The purpose of this study was to investigate the effects of a multimodal exercise program on pedal dexterity and balance by comparing older adults from different contexts. In the tapping pedal test, the results showed that for the time factor, both genders of the experimental group from the residential care home and the daily living center improved their performance significantly with both feet (preferred foot and non-preferred foot). In the hospital center, a significant main effect was found for the interaction between time and gender, namely males slightly decreased their performance while females improved theirs with both feet (preferred foot and non-preferred foot). In the control group, a significant main effect was found for time in all contexts; that is, both genders decreased their performance with the non-preferred foot.
It should be noted that in our study, all the older adults without mental pathologies of the experimental group (from the residential care home and the daily living center) improved their pedal dexterity with both feet through regular physical exercise. In other words, our results are in accordance with previous studies, which claim that the pedal dexterity of older adults can be improved through the practice of regular physical exercise [23, 32]. On the other hand, low levels of physical activity and weakness of the lower limbs have been identified as risk factors for functional status decline and falls [20, 28].
Literature emphasizes that an active lifestyle, complemented by regular physical exercise programs, can make an old person capable of performing daily tasks, providing meaningful improvement at the physical level [3, 42, 51].
Furthermore, the muscular structure of the lower limbs presents a strong relation with the mobility and functionality of the older adults . It is evident that the training of balance and muscular strength (especially directed to the lower limbs) can improve the physical function and the functional mobility (e.g., walking speed, transferences, climbing stairs, and standing up from the position of sitting down) and reduce the risk of fall [17, 28, 39].
As mentioned above, the males of the experimental group from the hospital center slightly decreased their performance with both feet from pre- to post-training. This means that the effect of the multimodal exercise program was not enough to improve this ability. Additional studies are necessary to elucidate the effects (with respect to this ability) of exercise on men with mental health disorders. In this way, the risk of injury—namely falls and fractures—is even greater among adults with impaired cognitive functioning [6, 29]. Additionally, it is important to recall that due to their impaired motor and mental function, adults with dementia have an increased risk of falling, and those who do fall run the risk of further injuries .
On the other hand, the females of the experimental group from the hospital center improved their performance with both feet from pre- to post-training. These results are in agreement with other studies that have shown that structured exercise training leads to an increase in physical fitness and function in daily life in adults diagnosed with dementia [18, 19]. Likewise, exercise in old age is increasingly recognized as an important tool to postpone disability and improve function [6, 38]. Carmeli, Zinger-Vaknina, Morad, and Merrick  reported identical results to ours, with females improving their pedal dexterity, that is, an improvement in balance and muscle strength as the result of the applied exercise program.
Furthermore, findings have shown that adults who are generally active have a smaller risk of developing dementia than those who take part in fewer activities. Whether the activity is energy intensive or not plays a minimal role in this context . Even in the oldest subjects (over 85 years), there are indications that regular physical activity protects against the development of dementia .
Exercise for adults diagnosed with dementia can yield physiological, psychological, and emotional effects. There is no basis for assuming that the volume and intensity of exercise components, such as muscle strength, flexibility, and balance, act differently in comparison to adults without dementia. When considering the impact of exercise on cognition and emotion, there is little knowledge regarding the amount and type of activity conducive to better results. Studies in the field of motor learning  indicate that the most important factors for learning are an adequate volume of practice together with a perceived meaningful and motivating task. However, considering our results, we think that additional studies are necessary to elucidate the effects of exercise on adults diagnosed with mental health disorders.
In our study, a pedal dexterity decrease was verified for the non-preferred foot in the control group (from the residential care home [older adults with mental health disorders], the residential care home, and the daily living center) for both genders, from pre- to post-training. In this sense, our results may suggest that the effect of aging is most visible in subjects who prefer the left foot. Nevertheless, further studies are necessary to confirm this hypothesis.
Concerning the Tinetti test, the older adults of the experimental group from the hospital center, residential care home (gender factor: males better than females), and the daily living center improved their balance from pre- to post-training. The older adults from the hospital center, who had shown a moderate risk of fall before the start of the exercise program, presented a low risk of fall after the program. In the residential care home, the males obtained a better performance than females (gender factor). However, after the training, the females were at a threshold that indicates a moderate risk of fall when, at the beginning, they exhibited a high risk. Otherwise, males showed a low risk. For the daily living center, the older adults displayed a low risk of fall after the training, when at the beginning it was moderate.
In summary, in the experimental group, all participants in this study improved their performance from pre- to post-training. Our results showed that the benefits of the multimodal exercise program are numerous, namely in balance, leading to a decrease of the fall risk [17, 35]. As some studies also confer (e.g., [12, 13]), it is expected that the older adults from our sample will be more autonomous when performing activities like sitting down, taking a bath, crossing a street, or cleaning a window.
Studies have shown that improvements in the proprioception and standing balance control of older adults may be specific to the type of physical training undertaken [47, 50]. It is important to mention that in our 12-month exercise program, we applied some Tai Chi exercises. One activity that has shown a strong relationship with the proprioceptive ability is the traditional Chinese exercise of Tai Chi, which involves slow movements and continuous monitoring of the body position. Tai Chi has been associated with increased joint position sense  and a way to enable older adults to feel their joint motion .
In the control group, no significant main effect or interactions were found in any of the context groups. These data are not in agreement with the study developed by Demura et al. , who find that with aging, balance declines especially after 80 years of age. Supported by these results, the authors suggest that the induced alterations through aging have influences on balance . The loss of motor function is a common consequence of old age, and it is associated with adverse health consequences [5, 12].
The major limitation of our study was the difficulty of finding a sufficient number of older adults with mental health disorders who could perform a 1-year program of regular exercise. A key strength of our study is that, to our knowledge, there is not much information or systematic research on this subject (in the Portuguese population). So we believe that our results can contribute to a better understanding of the effect of exercise in the pedal dexterity and balance in old males and females from different contexts.
As a conclusion, we confirmed our previous hypothesis, noting that from pre- to post-training: (1) in the hospital center, males slightly decreased their performance with both feet while females improved theirs; (2) in the residential care home and the daily living center, the older adults improved their performance significantly with both feet. Furthermore, in the Tinetti test, the older adults from the hospital center, the residential care home (gender factor: males better than females), and the daily living center improved their balance. Finally, we believe that Portuguese society should pay special attention to multimodal exercise programs for older adults because they seem to improve some important motor and functional abilities, such as pedal dexterity and balance, contributing in this way to an increase of the autonomy and a better quality of life for the older population.