Introduction
Regular physical activity is essential for healthier and happier aging; however, global levels of physical activity remain insufficient, and current trends indicate that we are unlikely to meet established targets for improvement.1,2 Health-oriented organizations face significant challenges in ensuring the long-term sustainability of interventions.3,4 While many programs show initial success, they often fail to establish lasting behavioral changes5,6, and the long-term maintenance of physical activity remains limited.7
Compounding this challenge, the modern lifestyle is increasingly characterized by prolonged sedentary behavior, driven by technological advancements, digitalization, and shifts in both occupational and leisure activities. This has led to a significant reduction in natural movement and more sitting time. In response to these trends, ensuring the long-term sustainability and satisfactory adherence of activity programs has become a critical priority.
Sustainability refers to the continued use of intervention components to maintain desirable health outcomes, encompassing both the long-term effectiveness of the program itself and the sustained engagement in physical activity of participants.4 The primary challenge is ensuring that behavioral changes persist beyond the structured intervention, becoming an integrated part of daily life. In this context, sustainability is not only defined by the program’s ability to create lasting behavioral change but also by the proportion of participants who continue engaging in physical activity over time, regardless of variations in individual adherence levels.
On the other hand, adherence refers to the extent to which an individual consistently follows a prescribed exercise regimen, reflecting both the frequency and regularity of participation.8 Unlike sustainability, which considers the broader persistence of participation across the entire group, adherence focuses on the individual’s commitment to following the recommended exercise routine.
However, no single intervention strategy has been universally effective in enhancing sustainability and/or adherence to exercise programs among older adults.9 Research suggests that approximately 50% of participants in physical activity programs drop out within the first six months,10 with further declines over longer follow-up periods,11 despite initially high levels of self-determined motivation during the intervention.12
A recent review reaffirmed that while exercise-based interventions for older adults can lead to short-term improvements in physical activity levels, their long-term effectiveness is often disappointing.13 Notably, only one study has demonstrated a stable, positive long-term trajectory.14 Similar findings have been observed in objectively measured sustained increases in physical activity levels following interventions, generally showing only modest effects and highlighting the need for additional support to maintain long-term engagement.15 Moreover, limited data exist on the mid- and long-term effects of strategies designed to enhance sustainability.13 To our best knowledge, only one study examined various fitness programs for older adults, reporting sustainability rates ranging from 33% for multi-activity programs to approximately 61% for fitness-focused programs over a ten-month period.16 Importantly, a recent study on sustainability confirmed that maintaining the effects of an exercise intervention requires continued participation, as no lasting effects were observed beyond the active research period in a long-term follow-up.6
These findings underscore the importance of integrating behavioral strategies, including understanding the wider context of physical activity in late life, to support both the sustainability of participation and adherence in exercise.17 Qualitative research has enhanced identification of complex factors influencing physical activity adherence18, and our understanding of how both program and participant characteristics impact adherence is crucial.19 Factors such as personalized program design, social support, self-efficacy, and the integration of physical activity into daily life have been identified as key contributors to the long-term success of the interventions.15
Several studies have explored the perceived barriers and facilitators of long-term physical activity among older adults and individuals with chronic conditions. This includes research on physical therapy interventions20 and broader studies on exercise adherence in populations with chronic diseases.21,22
It is important to note that long-term exercise interventions (≥1 year) in older adults are safe and do not pose an increased risk.23 Recent research has shifted focus from structured training sessions targeting isolated fitness components to functional exercises integrating complex, lifestyle-oriented movements5 and holistic approaches.24 Moreover,technology-based exercise interventions have been found effective,25 acceptable,26 and feasible.27 Given that digital literacy and access to technology vary widely among older adults, these differences may influence the uptake and effectiveness of technology-based interventions in this population.28–30
Building on existing scientific evidence and published experiences, we aimed to develop an exercise program that would foster long-term sustainability and ensure high adherence. The design of the PERMANENTO program was informed by principles of Self-Determination Theory,31 which emphasizes autonomy, perceived competence, and intrinsic motivation. These key elements were addressed through educational content, flexible delivery, and user-centered structure. To achieve this, we integrated three essential components. First, an educational element was incorporated to enhance participants’ understanding of movement principles and empower them to take an active role in their physical health. Second, given the growing role of digital solutions in health promotion, technology-based exercise programs offer a promising avenue for improving accessibility, flexibility, and long-term engagement. In context of this context, digital video-based technology enabled a home-based format, allowing participants to engage with the program at their own pace and convenience. Finally, by focusing on natural and functional movement patterns and incorporating principles of developmental kinesiology, the program adopts a novel approach that might further support physical competence and enhance daily functioning in later life.
The PERMANENTO program was developed as a home-based, low-threshold intervention grounded in developmental kinesiology and inspired by the Original Strength framework.32 It emphasizes natural movement patterns such as diaphragmatic breathing, head and eye control, and contralateral coordination – elements often used in rehabilitation but rarely translated into preventive exercise for older adults. Although no formal co-design process was conducted, the program was shaped by collaboration with professionals and informal feedback from older adults engaged in community-based activities, helping to ensure clarity, relevance, and usability. Its structure and content were also aligned with established behavioral principles to support intrinsic motivation and long-term engagement.
It is designed to support the fundamentals of functional fitness, which are crucial for the comfortable performance of daily leisure and self-care activities. Its feasibility was successfully tested in a randomized controlled trial.33 In this study, we focused on both actual and potential sustainability at the six- and twelve-month follow-ups, while also examining individual adherence rates. Additionally, we aimed to identify perceived barriers, facilitators, and benefits through self-reported questionnaires. Our goal was to address critical gaps in the understanding of long-term sustainability and adherence in physical activity programs among older adults.
We hypothesize that while sustainability will decline over time, it will remain above 50% at the twelve-month follow-up. Furthermore, we expect that more than 30% of participants will maintain high adherence levels at both six and twelve months. Finally, we anticipate that the identified barriers and facilitators will be consistent with previous research, reinforcing existing evidence on long-term engagement in physical activity programs.
Materials and Methods
Participants
The study participants comprised 82 independent, home-dwelling older adults (mean age 73.7 ± 3.4; 77% female) who were recruited through organizations providing activities for older adults (Život 90, Senior Fitness, Elpida, Právě teď, Inbaze, and Universities of the Third Age). All of these participants were part of a previously conducted 12-week randomized controlled trial (RCT) evaluating the acceptability, feasibility, and effects of a home-based online exercise program PERMANENTO.33,34 For ethical reasons, participants originally assigned to the control group were offered access to the same intervention immediately after the 12-week RCT period. This design ensured that all participants eventually received the program, avoiding the long-term withholding of a potentially beneficial activity. As a result, the follow-up data presented in this manuscript reflect outcomes from both former intervention N=45 and control N=37 groups, all of whom agreed to engage with the program after the RCT concluded. A sample size calculation was conducted using Statulator software. With an expected effect size of 0.20, alpha set at 0.05, and power of 0.95, a total of 72 participants were required. To accommodate potential dropout, 98 older adults were recruited from community settings. Methodological details are described in a Czech-language publication34 and in a preprint of a feasibility study currently under peer review.33 The participants were randomly allocated to intervention and control groups. Simple randomization was conducted electronically using Microsoft Excel by an independent researcher who was not involved in recruitment or data collection. No stratification was applied. The trial was conducted in Prague, the Czech Republic, between February and May 2023.
Online Exercise Program PERMANENTO
The program available at https://permanento-vekunavzdory.cz/ consists of educational and exercise parts. The educational part (10 chapters of the platform) includes relevant topics necessary to understand the wider context of aging in the modern world. The exercise part (9 chapters of the platform) offers 9 complex video routines ranging from 12 to 17 minutes that can be performed while sitting on a chair (#1, 2, 3), standing by a chair (#5, 6), or lying on a mat (#4) or a bed (#7, 8, 9). The exercises are inspired by developmental kinesiology. The main principles include activation of the diaphragm through breathing, activation of the vestibular apparatus through head movements and nods, and contralateral movements.32 These principles are performed in a set of varying movements enriched by other gentle motions supporting proper posture and functional components necessary for the safe and confident performance of daily activities, such as strengthening phasic muscles, stretching postural muscles, and joint movements. The intervention trial plan was to exercise at least 6 days a week for 12 weeks and then maintain the engagement according to individual needs.
Measurements
The custom-designed self-report questionnaire used at the six- and twelve-month follow-ups combined closed, semi-open, and open-ended items to capture both quantitative and qualitative aspects of participants’ engagement with the PERMANENTO program. All participants were asked to complete the same non-standardized online questionnaire at both the six-month and twelve-month follow-ups after the intervention. The questionnaire allowed for open narrative responses, giving participants the opportunity to share personal experiences, motivations, challenges, and feedback in their own words. The questionnaire was reviewed for face validity by an expert panel of physiotherapists and academics and piloted before use.
The questions were structured to reflect different levels of adherence (non-, irregular, and regular exercisers) and tailored accordingly, using adaptive logic to present relevant questions based on the respondent’s reported activity level. Key domains included: Current PERMANENTO engagement, Barriers and facilitators to participation, Perceived benefits of the program, Preferences for exercise format, Suggestions for improvement and open reflections on the program.
Actual and Potential Sustainability
Participants were asked to respond to the question: “How are you currently doing with the PERMANENTO exercise program?” by selecting one of the three response options: (1) I do not exercise, (2) I exercise irregularly, or (3) I exercise regularly. Based on their responses, participants were categorized into distinct groups. The questionnaire then continued with tailored follow-up questions specific to each group, ensuring that the subsequent inquiries aligned with their reported exercise status. To further assess participants’ engagement and earlier-mentioned potential sustainability, those who reported exercising irregularly were asked whether they would like to establish a regular exercise routine. Similarly, participants who indicated that they do not exercise were asked whether they would like to return to regular exercise. This approach allowed us to evaluate the potential for sustained participation over time and provided an opportunity to further explore the perceived barriers and facilitators influencing long-term engagement in physical activity.
Adherence
In the context of this study, adherence was assessed as the degree to which participants maintained engagement with the exercise program over time, distinguishing between high adherence (regular participation), moderate adherence (irregular participation or engagement limited to once per week), and no adherence (no participation). The cut-off for high adherence (≥ 2 sessions per week) was chosen pragmatically, guided by WHO recommendations and findings from previous studies showing that long-term adherence to physical activity programs in older adults often falls below 30%.35–37 This level was therefore considered a meaningful benchmark for sustained engagement. High adherence was further subdivided into three categories based on exercise frequency: (1) most commonly 2–4 times per week, (2) most commonly 5–6 times per week, and (3) an attempt to exercise daily. Moderate adherence was further categorized into four subgroups based on exercise patterns: (1) exercising consistently but only once per week, (2) exercising with fluctuations in frequency, sometimes more and sometimes less, (3) periods of intensive exercise alternating with periods of no exercise, and (4) sporadic exercise, only when remembered.
Perceived Barriers, Facilitators, and Benefits
The questionnaire explored key factors affecting long-term participation, including perceived barriers, facilitators, and the benefits of exercise, using a combination of semi-open and open-ended formats.
To better understand why some participants did not engage consistently, those who exercised irregularly were asked: “Why do you exercise irregularly?” (semi-open). Participants who did not exercise at all were asked: “Why do you not exercise at all?” (semi-open). Additionally, to identify possible strategies for increasing adherence, all respondents in these groups were asked: “What would need to change for you to engage in regular exercise or restart exercising?” (open-ended). Lastly, to gain insight into the perceived benefits of the program, participants were asked: “In what specific ways has regular or even irregular participation in the PERMANENTO program helped you?” (semi-open), with the opportunity to elaborate further under the option “Other”.
Data Analysis
Data analysis involved both quantitative and qualitative approaches. Descriptive statistics were used to summarize both actual and potential sustainability, with frequencies and percentages reported for each category of engagement (regular, irregular, and no-exercisers) at both the six-month and twelve-month follow-ups. Adherence was analyzed in the same manner, with further examination of subcategories within high and moderate adherence to assess participant distribution. Semi-open questions were employed to identify the participants’ perceived barriers and benefits.
For qualitative data, open-ended responses were systematically analyzed to identify recurring themes related to perceived barriers, facilitators, and benefits of participation. A thematic analysis38 was conducted, beginning with a careful review of responses to recognize significant patterns. Open coding was applied to extract key concepts, which were then grouped into broader categories based on conceptual similarities. These categories were refined to ensure clarity and avoid overlap. Finally, the identified themes were clearly defined, providing insight into factors influencing long-term engagement in the program. This structured approach ensured a reliable interpretation of the qualitative data. Responses to open-ended questions were voluntary. At both follow-up time points, more than 50% of participants provided narrative responses, which formed the basis for the qualitative analysis.
Results
The baseline demographic characteristics of the participants are presented in Table 1. A total of 82 participants took part in the initial randomized control trial. There were no statistically significant differences between the control and intervention groups. The mean age at the time of data collection was 74 years. Participants were primarily female (77.4%) and highly educated (53.7%).
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Table 1 Demographic Characteristics of the Total Number of Participants and in Accordance with Allocation to the Groups
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Actual and Potential Sustainability
The actual and potential sustainability at six and twelve months post-intervention is presented in Figure 1. Of the total sample (N=82), responses were collected from 76 participants (92.7%) at six months and 67 participants (81.7%) at twelve months, while 6 (7.3%) and 15 (18.3%) participants, respectively, did not respond. Discontinuation of exercise was observed in 13.4% (11/82) of participants at six months and 11% (9/82) at twelve months.
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Figure 1 Actual and potential sustainability of the PERMANENTO program at six- and twelve-month follow-ups. Proportion of participants reporting no, irregular, or regular engagement in the exercise program, those expressing willingness to (re)start, and missing responses. Total N = 82.
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At six months post-intervention, actual sustainability, defined as the proportion of participants exercising either regularly or irregularly, was 79.3% (65/82), decreasing to 70.7% (58/82) at twelve months. However, potential sustainability, defined as the proportion of participants who expressed a willingness to exercise regularly, was significantly higher, reaching 89% (73/82) at six months and 78.1% (64/82) at twelve months. This increase was driven by eight individuals from the no-exercise group reporting willingness to start exercising at six months, and six participants at twelve months. As a result, only 3.7% (3/82) of participants would remain non-exercisers at both time points.
Interestingly, a high number of participants expressed a desire to transition from irregular to regular exercise, with 25 participants at six months and 22 participants at twelve months indicating their intention to improve their exercise habits.
Adherence
Adherence levels at six and twelve months are presented in Figure 2. At six months (N=76), high adherence (regular exercisers) was observed in 51.3% (39/76) of participants. Within this group, 10.3% (4/39) attempted to exercise daily, 28.2% (11/39) exercised 5–6 times per week, and 61.5% (24/39) exercised 2–4 times per week. Moderate adherence (irregular exercisers) was reported by 34.2% (26/76), with participants engaging in exercise at varying frequencies. Among them, 23.1% (6/26) exercised once per week, 57.7% (15/26) fluctuated in frequency, 7.7% (2/26) alternated between intensive exercise and inactivity, and 11.5% (3/26) engaged in sporadic exercise only when remembered.
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Figure 2 Adherence patterns by frequency in PERMANENTO program at six- and twelve-month follow-ups. Exercise frequency among high-adherence participants (A and B) and moderate-adherence participants (C and D). N = 76 at 6 months (39 high, 26 moderate); N = 67 at 12 months (32 high, 26 moderate).
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At twelve months (N=67), high adherence was maintained by 47.8% (32/67), with 40.6% (13/32) attempting to exercise daily, 15.6% (5/32) exercising 5–6 times per week, and 43.8% (14/32) exercising 2–4 times per week. Moderate adherence was reported 38.8% (26/67), with 46.2% (12/26) fluctuating in frequency, 19.2% (5/26) alternating between intensive exercise and inactivity, and 34.6% (9/26) engaging in sporadic exercise only when remembered.
Barriers, Facilitators, and Perceived Benefits
The quantitative results based on participants’ responses to semi-open multiple-choice questions are presented in Figures 3 and 4. Qualitative results derived from participants’ responses to open-ended questions are presented in Tables 2–4.
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Table 2 Perceived Barriers: Thematic Analysis of Factors Affecting Sustainability and Adherence in the PERMANENTO Program
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Table 3 Perceived Facilitators: Thematic Analysis of Factors Affecting Sustainability and Adherence in the PERMANENTO Program
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Table 4 Perceived Benefits: Thematic Analysis of Factors Affecting Sustainability and Adherence in the PERMANENTO Program
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Figure 3 Perceived barriers at six- and twelve-month follow-ups. Self-reported reasons for irregular or no exercise group. N = 26 (irregular); N = 11 (no exercise) at six months; N = 26 (irregular); N = 9 (no exercise) at twelve months. Note. Data from both time points were combined for analysis as subgroup separation was not deemed clinically or analytically necessary.
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Figure 4 Perceived benefits of participation at six- and twelve-month follow-ups. Self-reported effects among regular and irregular participants. N = 65 (6 months); N = 58 (12 months). Note. Data from regular and irregular participation groups were combined for analysis, as both cohorts responded to identical semi-open multiple-choice questions. Subgroup separation was not deemed clinically or analytically necessary, given the absence of a priori hypotheses regarding differential responses between participation patterns.
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Regarding barriers (Figure 3), participants who reported exercising irregularly most commonly cited combining it with another type of exercise (34 responses) as the primary reason. Other frequently mentioned reasons included exercising only when needed (22), having other duties (15), exercising based on mood (7), or linking it to external motivation, such as receiving mail (6) or traveling (5). Among those who did not exercise at all, the most common reason was a lack of willpower (8), followed by a lack of time (5) and already engaging in their own form of exercise (5). Health issues (4) and discomfort with the activity (4) were also reported as barriers to participation.
The thematic analysis of open-ended questions regarding barriers (Table 2) identified five key themes. (1) Time and energy constraints emerged as a major challenge, with participants struggling to find time for exercise due to work, housework, and irregular schedules, often feeling too exhausted to engage in physical activity. (2) Health and physical limitations were another significant barrier, as medical conditions, surgeries, pain, and injuries restricted participants’ ability to exercise consistently. Some participants prioritized (3) alternative physical activities, such as yoga, weight training, or cycling, which either replaced or limited their engagement with the intervention. (4) Disruptions in routine and life transitions, including seasonal changes, participation in a control group, or starting a new job, also contributed to inconsistencies in exercise habits. Lastly, (5) external challenges, such as a lack of internet access or not living at home, further hindered participation.
The thematic analysis of facilitators (Table 3) identified five key themes. (1) Time and organization emerged as a crucial factor, with participants citing a need for better planning and time management. (2) Social support played a significant role, with respondents highlighting the importance of exercising in groups or with a partner. (3) Health and physical factors were also prominent, including rehabilitation needs, concerns about health deterioration, and appropriate exercise intensity. (4) Motivation, both external (rewards, research projects, professional feedback) and internal (self-discipline, intrinsic drive), influenced engagement in exercise. (5) External conditions, such as accessibility, space constraints, and weather conditions, affected participation. Additionally, having varied and adaptable exercise programs, including playful and customizable elements, was seen as beneficial.
Regarding benefits (Figure 4), the most frequently reported benefits among exercisers (both regular and irregular) at the six- and twelve-month follow-ups included overall improvement in well-being (43/42) and an increased sense of flexibility and stretch (41/37). A considerable number of participants also noted increased energy levels (20/20) and enhanced confidence (18/21). Fewer respondents reported improvements in persistent health issues (9/8) or feeling physically stronger (4/4). These findings suggest that even intermittent engagement in the program may contribute meaningfully to both physical and psychological well-being. The thematic analysis of perceived benefits (Table 4) of exercise also identified five key themes. (1) Physical benefits and pain relief were frequently mentioned, with participants reporting reduced pain, relief from fatigue, and correction of movement imbalances. (2) Improved movement and body awareness emerged as a significant factor, as participants felt more in tune with their bodies and recognized inefficient movement patterns. (3) Motivation, habit formation, and consistency played a crucial role, as participants developed a strong commitment to regular exercise, integrating it into their daily routines. (4) Flexibility and autonomy contributed to adherence, with the ability to exercise anytime, anywhere, and adjust workouts freely being highly valued. (5) Exercise variety and balance enhanced enjoyment and effectiveness, as well-structured and diverse workouts kept participants engaged.
Discussion
This study investigated the long-term sustainability and adherence to the home-based online exercise program PERMANENTO among community-dwelling adults over 70 years of age at six- and twelve-month follow-ups. The study confirmed all predefined hypotheses, demonstrating promising implications for clinical practice. Sustainability remained well above 50% at the twelve-month follow-up, and over 30% of participants maintained high adherence at both six- and twelve-month follow-ups. Additionally, the identified barriers and facilitators aligned with previous research, reinforcing existing evidence on factors influencing long-term engagement in physical activity programs.
These findings highlight the potential effectiveness of the intervention in promoting sustained exercise participation and suggest its applicability in clinical and preventive healthcare settings, while also emphasizing the importance of behavioral reinforcement, individualized programming, and contextual relevance in maintaining long-term engagement in physical activity.39,40
Our study demonstrated that integrating the three components, including education, the flexibility of an online home program, and a focus on natural and functional movement patterns, is a promising approach to supporting long-term participation in daily structured exercise. At six months, 79.3% of participants demonstrated actual sustainability, which declined to 70.7% at twelve months. Despite this decline, potential sustainability remained high, with 78.1% of participants at twelve months expressing willingness to re-engage under favorable conditions. These rates exceed those observed in many structured physical activity interventions, where attendance often drops significantly within six months.13 Notably, only about 42% of participants in multi-activity physical activity programs would continue for ten consecutive months.16 While short-term participation above 80% can be achieved in clinical trials, long-term sustainability remains either poor or untested globally, particularly once individuals transition out of in-person supervised sessions to the home environment41,42 which is posing a significant challenge.43
A critical factor contributing to sustainability was the educational component, which helped participants understand aging and the role of physical activity in maintaining health. Studies suggest that when individuals comprehend the benefits of physical activity, they are more likely to sustain participation.17 Educational content may have strengthened intrinsic motivation and self-efficacy.44 Understanding the “why” (health) and the “how” (technique, recovery) gives people a sense of control45 and aligns with Self-Determination Theory, which highlights autonomy, intrinsic motivation, and perceived competence as critical drivers of long-term behavioral change.31 This is reflected in participant e-mail feedback of a 72-year-old female who stated:
The theoretical explanation of the principles and effects of regular exercise on ‘core strengthening’ gives me hope that my aging will be graceful, pleasant, and natural. I am delighted that I can actively prepare for this stage of life without fear of the future.
Such insights underscore how education fosters empowerment, enhancing sustainability beyond intervention trials.
At six months, 51.3% of participants adhered to the program at least twice a week, with 47.8% maintaining this level at twelve months. These rates surpass those observed in conventional fitness programs, where dropout rates often reach 50% within six months.10
To the best of our knowledge, few studies have reported follow-up adherence rates at 6 or 12 months for digital exercise programs targeting older adults. Most interventions assess adherence only during the active program period. Our twelve-month adherence rate of 47.8% surpasses typical figures for digital or home-based programs, which often fall below 30%.35,36 This aligns with recent findings from a Japanese cohort using a peer-supported mobile app, where 46% of participants maintained daily walking at 12 months.46 While cultural and delivery differences limit direct comparison, these findings support the potential of low-threshold, autonomy-driven interventions. In contrast to the pooled 21% adherence observed in fall-prevention trials,37 our program demonstrated both high adherence and over 70% sustained engagement at one year. These findings highlight the relative novelty and robustness of the PERMANENTO approach in sustaining long-term engagement among older adults.
Among those with high adherence at twelve months, 40.6% exercised daily, suggesting that habit formation and routine-based engagement play a key role in long-term sustainability, making exercise an automatic part of life.47 Meanwhile, 43.8% of the high adherence group exercised two to four times per week, indicating that a structured but flexible approach supports continued participation. Participants with moderate adherence exhibited greater variability, with 46.2% fluctuating in frequency and 34.6% engaging in sporadic movement only when remembered. The findings indicate a positive difference compared to adherence levels in patients with cardiac failure, where the adherence rate at twelve months was 35% in the enhanced usual care group.48
Despite high motivation among many participants, our findings highlight a notable intention-behavior gap. This observation is consistent with,49 who reported that approximately 46% of adults with strong intentions to exercise fail to translate them into action. This suggests that, beyond fostering intention, interventions must also support behavior enactment through strategies such as planning, habit formation, and contextual reinforcement to sustain long-term physical activity.
The video-based format of the intervention appears to mitigate adherence decline, allowing participants to adjust their engagement based on individual needs and schedules.5 Longitudinal studies suggest that structured but adaptable home-based interventions sustain adherence better than rigid, gym-based programs6 and can achieve or exceed those of supervised, in-person programs, especially when they include support mechanisms such as digital feedback, social engagement, or personalized reminders.50 However, the lack of real-time supervision presents a challenge, particularly for individuals needing external motivation or professional feedback. Previous research emphasizes the importance of interactive components in digital interventions to optimize long-term adherence.39 However, digital literacy can influence adherence levels, as those with lower digital literacy may struggle with technology-based interventions.40 But this was not observed in our study, likely due to our sample consisting of elite and highly educated participants. Previous research has shown that individuals with higher education are more likely to successfully engage with online interventions, suggesting that digital competence may act as a facilitator of long-term participation in similar programs. These specific participant characteristics may have contributed to the fact that, in contrast to other studies,28–30 our research did not identify organisational-level challenges commonly associated with the digital transformation of exercise programs, such as onboarding difficulties, technical issues, structural disruptions, feelings of isolation, or decreased motivation.51
The functional movement focus of the program likely played a critical role in maintaining engagement. Unlike traditional fitness programs that emphasize isolated strength or endurance training, functional exercises improve balance, mobility, and neuromuscular coordination, supporting natural movement patterns.5 Studies suggest that older adults are more likely to sustain participation in programs where exercises directly enhance daily functionality rather than those centered solely on fitness metrics.6 Our findings reinforce this, with many participants reporting improved mobility, flexibility, energy levels, and confidence in daily tasks. These benefits align with research demonstrating neuromuscular advantages of functional movement training23 and confirm that exercise adherence is strongly linked to subjective well-being rather than objective fitness outcomes.13
Many participants reported enhanced movement awareness and reduced discomfort in daily activities. One participant noted: “My body movement improved”. Another emphasized improved body symmetry and movement efficiency: “Before, I moved a lot, but unilaterally, so my body was unevenly loaded without realizing it”. Such feedback underscores the program’s capacity not only to enhance functional ability but also to foster greater self-awareness in movement patterns, which are vital for autonomy in later life. These insights complement the quantitative outcomes, reinforcing the value of integrating subjective assessments and participant narratives into program evaluation.
Surprisingly, even irregular participation provided meaningful benefits, supporting the “every movement counts” paradigm. Many participants reported improved well-being even if they did not strictly follow the program. This aligns with WHO recommendations that any level of physical activity contributes to overall health and function.2 Given that fluctuations in health, motivation, and external circumstances frequently disrupt physical activity in older adults,14 the findings highlight the importance of flexible engagement models. Allowing for nonlinear participation patterns reduces the risk of disengagement, as participants do not perceive temporary lapses as failures but rather as pauses before resuming activity.
Previous research suggests that even minor improvements in mobility or well-being can create a positive feedback loop, fostering long-term adherence.18,52 Other facilitators include group-based exercise, having more available time, exercising “on doctor’s orders”, or having greater intrinsic motivation. Despite these positive findings, barriers to long-term sustainability persist, particularly to lack of motivation, health-related limitations, time constraints, and external obligations. Those who exercised irregularly reported that the primary reason for their inconsistency was engagement in other forms of physical activity. These challenges align with recent research, where commonly reported barriers to physical activity maintenance included lack of self-motivation (41%), time constraints (33%), illness or injury (29%), and family obligations (23%).53 Our analysis revealed that perceived barriers and reported facilitators aligned. For example, the barrier “I have little time to exercise” frequently mirrored the facilitator “I would exercise if I had more time”. Some respondents focused on constraints, and others identified potential conditions for change, revealing a spectrum from problem-focused constraints (eg, time scarcity) to solution-focused opportunities (eg, time availability as a catalyst for change). By using a combination of semi-open and open-ended questions, we maximized the depth of insight, allowing for a nuanced understanding of individual variability. This alignment of barriers and facilitators mirrors findings from qualitative studies on older adults’ exercise motivations, where perceived constraints often coexist with aspirational conditions for change.54 Addressing these challenges requires targeted support strategies that strengthen intrinsic motivation and establish a stable physical activity routine, as has been emphasized in previous studies.53
Given the increasing demand for scalable, accessible preventive care for older adults, digital exercise programs such as PERMANENTO may represent a valuable and cost-effective addition to existing services. Healthcare systems should consider integrating such programs into standard care pathways and explore options for reimbursement to support equitable access. These steps would align with broader goals in healthy aging and promote long-term engagement in physical activity beyond clinical trials.
Limitations
This study has several limitations. Self-reported adherence measures may introduce recall and social desirability bias, suggesting the need for objective tracking methods, such as wearable monitors, to improve accuracy. This reliance on self-reporting also limits the generalizability of our findings, as it may not fully reflect actual behavior. Additionally, while the study assessed sustainability at six and twelve months, long-term effects within and beyond one year remain unknown, warranting extended follow-ups to examine both continued engagement and the sustainability of exercise-related effects, rather than just participation itself. Although the engagement in participation is a critical factor in physical activity adherence.
Another limitation is a sample composition, as participants were predominantly highly educated and motivated individuals, which may not fully represent the general population. Future studies should aim for larger and more diverse cohorts, ensuring a more representative sample that includes individuals with varying educational backgrounds, fitness levels, and digital literacy. The homogeneity of our current sample may therefore limit the applicability of the results to more diverse older adult populations. This would provide a clearer understanding of potential barriers to engagement in broader clinical and community settings.
Moreover, the lack of real-time supervision in this video-based intervention may have limited guidance for participants requiring external motivation or professional feedback. In the context of clinical applications, future research should explore hybrid models that combine online home-based programs with in-person group sessions, as this may enhance engagement, accountability, and overall adherence while leveraging the benefits of both flexibility and social support.
Conclusion
This study confirms that long-term sustainability and adherence to a home-based, online exercise program for older adults are both achievable and beneficial. Program sustainability remained above 70% at twelve months, with nearly half of the participants maintaining high adherence, exceeding typical retention rates observed in physical activity interventions. Our twelve month adherence rate of 47.8% is more than double the average adherence reported in fall-prevention programs (~21%).37 Notably, even irregular participation led to perceived improvements in well-being, flexibility, and confidence, reinforcing the value of flexible engagement models tailored to individual capacities. These findings emphasize the effectiveness of combining educational content, technology-supported flexibility, and functional movement approaches to promote long-term participation. As one participant expressed,“The theoretical explanation of the principles and effects of regular exercise on ‘core strengthening’ gives me hope that my aging will be graceful, pleasant, and natural.” From a clinical perspective, integrating online programs with periodic in-person group sessions could further enhance adherence through social connection and support. Overall, the study offers insights into the development of scalable, sustainable interventions that support healthy aging and long-term physical activity engagement in older populations.
Trial Registration
The trial was retrospectively registered at ClinicalTrials.gov (NCT06133894) on November 14th, 2023, and is available at https://clinicaltrials.gov/study/NCT06133894?term=NCT06133894&rank=1.
Data Sharing Statement
The data supporting this study’s findings are available from the corresponding author, KM, upon reasonable request.
Ethics Approval and Informed Consent
The Ethical Committee of the Faculty of Humanities, Charles University, Prague, Czech Republic, UKFHS/152517/2021, 017021/Ren, approved the study design, along with the written informed consent form that was signed by all participants prior to the initial testing. All methods were performed following the Declaration of Helsinki.
Consent for Publication
Consent for publication was granted by all participants.
Acknowledgments
We appreciate each participant’s contribution and the study members’ participation.
The authors acknowledge the use of ChatGPT (OpenAI, GPT-4, March 2025) for language refinement and stylistic editing during the manuscript preparation. The tool was used exclusively to improve clarity and readability. All scientific content, analysis, and interpretation remain entirely the work of the authors.
Funding
This research study was funded by NU22-09-00447 (2022–2025).
Disclosure
The authors declare that they have no competing interests in this work.
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