The Lifestyle-integrated Functional Exercise (LiFE) program and its modifications: a narrative review

As of now, there are four group formats of the LiFE program (Table 1). First, the idea of delivering LiFE in a group was raised by Gibbs et al. (2015) in a primary care context. Their group format of LiFE (Mi-LiFE) included four group sessions and two telephone debriefings, but still contained one individual home visit to ensure the fit of LiFE activities to participants’ home environment. Further details on the intervention setting and results of their evaluation study (Gibbs et al., 2019) are listed in Table 1. Recently, Fleig et al. (2016) published a pilot study on a group LiFE version (Everyday Activity Supports You—EASY) which contained an extended behavior change concept, e.g., a stronger focus on goal setting, action planning, and habit formation. In their pilot study, participants were solely female and 66 years old on average. A third pilot group LiFE version was presented by Li et al. (2018) who focused on the residential community setting. In their study, the time frame of the intervention period was extended compared to original LiFE. All these studies provided valuable input for the development of the group-based LiFE (gLiFE) format which was developed as part of the LiFE-is-LiFE project (Jansen et al., 2018), a randomized non-inferiority trial. Unlike in earlier studies (Fleig et al., 2016; Gibbs et al., 2015; Gibbs et al., 2019; Li et al., 2018), gLiFE was developed and evaluated with clear focus on large-scale implementability (Kramer et al., 2020) and compared against the original LiFE regarding effectiveness and cost-effectiveness (Jansen et al., 2021).

The main difference between LiFE and gLiFE is their delivery format (Table 1). gLiFE is delivered in groups of 8–12 participants and led by 2 trainers (1 main trainer and 1 co-trainer). While the single trainer in LiFE serves as a teacher and facilitator during home visits, gLiFE trainers’ roles are to teach the LiFE contents and to facilitate interaction between participants. Other than the 1.5 h LiFE home visits, gLiFE group sessions have a duration of 2 h. Furthermore, each gLiFE session follows a predefined order and is designed in an interactive manner including group discussions and practicing activities together with peers (Kramer et al., 2020). In comparison to LiFE where all LiFE activities are introduced in the first session, LiFE activities are introduced gradually and repeated in the subsequent session in gLiFE. This helps participants to familiarize themselves with the LiFE activities and to try them out between sessions. Furthermore, the behavior change concept was extended in gLiFE grounding on the health action process approach (Schwarzer, 2008) and self-determination theory (Ryan & Deci, 2000). In addition, the intervention contents were coded using the behavior change techniques taxonomy (Michie et al., 2011). In gLiFE, each participant receives the German version of the LiFE participants’ manual (Clemson, Munro, Singh, Schwenk, & Nerz, 2019) and a workbook. An activity planner and activity counter are combined in the workbook in order to simplify the planning and self-monitoring procedure (Kramer et al., 2020). In addition, specific gLiFE material was developed (e.g., posters with the LiFE principles and LiFE activities) to support group teaching.

The initial feasibility testing of gLiFE was reported jointly with the intervention concept (Kramer et al., 2020). The results showed positive group experiences and participants implemented 75% of the activities learned during gLiFE sessions, which is comparable to the adherence rate reported for LiFE (76%). Reicherzer et al. (2021) conducted a qualitative focus group analysis that showed a high acceptance rate of gLiFE among 30 participants. gLiFE participants’ attitude and motivation to participate was positively associated with learning in a group. One critical aspect of gLiFE identified in this analysis was that the implementation of activities into everyday life which was perceived as more difficult compared to LiFE.

In summary, gLiFE is the culmination of earlier pilot studies on a group-based LiFE format with a strong focus on large-scale implementability and is the first group-based LiFE approach tested in a larger sample. The current results indicate that the gLiFE concept is a feasible and accepted alternative to the original LiFE. The publication of the main results of the LiFE-is-LiFE trial including gLiFE’s potential for large-scale implementation and its cost-effectiveness are currently in preparation (Jansen et al., 2021). Several secondary analyses regarding the underlying psychological mechanisms are currently under investigation.

In recent years, four adapted versions of LiFE for younger seniors (EASY-LiFE, adapted LiFE [aLiFE], enhanced LiFE [eLiFE], Thai LiFE [TLiFE]) were developed to prevent early functional decline by providing an adequate level of difficulty and possibilities for progression (Table 2).

In 2016, Fleig et al. had adjusted the content of the EASY-LiFE approach to women at retirement age. Their group variation of LiFE is described in the section above and only includes women ≤ 70 years. They highlighted this target group because the point of retirement has been shown as a good opportunity to change healthy behaviors and reduce risks for upcoming chronic diseases.

Another adaption of the original LiFE program to younger seniors, aLiFE, was developed as part of the EU-funded PreventIT project. Herein, aLiFE was created as an intervention with more challenging tasks suitable for young seniors between 60–70 years. Contrary to LiFE, aLiFE aims to prevent age-related functional decline and includes both basic and more challenging activities for individual tailoring and progression of training in young seniors. aLiFE is delivered equally to the original LiFE (Schwenk et al., 2019). Contentwise, more challenging strength and balance activities are included. By using the aLiFE Assessment Tool (aLAT), trainers can individually adjust participants’ strength or balance activity levels based on a standardized procedure. In aLiFE, the new strength principle increase the range of your motion is added. Task challenge levels vary between levels 1 and 4 but are more challenging than in LiFE. Exemplary challenging strength activities in aLiFE are the one-legged squat or lunge, whereas LiFE only implements usual squats. Stepping, hopping and jumping in different ways is a new balance principle introduced in aLiFE. Through this added principle, aLiFE comprises agility activities that are based on square-stepping exercises. The seven balance activities are carried out just as in LiFE and also gLiFE. Again, more challenging balance activities such as one-leg stand with eyes closed plus cognitive task (e.g., counting backwards) are added. To reduce sitting time and interrupt sedentary phases, and to walk more, aLiFE includes structured recommendations for integrating PA into specific routines compared to original LiFE. For example, participants can park the car further away from the grocery store to walk more. Some adaptions were also made to the original behavioral change framework. To foster habit formation, individual activity goal setting, planning, and prompts were implemented into aLiFE.

Two further noteworthy approaches for younger seniors are modifications of the aLiFE program. Taraldsen et al. (2020) adapted aLiFE to an ICT-based delivery format (eLiFE) which will be described in detail in the following, while Ounjaichon (2020) implemented this modified version in Thailand and named it TLiFE. Adapted to the Thai lifestyle and culture, she embedded specific TLiFE activities into daily life.

Unlike EASY-LiFE which was investigated in women, the feasibility and acceptance of aLiFE was also tested in male younger seniors (Schwenk et al., 2019; Boulton et al., 2019). The aLiFE pilot feasibility trial of Schwenk et al. (2019) showed an increase in balance and mobility as measured by the Community Balance and Mobility Scale (CBMS). aLiFE participants implemented on average 12.1 (±1.8) out of 16 activities into their daily life; strength activities were most frequently implemented, followed by balance activities and PA. The frequency of practice ranged between 3.6 and 6.1 days/week depending on the activity (Schwenk et al., 2019). A study with older seniors reported 4.9 days/week of LiFE practice (Burton et al., 2013), which means that aLiFE achieved a similar level of adherence. Within the 4‑week pre–post intervention pilot study, aLiFE was additionally evaluated via interviews and focus groups with both participants and trainers. The evaluation was positive regarding participants’ perception about the overall program (Boulton et al., 2019). Participants appreciated the flexible and individual approach and valued the personalized tailoring by trainers. Trainers confirmed the benefits of the delivery format to the target group. In the short 4‑week timeframe, participants were not able to implement a large number of activities into their daily routines and found this burdensome. However, they were able to create new habits with some activities. Both participants and trainers reported extensive study paperwork but changes to this had already been made reflecting suggestions after this pilot study.

The acceptability and feasibility of the TLiFE program was investigated in older adults aged 60–75 years. The majority of the participants were fully (57.1%) or partially (40.0%) engaged in TLiFE after 6 months. Furthermore, results suggested that the TLiFE program was acceptable and safe for conducting a larger RCT for further evidence (Ounjaichon, 2020).

In summary, the transfer of LiFE to the population of young seniors seems to have been successful resulting that lifestyle-integrated functional exercises do not have to be limited to simple activities as in original LiFE but can also include more complex activities promoting the prevention of earlier functional decline in younger seniors.

To date, there is one existing ICT-based LiFE format. Enhanced by an eHealth smartphone and smartwatch-based system, the eLiFE program combines behavioral changes and ICT in a further implicit approach of integrating functional exercises into daily routines targeting younger seniors (Taraldsen et al., 2019).

The eLiFE program implements the same lifestyle-integrated exercise intervention as aLiFE but differs in the delivery format: eLiFE is enhanced by a smartphone- and smartwatch-based system in which contents are delivered through video clips, pictures, and text/verbal instructions for each activity. eLiFE provides motivational messages and real-time feedback to the users to keep them engaged in the program. According to their individual progress, eLiFE participants receive tailored recommendations to upgrade their activities via app compared to a series of home visits and phone calls as in aLiFE. eLiFE instructors only support participants to understand and undertake the program in four home visits so that they learn how to set goals and include activities into daily life situations (Table 2).

In a multicenter, feasibility RCT in three European countries (Norway, Germany, Netherlands) as part of the European PreventIT project, 180 younger seniors (ages 61–70 years) were randomly assigned to either eLiFE, aLiFE, or control group (Taraldsen et al., 2020). The feasibility of the digital technology delivery format of eLiFE was investigated and both programs were compared. Within the 12-month intervention duration, participants were supported by a trainer for the first 6 months and were then encouraged to continue with their individual activity program for the following 6 months (unsupervised follow-up). aLiFE and eLiFE indicated new habit formation during the first period which were sustained at follow-up. eLiFE’s overall concept was generally well accepted. However, some challenges due to technical issues of the delivery format were reported. Improvement in clinical outcomes was found in all groups, but no significant differences in change between the three groups (Taraldsen et al., 2020).

In conclusion, results suggest that functional and behavioral changes can be achieved through different pathways. It was shown that the ICT-based eLiFE enriches daily routines by challenging participants’ balance and strength capacity.

There is one existing adaptation of LiFE within a multicomponent intervention, which is called LIVE LiFE (Table 2). Like the original LiFE, the program also targets community-dwelling adults aged 70 years and older. However, LIVE LiFE not only includes balance and strength training, which is integrated into daily routines, but also an additional individualized home safety assessment, home hazard elimination, vision contrast screening, and a medication review. Thus, this program incorporates both intrinsic and extrinsic fall risks (Granborn et al., 2019). Results from an initial pilot study showed that all fall-related measures in the intervention group improved after 16 weeks. A statistically significant difference between the intervention and control group could be shown in tandem standing time for example which provides evidence for further investigations (Szanton et al., 2021).

Older adults with cognitive, visual, or mobility disabilities are at particular risk of functional decreases (van Alphen et al., 2016; Ivers, Cumming, & Mitchell, 2003). Currently, there are four modified versions of LiFE for populations with disabilities (Table 3): LiFE for people with dementia (LiFE4D), LiFE for people with dementia in acute care (diaLiFE), LiFE for people using Restorative Home Care Service and LiFE for older adults with visual impairments (v-LiFE).

One of these modifications was developed by Almeida et al. (2020) who adapted LiFE for people with dementia (LiFE4D). In addition to the already included activities for lower limb strength and balance in the original LiFE, they complement components for upper limb functionality, flexibility, and cardiorespiratory endurance. Moreover, educational and psychosocial components, such as talks and flyers on dementia-related topics (e.g., fall prevention, communication, support in the community) are included. The program lasts 3 months and comprise face-to-face sessions in a familiar environment of about 1 h and telephone calls of no more than 15 min. It starts with three weekly face-to-face sessions in the first month and ends with one weekly face-to-face session and one phone call biweekly in the last month and finally only two phone calls in the last week (Almeida et al., 2020). Belala et al. (2019a) took a first step to develop an early rehabilitation and transitional care intervention for people with dementia in acute care (diaLiFE). They investigated the feasibility and acceptability of the original LiFE exercise framework in cognitive impaired people in a clinical setting. Burton et al. (2013, 2014a, b) modified the LiFE program for the use in a restorative home care setting. Restorative home care services are short-term services for 6–12 weeks with the goal of helping older people regain function and regain or maintain independence, often after hospitalizations. For this purpose, the paperwork is adjusted to save time for the care managers. In addition, instead of five sessions in original LiFE, participants receive three sessions over the time. Within these three sessions, the LiFE program is only one aspect of their service. Keay et al. (2015) reported an adaptation and implementation of the LiFE program as a fall prevention strategy for adults over 50 years with visual impairments (v-LiFE). Due to visual limitations, the program is delivered by orientation and mobility (O&M) specialists (Dillon, Clemson, Coxon, & Keay, 2018). Just like the original LiFE program, v‑LiFE consists of three balance and four strength principles. The program is delivered through five sessions weekly, two booster visits within 3 months, two support services after the visits, and two additional sessions if needed. In support of this, v‑LiFE participant’s manual is created specifically for this target population in audio, large print, and electronic formats (Keay et al., 2018).

A number of studies investigated feasibility, acceptability and effectiveness of these modified LiFE versions for older adults with disabilities. In a pilot study, Almeida et al. (2021) explored feasibility and preliminary effectiveness of LiFE4D in 12 sedentary people with minor to major neurocognitive impairment. The authors reported an average adherence of 95.6% to the sessions. Potentially relevant functional progress in the LiFE group was found for cardiorespiratory endurance and balance. However, the group was too small to actually be able to make statements about effects. Numerous other measurements (e.g., upper and lower limb muscle strength) also showed no effect (Almeida et al., 2021). Belala et al. (2019a) recruited 20 inpatients from a subacute geriatric rehabilitation center with mild to moderate cognitive impairment. In this pilot study, they found a good acceptance rate for the overall activity framework in cognitive impaired people in a clinical setting. However, the activities were only feasible under supervised conditions and with support by trainers. The LAT was conducted successfully, but floor effects occurred in every activity. This reflected that the activities were too demanding for part of the subjects and must be started at a lower level. Accordingly, adjustments of LiFE activities are needed before it can be applied in a hospital population. The amount of adjustment is probably dependent on the target population of inpatients. In order to avoid floor effects and enable an autonomous and safe training, even lighter exercises should be integrated into the program, e.g., heel raises (calf raises) in standing position with both hands on a wall instead of walking on heels. To obtain further information for developing an adapted activity framework, Belala et al. (2019b) conducted an observational study to analyze activity behaviors and reasons for physical inactivity among cognitively impaired hospitalized individuals. Results revealed that subjects were inactive for more than 85% of the observed time and that sedentariness was linked to the time spent alone, to the presence of neuropsychiatric symptoms and to the daytime. While most therapeutic and nursing activities took place in the morning, there was a lack of activities in the afternoon, which could be used for the implementation of LiFE activities. LiFE was also found to be feasible for inclusion in a restorative home care setting (Burton et al., 2014a). There were no differences between groups in adherence, but significantly better outcomes for the LiFE group in 40% of the measures (Burton et al., 2013). Six months later, this effect was still evident in 25% of the outcome measures (Burton et al., 2014b). Therefore, the inclusion of LiFE instead of classical exercise programs might demonstrate a possible alternative for organizations that provide restorative home care services in order to improve functional outcomes.

v‑LiFE was evaluated regarding feasibility and acceptability in a pilot study (Keay et al., 2015). Significant positive effects were obtained in fall rates and function, making the program a promising approach to improve balance and strength in adults with visual impairment (Keay et al., 2015). Improvements in the pilot evaluation supported the plan to conduct a large-scale trial (pragmatic RCT) to evaluate the effectiveness, cost-effectiveness, and implementation of this strategy (Keay et al., 2018). Both quantitative and qualitative data are processed for the process evaluation (Dillon et al., 2018). The results of the process are currently pending.

In summary, modified versions of the LiFE program have been shown partial evidence for the feasibility, acceptance, and effectiveness in different populations with disabilities and different settings. Further studies are needed to explore whether clinical relevant effects can be achieved in terms of health and quality of life and to compare them to those of structured exercise programs.

This article shows that several modifications of the LiFE program have been made and evaluated since the development of the original LiFE program by Clemson et al. in 2010. Modifications range from different delivery formats as group approaches to ICT-based programs implemented using a mobile app (application). In addition, adaptions were made to reach younger target groups as well as older adults with disabilities. The numerous modifications of the original LiFE program highlight the high need for effective falls prevention for the heterogeneous population of older adults.

So far, the original LiFE program is best investigated with respect to effectiveness regarding falls rate and physical function. A RCT with a large sample (N = 317) showed excellent feasibility and positive effects on balance, strength, and fall rates in adults aged 70 years and older (Clemson et al., 2012). The reduction in falls of 31% exceeds the average fall reduction described in Cochrane reviews. To date, several studies suggest (e.g., Gibbs et al., 2019; Kramer et al., 2020) that the feasibility of group formats of LiFE is comparable to the original format in terms of adherence rates, safety, and acceptability. Most recent findings of a randomized non-inferiority trial suggest that gLiFE is comparably effective regarding functional outcomes and strongly improves physical activity to a greater extent than LiFE. On the other hand, non-inferiority regarding physical activity-adjusted fall risk was inconclusive (Jansen et al., 2021).

The adaption to young seniors (aLiFE) is in the feasibility stage. Current studies show promising results with respect to feasibility for short-term (Schwenk et al., 2019; Boulton et al., 2019) and long-term interventions (Taraldsen et al., 2020). Pilot studies indicated effects on balance and mobility (Schwenk et al., 2019) and changes in PA patterns (Zhang et al., 2018), event after a short period. However, evidence is low due to uncontrolled study designs. On the same note, no significant differences between groups were found in primary outcomes in a large-scale RCT (Taraldsen et al., 2020), suggesting that aLiFE needs to be refined to include more appropriate task challenges. The implementation and feasibility in the Thai context has been investigated and confirmed so far (Ounjaichon, 2020). Further studies evaluating the effectiveness of this version (TLiFE) are needed.

Participants’ overall satisfaction with the ICT-based eLiFE was shown in the PreventIT project in which delivery of a 6-month lifestyle-integrated intervention via ICT was as successful as via the traditional paper-based format (Taraldsen et al., 2020). However, primary outcome measures of this RCT did not differ between intervention groups and controls, again highlighting the need for program refinement to improve effectiveness.

Feasibility of a multicomponent LiFE format was demonstrated by Granbom et al. (2019). The multicomponent LIVE LiFE format improved all performance measures with small to large effect sizes, showing significant differences between the intervention and control group (Granbom et al., 2019). This pilot study provided a good basis for large-scale studies.

Overall, the results of the modified LiFE formats for populations with disabilities suggest good feasibility, i.e., high adherence rates were shown for people with dementia in LiFE4D. However, the small sample size of the pilot study (Almeida et al., 2020) diminishes the power of the results and more robust methods are required in further investigations. DiaLiFE, as a clinical setting approach, is still in the development stage. To date, it is unclear whether the hospital setting is appropriate to facilitate behavior change with respect to PA. However, it might present an important part of future transitional care interventions. Burton et al. (2013) investigated the feasibility of the LiFE program in a Restorative Home Care Service. Participants disliked some of the exercises but were still able to perform them correctly (Burton et al., 2013). Nonetheless, the positive short-term as well as long-term effects are predominating and promote the aim of increased PA (Burton et al., 2014b). v‑LiFE is the first fall prevention program for the visually impaired, filling a major gap in current orientation and mobility services (Keay et al., 2018). Should the results of the pragmatic RCT (N = 500) show v‑LiFE’s effectiveness and efficacy, both individuals and the health care system may benefit.

The main potentials of LiFE are the integrated, personal approach, adjusted to the individual daily schedule although the personalized approach comes with a challenge: implementing LiFE during seven home visits requires high resources and thereby hampers large-scale implementation. Although group-based LiFE formats might be able to facilitate cost-efficient implementation of LiFE, participants might struggle with meeting at fixed appointments or transferring exercises from group training to daily routines at home. On the other hand, the group-based delivery could come with benefits through presence of peers and a sense of relatedness.

The aLiFE adaptation seems to be a time-efficient program for preventing functional decline in young seniors but has difficulty with providing adequately challenging tasks. TLiFE provides the same potential for younger Thai seniors. The transfer to the ICT-based eLiFE format for younger seniors has realistic potential for a simplified and even cost-effective delivery. Nevertheless, technical issues with the mobile app required additional home visits during the intervention period and need to be considered and revised.

The potential of the multicomponent LIVE LiFE program lies in combining adapted components. However, the cost factor is a particular challenge of the program.

LiFE for populations with disabilities are useful extensions of the program. While LiFE4D shows additional potential for improving health-related cardiorespiratory fitness and balance for people with dementia, diaLiFE is a promising format to increase PA during hospitalizations and after discharge. However, one key question of the program is whether the program results in inpatients can be successfully transferred from the hospital to the home environment. With LiFE in Restorative Home Care Services, there is an additional approach promoting the regain of independence. But time constraints of caregivers pose immense challenges to the successful and effective implementation of this format. Also, the time-intensive referral process by specially trained orientation and mobility specialists presents a unique challenge for v‑LiFE. Nevertheless, this visually impaired group with high risk of falls needs to be considered in future modifications.