an exercise leader.

Results

As indicated in Multimedia Appendix 2, we followed the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) checklist. We identified 4870 records, and after removing duplicates, 4242 were screened independently by 3 reviewers for titles and abstracts that appeared to match the inclusion/exclusion criteria described above. When 2 or more reviewers agreed on an apparent match, records were advanced to the next stage. Reasons for exclusion during this phase were not systematically recorded. A total of 76 records were retrieved and reviewed in full text, and 23 studies fulfilled all criteria and were included in this review. Two investigators, blinded to each other, extracted data on study elements related to the intervention methods and study results. The headers of the extracted data are provided in Multimedia Appendix 3. Following this independent review, the 2 investigators jointly checked the data extractions for omissions and possible discrepancies, with support from the third investigator. This data flow is shown graphically in Figure 1.

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Details on key demographics of the study samples, interventional methods, outcome measures, and results of the 23 reviewed studies are presented in Tables 1 and 2—12 of the 23 studies were nonrandomized trials (n=5) or single-group (n=7) observational studies reporting pre/postexercise intervention results; the remaining 11 were randomized controlled trials. The studies were conducted across 14 countries: the United States (n=7), Canada (n=3), Cyprus (n=2), and 1 each from Australia, Brazil, England, France, Germany, Greece, Israel, Malaysia, Mexico, South Korea, and Turkey.

Self-reported health status and fall risk varied widely across studies: 15 (65%) studies involved presumptively healthy older adults without known or reported comorbidities. The remaining studies (8/23, 35%) included participants with various health concerns, such as controlled mild to moderate hypertension and type 2 diabetes mellitus. Although the fall-risk category was not an explicit inclusion or exclusion criterion, the requirement that participants be ambulatory without assistive devices resulted in most samples being classified as low to moderate risk.

Among the 18 (78%) studies that reported class size, the number of participants per class ranged from as few as 4 to as many as 32. Most commonly (10/18, 56%), classes had 8 or fewer participants, although 3 (17%) studies reported class sizes greater than 15. The interventions lasted between 6 and 26 weeks. Of the studies that reported class frequency (n=20), the plurality (n=9, 45%) offered 2 sessions per week; others reported either 1 or 3 sessions per week, or did not include specific details regarding the number or timing of classes. The majority of studies (18/23) provided details on class length. Of these, 16 (89%) held sessions lasting between 30 and 60 minutes, 1 study (6%) held sessions shorter than 30 minutes, and another (n=1, 6%) held sessions longer than 60 minutes.

The level of instructor expertise was reported in some, but not all, of the reviewed studies. Specifically, 12 of the 23 (52%) studies indicated that classes were taught by a licensed or highly experienced (>10 years) exercise professional. These included 6 licensed physical therapists, 3 certified trainers, 2 Tai Chi–trained or experienced instructors, 1 kinesiologist, and 1 adapted physical educator. The remaining studies indicated that “trained” staff were used, but did not specify the level or duration of training; in others, this information was not provided. Details about the specific strategies and instructional methods employed were also lacking in most of the reviewed studies. Nevertheless, the majority of interventions (17/23, 74%) appeared to be led by a single instructor. Among those that reported using multiple instructors, 3 out of 6 (50%) employed 2 licensed instructors (eg, physical therapist or certified trainer), while the other 3 (50%) used a licensed instructor in combination with “trained volunteers.”

Outcome measures varied, but most aimed to assess aspects of physical function, particularly functional strength and dynamic balance. In the few studies that did not include these measures, the primary outcomes were acceptability or usability of a digital platform by older adults, although the training still targeted improvements in movement and physical performance. Muscular strength or endurance was the most commonly assessed metric (16 of 23 studies), with the “30-second chair stand” and “timed up and go” tests being the most frequently used in 7 and 5 studies, respectively. Other moderately common physical outcome measures were static standing balance (n=6), aerobic capacity (n=5), body composition (n=5), and gait speed (n=3). Although the magnitude of the results varied, most studies reported improvements in at least one—but often not all—of the assessed physical function metrics.

Acceptability and usability were also commonly reported, with 17 out of 23 (74%) studies including at least 1 related metric. These measures included attrition (10 of 17), adherence to prescribed activity (n=8), and attendance (n=8), with some studies reporting more than 1. Most found high acceptability, with over 80% adherence and attendance in 63% of the studies reporting each metric (5/8 for both). Among those reporting attrition (n=10), 3 (30%) studies had rates over 25%, while 5 (50%) reported rates less than 10%. Additionally, of the 23 studies, 4 (17%) used study-specific acceptability surveys, 3 (13%) conducted qualitative interviews, and 1 (4%) assessed perceived difficulty at multiple time points. These usability and qualitative data suggest that participants generally perceived the digital platforms as user-friendly and the exercises as beneficial.

Injuries specifically related to the intervention or measurement, as well as adverse events more broadly, were inconsistently reported, with only 10 studies providing any relevant data. Of these, 5 tracked all adverse events, while the remainder tracked only falls (n=4) or serious exercise-related events (n=1). Among the reporting studies, 4 indicated no adverse events, 3 reported events in both the intervention and control groups, 2 reported only intervention- or measurement-related events, and 1 reported events without specifying whether they were related to the intervention or measurement (though they were likely related). Of the 6 studies reporting adverse events, 4 provided severity details, with only 1 reporting any serious adverse events (injurious falls).

Additional quality of life data were collected via survey in 15 of the 23 studies. Validated quality of life instruments were most common (10 of 15), although the specific tools varied widely, with no single survey used in more than 2 studies. Depression was also relatively frequently assessed (6 studies). Other occasionally measured outcomes included self-reported physical activity (n=4 studies), fear of falling (n=4 studies), resilience (n=3 studies), self-efficacy to exercise (n=2 studies), and comfort with technology (n=1 study). The vast majority of studies reported improvements in quality of life, resilience, and self-efficacy, as well as reductions in depression following the digital intervention.

Further details regarding the study populations, interventions, and significant results are provided in Tables 1 and 2. Table 1 summarizes the sample and intervention characteristics of the reviewed manuscripts, while Table 2 outlines the measures used and the results reported.

Discussion

Principal Findings

This scoping review examined the quantity and quality of publications on digitally delivered, instructor-led group exercise classes aimed at improving physical function and preventing falls among older adults. Eligible studies included randomized and nonrandomized trials, as well as single-arm pilot studies, conducted over at least 6 weeks, regardless of the number of weekly sessions.

Overall, only a small number of studies met our inclusion criteria (n=23). Considering the wide range of exercise programs now delivered online, the growing internet use among older adults, and the increasing public health emphasis on the benefits of exercise for this population, the limited number of eligible studies was somewhat surprising. We anticipate that the number of eligible studies will grow substantially as more exercise programs are designed and delivered digitally. Of the articles published between 2006 and July 2024 that met our inclusion criteria, 11 were randomized controlled trials, while the remainder comprised 7 single-group studies and 5 two-group pre/postcomparison nonrandomized studies. The studies represented populations from 14 countries, offering noteworthy racial, ethnic, and geographical diversity among older adults.

Most studies included in this review did not compare digital programs with in-person equivalents, making it impossible to determine whether digital delivery is superior—or even noninferior—to traditional “live” exercise programming. Nevertheless, digitally delivered programs generally improved physical outcomes related to lower limb strength and balance, with some also demonstrating gains in cardiovascular function and upper body strength. In addition, evidence suggests these interventions tended to enhance overall quality of life and reduce depression among participants.

It is also worth noting that participants responded positively to the digitally delivered experience when queried. Although rarely reported [32,34,36,37], studies that assessed older adults’ comfort with technology found that those who took part in the interventions improved their ability to use technology in general, and videoconferencing in particular. More importantly, the relatively high adherence and attendance rates across these studies suggest that technological challenges did not substantially reduce participation. In fact, adherence rates were comparable to those seen (~70%) in healthy older adults [45] and the 60%-70% observed in clinically defined groups [46] engaged in live exercise interventions. Although this level of adherence to a technological intervention is promising, it is important to note that individuals willing to participate in such interventions may already be more knowledgeable about, or more comfortable with, technology than the general population. Given previous findings on difficulties with technology among some older adults [5,6], caution should be exercised when generalizing these results to other older adult populations.

Although many of the included studies did not provide detailed information on injuries, it appeared that few adverse events—and very few serious adverse events—resulted from digitally delivered exercise programs. High-quality evidence on injury rates specifically among older adults initiating an unsupervised, video-based exercise program is lacking. However, during the COVID-19 lockdown, a survey of British citizens found that approximately 14% of the adult population sustained an injury while exercising, with more than 30% of these injuries occurring during video- or app-led exercise [47]. While some of these injuries were likely due to overuse or unavoidable factors, it is reasonable to assume that real-time digital classes led by a live instructor may help address certain safety concerns associated with prerecorded, video-based instruction. In particular, monitoring proper form and progression—especially when paired with personalized instruction and feedback—can reduce injuries related to limited exercise knowledge or fatigue-induced changes in movement. However, even in live digital formats, instructors may need to position themselves at a considerable distance from their recording device(s), which often also serve as their class display device (eg, laptop or tablet). As such, viewing participants with enough clarity to offer meaningful, form-based feedback can be challenging. In larger classes, participants may appear in increasingly smaller windows, or the instructor may have to forgo viewing all participants simultaneously—both of which hinder effective observation. These limitations make it difficult for a digital instructor to provide timely and precise feedback. While this review does not aim to draw a definitive conclusion on the matter, it is plausible that having a second instructor dedicated solely to real-time feedback could enhance safety and sustain participant engagement.

The limited reporting regarding the specifics of the intervention—such as instructor expertise, exercise details and progressions, at-home exercise prescriptions (if any), and, perhaps most importantly, the amount and type of instructor feedback—is worth highlighting. Although these details could likely be obtained by directly contacting the study authors, their absence in the published reports substantially limits the ability to compare interventions and assess reproducibility. Given that “exercise” can vary widely in domain (eg, cardiovascular, strength), intensity, and level of instruction, explicitly reporting these details is essential. While this holds true for exercise interventions in general, it is particularly critical for emerging digitally delivered programs—especially those targeting geriatric populations and other groups at higher risk for injury. Similarly, the limited reporting of adverse events hinders the ability to assess the relative safety of these interventions and reduces the confidence with which they can be recommended to at-risk individuals.

Strengths and Limitations

A strength of our study is the diversity of the sample included in the review, encompassing 14 countries with multiracial, multiethnic, and economically varied populations worldwide. This breadth—though an incidental outcome—underscores the global interest in fall prevention, particularly through exercise-based interventions. Another strength lies in the variety of outcome measures used in most, though not all, of the studies reviewed, offering a more comprehensive understanding of intervention effects.

Although this scoping review offers a reasonably comprehensive overview of currently available digital exercise programs, several limitations should be acknowledged. First, our conclusions are based on the evidence presented in the reviewed articles and on the assumption that, had there been meaningful injuries (in either number or severity), they would have been reported. However, because most of the reviewed studies did not include adverse event data, our conclusions regarding safety may be unreliable. Perhaps the most significant limitation of this review is the absence of any formal assessment of the quality of the included studies and their reported data. While this egalitarian approach ensures the inclusion of a wide range of studies, it does not account for variations in methodological rigor, the presence of a control group, or sample size. Furthermore, no meta-analysis was conducted to determine the actual effect size of this type of intervention. Consequently, although general conclusions can be drawn, caution is warranted when interpreting the overall efficacy of digital exercise interventions for improving physical function, enhancing quality of life, or reducing fall risk. Additionally, because our review focused exclusively on digital interventions in (mostly) healthy individuals, these findings are not generalizable to clinically relevant subpopulations who may stand to benefit most from high-quality digital programs. Finally, although the 3 databases used in our search likely captured all relevant manuscripts published in English, it is possible that including additional databases could have yielded further relevant studies.

Insights/Future Directions

The results of this scoping review indicate that digitally delivered, instructor-led exercise interventions for older adults show considerable promise, offering improved accessibility while fostering participant engagement and emphasizing safety. Despite heterogeneity in design, the reviewed studies collectively suggest that such interventions can support meaningful improvements in lower-body strength, balance, and quality of life, while maintaining high acceptability and adherence. This suggests a conceptual framework in which digital group exercise programs enhance physical function through both physiological and psychosocial pathways—leveraging not only movement but also social connectedness, routine, and perceived competence with technology. The presence of a live instructor appears central to this process, acting as both a facilitator of physical safety and a source of motivation and encouragement. Yet, variability in reporting across studies—particularly in instructional strategies, feedback mechanisms, exercise progressions, and the number and severity of adverse events—underscores the need for standardization. This is especially critical when addressing safety and adverse event reporting. Studies should explicitly state when no injuries or adverse events occurred, rather than omitting safety information from reports on intervention effects. Comprehensive tracking and reporting of adverse events, including those occurring outside of direct instruction, would not only help establish the relative safety of such interventions but also clarify which populations are most appropriate for participation. Similarly, detailed reporting of exercise programming, progression, and instructor training and engagement strategies is essential to enable replication, synthesis, and iterative development. As digital instruction continues to proliferate and evolve, situating these interventions within broader determinants of healthy aging—such as autonomy, self-efficacy, and digital literacy—can inform both future research and practical implementation.