Key words: Sarcopenia, muscle strength, awareness

Strength training is a modifiable lever for maintaining independence in later life: it preserves muscle mass and function, improves balance and gait confidence, and reduces falls. It is also a modifiable risk factor for frailty (1). The table below links the Rockwood Clinical Frailty Scale (CFS)(2) to three delivery columns so that the same core movement patterns can be scaled safely from “supported” to “power”, matching the individual’s current physiological reserve.

Frailty is more than “getting older”. It is a distinctive long-term health condition characterised by reduced inbuilt reserves across multiple systems, leaving a person more vulnerable to stressors and slower to recover after illness, injury, or medication changes. Importantly, frailty is dynamic: it can worsen with deconditioning and intercurrent disease, but it can also improve with targeted intervention. This matters because it reframes frailty as clinically actionable rather than inevitable—something we can assess, monitor, and treat.

The Rockwood CFS is widely used across community, hospital, and care settings and is a validated tool in adults aged >65 (3). Scoring is based on history relating to function. It is important to further explore history around comorbidities and presentations relating to frailty syndromes such as for example falls , cognition and delirium risk, immobility and polypharmacy, Central is the person’s goals, confidence with everyday tasks and what matters most to the person. A free Rockwood CFS app is also available and can support consistent scoring and documentation across clinicians. The British Geriatric Society has also published helpful guidance on pragmatic prescribing (Figure 1) (4).

Figure 1: BGS link – https://www.bgs.org.uk/PragmaticPrescribing

Although this guide focuses on exercise delivery, it sits within the broader evidence base for frailty care. The cornerstone intervention is Comprehensive Geriatric Assessment (CGA): an MDT-delivered process that assesses medical, functional, psychological/cognitive, and social domains and converts these into a personalised care and support plan (5). In that context, progressive resistance training and balance work are frequently central “active ingredients”, alongside medication optimisation, nutrition support, falls risk mitigation, and tailored management of multimorbidity.

Using the table is intentionally simple. Step 1 is to assign a CFS score using clinical history and functional judgement, then map that band to an initial delivery level: Level 2 for CFS 1–3, Level 1 for CFS 4–6, and supervised rehabilitation rather than an unsupervised home plan for CFS 7–9. Step 2 is the practical prescription: select 4–6 exercises(prioritising a sit-to-stand/squat pattern, stepping or marching, calf raises, lateral hip work, an upper-limb push/pull if tolerated, plus a brief balance “sprinkle”), then use the relevant column to scale support, range, and load. Power intent is introduced only once the movement is repeatably safe and technically consistent.

Delivery should remain time-efficient and progression should be staged. Apply basic “safety first” checks (stable support, appropriate footwear, hazard reduction, clear symptom stop rules), then use dose rules to structure training: two non-consecutive days per week, 10–20 minutes, beginning with one set of 6–10 repetitions (or 20–30 second holds) and progressing stepwise (repetitions → second set → external load). The aim is “challenging but safe”—and progression only happens when steadiness and confidence are maintained. Finally, use musculoskeletal (MSK) modifications to keep symptoms tolerable, and where rapid weight loss is occurring, emphasise muscle protection with planned strength days alongside adequate protein and recovery.

Step 1: Choose a starting level using Rockwood CFS

CFS Group	Typical Presentation	Start Level + Delivery Notes
1-3	Very fit / Well / Managing well. Independent in personal care and daily tasks May be active or keen to be.	Start at Level 2 (standard). Progress to Level 3 once steady.
4	Vulnerable. Slow or easily fatigued; symptoms limit activity.  Still independent day-to-day.	Start at Level 1 (supported) and build towards Level 2 over 2-6 weeks.  Prioritise confidence, consistency, and symptom-guided progression
5	Mild frailty. Needs help with higher-order tasks (shopping, household and transport).  Often reduced walking speed and increase falls concern.	Start at Level 1 (supported). Keep sessions short (10-15 min) initially.  Consider supervised start if recent fall, marked fear of falling, or very low confidence.
6	Moderate frailty. Needs help with outside activities and may need help bathing or dressing.  Often uses a walking aid.	Level 1 (supported) with reduced dose (1 set; 5-8 reps). Strongly consider physiotherapy/falls support service. Focus on safe transfers and steady gait confidence.
7-8	Severe to very severe frailty.  Dependent for personal care; mobility is very limited.  CFS 8 often housebound/bedbound.	Unsupervised home programs are usually not appropriate.  Consider supervised rehabilitation with tailored seated/bed-based strengthening and transfer practice. Goals: comfort, function and safety.
9	Terminally ill.  Life expectancy <6 months (frailty score reflects prognosis rather than function alone).	Goals of care dependent.  Prioritise comfort, symptom control and gentle movement as tolerated.  Avoid prescribing burdensome targets.

 

Step 2: Pick 4-6 exercises and follow the column for your level and “sprinkle” some balance exercise. 

Exercise	Level 1: Supported	Level 2: Standard	Level 3: Challenge/Power
1. Sit to stand (chair rise)	High chair; hands allowed.  Aim for smooth control.	Standard chair.  Arms crossed if able.	Add a backpack OR stand up quicker and sit down slower (only if steady).
2. Squat to chair / Mini-squat	Small range holding a counter or chair.	Tap chair then stand; control the lowering phase.	Deeper range OR add load (as tolerated).
3. Step up / Marching	Marching holds with support (20-30 seconds).	Low step-ups;  Slow and controlled.	Step ups are slightly faster once confident. Keep safe support nearby.
4. Calf raises	Both legs; small range, hold support.	Full range.  Pause at top	Single leg (light fingertip support). OR add load.
5. Lateral hip (side steps)	Side to side weight shifts, holding support.	Side steps along a counter.	Add a band or increase step length while keeping control.
6. Upper body (chose one)	Wall push ups  OR Very light band row.	Lower wall push up OR Moderate band row.	Counter push ups OR Heavier band row (with slower lowering).
7. Balance “sprinkle” (2 minutes)	Tandem stand with support.	Single-leg stand with fingertip support.	Heel-to-toe walk or reduce support (if safe).

 

Safety First Exercise near a stable support (kitchen counter). Wear stable footwear; clear trip hazards.  Stop and seek advice for chest pain, severe dizziness/blackouts or new neurological symptoms.  If you have recurrent falls or feel very unsteady, start with supervised input.	Dose rules (keep it simple) 2 days per week (non-consecutive), 10-20 mins. Pick 4-6 exercises from the grid.  Start: 1 set of 6-10 reps (or 20-30 sec holds). Build: add reps, then a second set, then load (band/backpack).  Effort: “challenging but safe” by the last few reps. Progress only when steady and confident; keep one “easy” session.
Quick MSK Modifications Knee pain: use a higher chair, reduce squat depth, slow the lowering phase.  Hip pain: shorten step length; prioritise sit to stand and calf raises; keep movement controlled.  Back pain: keep torso upright; avoid deep hinge; use support; reduce load initially.  Shoulder pain: skip push/pull options; focus on lower limb program.	Keep walking, but don’t let it replace strength.  Walking is excellent for health.  Strength protects functions and steadiness.  Rapid weight loss (diet or medication): protect muscle – keep strength days and prioritise adequate protein intake.

 

Why these exercises? Sit-to-stand and squat-to-chair rehearse the task people fear losing—rising from a chair—while strengthening quadriceps, gluteals and trunk (6) . Step-ups/marching and calf raises target gait and ankle capacity for stairs and trip recovery (7). Lateral hip steps address hip abductor weakness, commonly driving poor single-leg control and lateral falls (8). A simple upper-body push or row maintains push/pull capacity for carrying, gardening and sport, and provides a stimulus if lower-limb symptoms flare. A short “balance sprinkle” is included because balance-functional training is the consistent exercise ingredient for fall reduction.

Why these levels? Level 1 uses supports, hands allowed, and smaller ranges to build confidence and symptom-tolerant volume. Level 2 standardises full-range strength work. Level 3 adds load and, only when steady, faster concentric intent to train power, which declines early and links strongly to functional performance (9).

The twice-weekly strength and balance dosing mirrors UK Chief Medical Officers’ guidance for older adults (10).

Authors:

Dr Tom Leggett – Para Football, Lead Performance Doctor, The FA; GP and SEM Physician

Dr Callum Innes – ST3 Sport and Exercise Medicine

Dr Andrew Shafik – Club Doctor Chelsea FC; GP and SEM Physician

Dr Malin Farnsworth – Consultant Physician and Geriatrician , Surrey Downs Health and care, GESH hospital group 

References:

(1)Talar, K. et al. (2021) ‘Benefits of Resistance Training in Early and Late Stages of Frailty and Sarcopenia: A Systematic Review and Meta-Analysis of Randomized Controlled Studies’, Journal of clinical medicine. J Clin Med, 10(8). doi: 10.3390/jcm10081630.

(2) Church, S. et al. (2020) ‘A scoping review of the Clinical Frailty Scale’, BMC geriatrics. BMC Geriatr, 20(1). doi: 10.1186/s12877-020-01801-7.

(3) Rockwood, K. et al. (2005) ‘A global clinical measure of fitness and frailty in elderly people’, CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne. CMAJ, 173(5), pp. 489–495. doi: 10.1503/cmaj.050051.

(4) BGS guidelines (2025) https://www.bgs.org.uk/PragmaticPrescribing

(5) Parker, S. G. et al. (2018) ‘What is Comprehensive Geriatric Assessment (CGA)? An umbrella review’, Age and ageing. Age Ageing, 47(1), pp. 149–155. doi: 10.1093/ageing/afx166.

(6) Fujita, E. et al. (2019) ‘Repeated sit-to-stand exercise enhances muscle strength and reduces lower body muscular demands in physically frail elders’, Experimental Gerontology. Elsevier Inc., 116, pp. 86–92. doi: 10.1016/j.exger.2018.12.016.

(7) Hinman, M. R. et al. (2014) ‘Functional predictors of stair-climbing speed in older adults’, Journal of geriatric physical therapy (2001). J Geriatr Phys Ther, 37(1), pp. 1–6. doi: 10.1519/JPT.0b013e318298969f.

(8) Gafner, S. C. et al. (2020) ‘The Role of Hip Abductor Strength in Identifying Older Persons at Risk of Falls: A Diagnostic Accuracy Study’, Clinical interventions in aging. Clin Interv Aging, 15, pp. 645–654. doi: 10.2147/CIA.S246998.

(9) Reid, K. F. and Fielding, R. A. (2012) ‘Skeletal muscle power: a critical determinant of physical functioning in older adults’, Exercise and sport sciences reviews. Exerc Sport Sci Rev, 40(1), pp. 4–12. doi: 10.1097/JES.0b013e31823b5f13.

(10) Department of Health and Social Care (2019) Physical activity guidelines: UK Chief Medical Officers’ report. Available at: https://www.gov.uk/government/publications/physical-activity-guidelines-uk-chief-medical-officers-report (Accessed: 12 February 2026).