Evidence summary (Updated 2022)
A systematic review identified eleven trials investigating the effects of exercise interventions on gait ability in those with frailty. Six studies revealed improvements in gait after the physical training period, whereas five studies demonstrated no improvement. Three of the studies that demonstrated improvements used multi-component exercise programs, two studies used only resistance exercises, and one study used endurance training combined with yoga. The mean improvement in gait ranged from 4% to 50% .
Ten studies investigated the effects of exercise interventions on balance. Eight of the investigations revealed enhanced balance after the physical training period, whereas two studies did not demonstrate any improvement. Seven of the studies with balance improvements used multi-component exercise programs that included balance training, and one study included Tai Chi exercises. The mean improvement in balance ranged from 5% to 80% .
Thirteen studies investigated the effects of exercise interventions on lower-body muscle strength. Nine studies revealed increased muscle strength after the physical training period, whereas four studies did not identify any improvement. Five of the studies that demonstrated enhanced strength used resistance exercise programs, and four studies used multi-component exercise interventions. The mean increase in strength ranged from 6% to 60% 
A meta-analysis found no effects upon gait speed (n= 3 studies, SMD -0.06 (CI -0.49 to 0.37), moderate heterogeneity) or timed up and go speed (n = 2 studies, SMD 0.57 (CI -0.01 to 1.16), low heterogeneity), but significant differences in muscle strength (n = 4, SMD 0.44 (CI 0.11 to 0.77)), moderate heterogeneity) and balance (n = 3 studies, SMD 0.33 (CI 0.08 to 0.57), low heterogeneity)) were observed. Included studies were generally small and low quality, with short follow-ups and focused on observed physical functioning outcomes .
Recent systematic review showed significant improvements in: handgrip (SMD 0.51, p = 0.001) and lower-limb strength (SMD 0.93, p < 0.001), agility (SMD 0.78, p = 0.003), gait speed (SMD 0.75, p < 0.001), postural stability (SMD 0.68, p = 0.007), functional performance (SMD 0.76, p < 0.001), fat mass (SMD 0.29, p = 0.001), and muscle mass (SMD 0.29, p = 0.002). This was true for both early and late stages of sarcopenia and frailty .
A further study in healthy adults >60 showed aerobics combined resistance/strength training (CEX), multi-component training (ME), and dance combined training have positive had significant effects on physical performance (upper and lower body strength, dynamic balance, fall risk, mobility, gait, agility, flexibility) in the elderly. CEX was superior versus aerobic training (AER) alone and resistance/strength training (RES) alone in gait speed, lower limb strength, and trunk fat. CEX was superior to AER in improving sitting and stretching, elbow flexion, knee flexion, shoulder flexion and stretching, strength, body fat, function reach test, 30-s chair standing test and 6-min walking test, and self-evaluation of body function .
In a further SR of community dwelling frail elderly at risk of falls (5960 people) showed significant improvements in: mobility (sit-to-stand, TUG, gait speed); injurious falls incidence. No change in single leg balance or overall falls incidence . Further corroborated by Zhang et al: Exercise interventions improved knee extension strength, walking speed, timed up-and-go test (TUG), semi-tandem balance, Berg balance scale (BBS), Short Physical Performance Battery (SPPB), Physical Performance Test (PPT) and ADLs 
Multi-component exercise interventions can currently be recommended for pre-frail and frail older adults to improve muscular strength, gait speed, balance and physical performance, including resistance, aerobic, balance and flexibility tasks. RT (alone) was also suggested to be beneficial, in particular for improving muscular strength, gait speed and physical performance, and should be considered as part of a multi-component exercise intervention. Other types of exercise were not sufficiently studied and their effectiveness is yet to be established. Exercise combined with nutritional interventions was also comparatively little studied and results were mixed 
A smaller SR in nursing home patients of any age found exercise did not significantly reduce odds of falling (OR 0.88, CI 0.48-1.49), but did significantly improve TUG scores (SMD -0.39, CI -0.64 to -0.13, p=0.003), and the gait component of the performance-oriented mobility assessment (POMA-G) (SMD 0.36, CI 0.07 – 0.66) 
Quality of evidence
B – large number of studies with large numbers but with heterogeneity in the studies.
Strength of recommendation
1 – strong
Group exercise may produce some benefits to physical functioning, in particular strength and balance, but conclusions limited by moderate heterogeneity. Exercise prescriptions that start slow and are then gradually titrated to continually deliver a training stimulus in the form of volume, intensity and complexity will be most effective.
Multi-component exercise interventions can currently be recommended for pre-frail and frail older adults to improve muscular strength, gait speed, balance and physical performance, including resistance, aerobic, balance and flexibility tasks
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