Evidence summary (Updated 2022)
Physical exercise programs are generally effective for reducing or postponing frailty but only when conducted in groups. Favourable effects on frailty indicators are also observed after the interventions, based on physical exercise with hormone supplementation, supplementation alone, cognitive training and combined treatment. Group meetings and home visits are not universally effective. There is lack of efficacy for physical exercise performed individually or delivered one-to-one, hormone supplementation and problem-solving therapy .
Exercise classes including a combination of moderate-intensity aerobic exercise, progressive strength training, flexibility and balance result in significant improvements in total scores of the frailty checklist compared to control groups (exercise group from 7.41 ±98 to 7.11 ± 4.00, control group from 7.34 ± 4.27 to 8.02 ± 4.81, P < 0.001). Individual components with significant improvement include forgetfulness, seclusion, emotion and daily domains, there is no significant difference in other domains .
Moderate physical activity at least once a week is associated with improved frailty progression in those aged 65 and over as well as those aged 50–54. A greater improvement in frailty progression occurs in adults who report vigorous physical activity at least once a week .
Updated review since 2018 shows resistance band exercises demonstrates significant reductions in frailty score after 24 weeks (SMD -0.29, CI -0.55 to -0.03), and depression score after 12 and 24 weeks 
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 .
Physical activity is one of the most effective frailty interventions. Main NMA result: PA interventions reduced frailty (SMD -0.92, CI -1.55 to -0.29). However quality of evidence was low or very low. More robust RCTs are needed to increase the confidence of our NMA results and the quality of evidence .
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 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 
Quality of evidence
B Large numbers but some heterogeneity of studies
Strength of recommendation
Exercise is likely to reduce frailty severity and progression. The strongest evidence is for group-based programmes which include aerobic, strength and balance training. 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. Vigorous activity is probably more effective than moderate exercise in limiting frailty progression (strength, energy, mobility) but this may be unachievable in a large proportion of frailty patients.
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