Position statement: Evidence-Based Exercise Guidelines for Sarcopenia in Older Adults: Insights from the Korean Working Group on Sarcopenia

Selection of KQs

The committee reviewed position statements published by the European Working Group on Sarcopenia in Older People,2) the Asian Working Group for Sarcopenia,1) and the Korean Working Group on Sarcopenia4) to establish the KQs. The committee selected the five most appropriate KQs based on a review of other position statements considering their national context and clinical importance (Supplementary Table S1). Through an iterative consensus process, the committee prioritized questions that addressed critical gaps in current practice and were most relevant to the Korean healthcare context. The KQs included elements of a typical exercise prescription, including FITT (frequency, intensity, time, and type).

Data Sources and Search Strategy

To answer the KQs, an extensive literature search was conducted using a systematic review of evidence identified through online databases, such as PubMed of the US National Library of Medicine, ScienceDirect of Elsevier, and Springer Link of Springer Nature. Only data from randomized controlled trial (RCT) published between January 1, 2000, and May 31, 2024, were considered. The keywords used for the literature search are described in the Supplementary Materials (Supplementary Table S2). In the review stage, the committee used the Participants, Intervention, Comparison, Outcomes, Time, Setting, and Study Design (PICOTS-SD) framework to determine the scope of inclusion in the literature for the use of systematic review methods. Specifically, we included studies with participants aged ≥60 years with or at risk of sarcopenia; interventions involving structured exercise programs; comparisons with control groups receiving usual care, health education, or no intervention; outcomes measuring changes in muscle mass, strength, or physical performance; timeframes of at least 6 weeks; settings in both clinical and community contexts; and randomized controlled trial study designs. Among the 1,314,218 duplicate studies were excluded using EndNote (Clarivate Analytics, Philadelphia, PA, USA), yielding 36,528 relevant articles. The initially selected articles were further reduced to 335 of the most relevant papers, of which 42 were finally selected, excluding those with no sarcopenia or age <60 years (65 cases), no RCT design (26 cases), exercise not included in the intervention program (154 cases), not written in English (11 cases), and others (37 cases) (Fig. 1). The selected papers were experimental papers with a randomized controlled trial design and clear PICOTS-SD, which provided evidence-based recommendations for the KQs selected by the committee.

Fig. 1.

Flowchart illustrating the systematic literature search methodology and selection process for developing evidence-based exercise guidelines for patients with sarcopenia. Literature sources included PubMed from the National Library of Medicine (NLM), ScienceDirect (Elsevier), and Springer Link (Springer Nature).

Risk of Bias Assessment

The articles selected for review were assessed for quality by two independent reviewers using the Cochrane Collaboration tool to measure the risk of bias. Prior to the formal assessment, the reviewers underwent standardized training and concensus in the use of the Cochrane risk of bias tool to ensure consistency in evaluation. Any conflicts were discussed among the reviewers and then confirmed and finalized. Quality items included potential randomization process bias, deviations from intended intervention bias, missing outcome data bias, outcome measurement bias, and selection of reported result bias. The reviewers evaluated each item as “low risk,” “high risk,” or “unclear risk.” Each domain was assessed according to the specific criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Version 6.3, 2022), with detailed justifications documented for each judgment. Supplementary Figs. S1 and S2 show the results of the risk of bias evaluation for each study by domain. Of the 42 studies, 36 used appropriate methods to generate the allocation sequence, and all applied adequate methods of allocation concealment. The risk of bias was unclear in the remaining six studies owing to insufficient information regarding allocation concealment. The risk of deviation from the intended interventions was low in 30 studies and unclear in 12 studies. The risk of bias owing to missing outcome data was low in 39 studies and unclear in three studies. Outcome measures were appropriate, and the data were unlikely to have been influenced by knowledge of the intervention received. However, two studies did not provide sufficient information. The risk of selection bias among the reported results was low in 34 studies, unclear in 7, and high in 1. Overall, the general risk of bias was low-to-moderate in the included studies.

Procedures for Conclusive Selection and Formulation of Guidelines

Following a review of the evidence from the selected literature, the committee reviewed the capability of applying the guidelines for each KQ by summarizing the contents of the selected evidence as a response to the KQ. The committee employed a structured consensus development method, combining elements of the Delphi technique and nominal group process, to systematically integrate empirical evidence with clinical expertise. Comments from committee members were subsequently collected and recommendations were completed. Based on the applicability review, ratings were provided for the type, strength, and grade of the evidence. The rate of evidence was categorized into four levels (Supplementary Table S3), and the recommendation grade was established according to the committee’s consensus, with a principle of ≥80% (Supplementary Table S4).

KQ1. What types of exercise are effective for each of muscle mass, muscle strength, and physical performance?

First, we summarized the FITT principle of exercises that improved muscle mass based on previous research (Table 1).6-25) Resistance training is the most recommended type of exercise for improving muscle mass in older adults with and without sarcopenia. Two studies that used high-intensity resistance training (HIT-RT) twice weekly for 18 months, with weights set at 60%–85% of one-repetition maximum (1RM) over 12–14 exercises per session, significantly improved lean body mass, metabolic syndrome markers, and muscle quality in the intervention group.6,7) Madrid et al.8) compared weight loss with aerobic training, resistance training, and diet-induced weight loss over 18 months. The resistance training group had better preserved muscle area and improved muscle quality than the other groups. Heo and Jee9) investigated low-, moderate-, and high-intensity resistance exercises in older adults for 12 weeks. Moderate- and high-intensity exercise groups showed increased thigh muscle mass. Balachandran et al.10) conducted a strength training program over 15 weeks, finding significant increases in D3-creatine muscle mass and dual-energy X-ray absorptiometry assessed appendicular lean mass. It has also been reported that aerobic exercise coupled with resistance training can help improve muscle mass. Sheshadri et al.11) focused on dialysis patients, implementing a daily aerobic exercise program for 6 months, leading to increases in total body muscle mass, daily steps, and reductions in fat and body mass index (BMI). Another study examined the effects of walking exercise with nutritional support in older adults over 6 months.12) Both walking groups showed improvements in skeletal muscle mass index (SMI), insulin-like growth factor-1 (IGF-1), and vitamin D (25(OH)D) levels.

Table 1.

Distinct FITT principles for improving muscle mass, muscle strength, and physical function in older adults with and without sarcopenia

Previous studies have recommended resistance exercise for improving muscle strength in older adults (Table 1). Nine trials examined the effects of various exercise modalities on muscle function in older adults with and without sarcopenia, with intervention durations ranging from 8 weeks to 6 months. Chen et al.13) observed that older women with sarcopenia who underwent kettlebell training twice weekly for 12 weeks at 60%–70% of 1RM experienced significant gains in handgrip and back strength. Similarly, Dong et al.14) found that patients with sarcopenia undergoing hemodialysis and engaging in bodyweight exercises with a ball three times a week for 12 weeks showed improvements in grip strength, daily walking pace, and overall physical activity levels. Cebria I Iranzo et al.15) reported that older adults with sarcopenia who engaged in resistance training with dumbbells three times weekly for 12 weeks demonstrated enhanced knee extension and arm flexion strength. Rondanelli et al.16) evaluated a group that received a combination of physical activity and dietary supplements (whey protein and vitamin D) five times a week for 12 weeks. They found an increase in handgrip strength and skeletal muscle mass compared to those in the control group. Kemmler et al.17) conducted a HIT-RT study in older men with osteosarcopenia, showing improvements in leg strength and muscle mass after 8–12 weeks of HIT-RT combined with vitamin D and protein supplements. Resistance exercise has positive effects on muscle strength and function in older adults without sarcopenia. Vitale et al.18) demonstrated improvements in chair-stand test scores and thigh muscle cross-sectional area in participants performing bodyweight exercises or using small weights four times a week over 24 weeks. Tsuzuku et al.19) reported that slow-movement resistance training with body weight led to significant gains in knee extension, hip flexion strength, and thigh thickness compared with the control group. In addition, multicomponent exercise programs combining resistance, balance, and walking exercises can further improve muscle strength and power. For example, Saez de Asteasu et al.20) conducted a study with hospitalized patients and found significant increases in 1RM strength in leg and chest press exercises after multicomponent training sessions held twice daily for 5–7 days. Hassan et al.21) showed that nursing home residents improved grip strength and reduced BMI with a twice-weekly resistance and balance training program over 6 months.

Table 1 summarizes the FITT principles for improving physical function. Bernabei et al.22) investigated the effects of a multicomponent exercise intervention over 36 months in 1,549 older adults with physical frailty and sarcopenia. Participants in the intervention group, who participated in moderate-intensity aerobic exercise, strength training, flexibility training, and balance exercises twice a week at a community center and four times a week at home, showed significant improvements in short physical performance battery scores, grip strength, and appendicular muscle mass compared to the control group. The combined effects of exercise and tea catechin supplementation were evaluated in 128 community-dwelling older women with sarcopenia over a 3-month period. Participants in the exercise and tea catechin groups showed improvements in muscle mass and walking speed, whereas those in the exercise-only group (exercise) showed significant improvements in walking speed.23) The study included 57 older adults with sarcopenia who performed home-based resistance exercises using elastic bands and walked >7,500 steps daily for 12 weeks. The exercise group showed significant improvements in hand strength and walking speed while maintaining their SMI.24) Lee et al.25) examined the effects of resistance, balance, and functional training in 27 postmenopausal women with osteoporosis for 12 weeks. The exercise group performed progressively higher-intensity elastic band exercises three times a week, and their physical function (timed up-and-go [TUG] test) and balance (single-leg stance) improved.

KQ2. What is the most effective way of applying exercises to improve muscle strength and physical performance?

Table 2 presents the findings of various studies that evaluated the effects of exercise interventions on muscle strength and physical function in older adults.26-32) Each study included different groups of participants, including those with and without sarcopenia, and different types of exercises, frequencies, intensities, and durations. Three studies recommended resistance training to improve muscle strength and physical function. Seo et al.26) focused on resistance training using elastic bands in older adults with sarcopenia conducted three times a week for 16 weeks. The results revealed improvements in functional fitness, grip strength, and isometric muscle strength. Resistance training, including elastic band exercises three times per week for 12 weeks, resulted in significant improvements in lower extremity function, including body fat mass, handgrip strength, leg strength, TUG scores, and gait speed.27,28) Exercises to improve strength and physical performance are characterized by combined strength training and aerobic exercise. Villareal et al.29) examined combinations of weight, aerobic, and resistance training in obese older adults over 26 weeks and found that the exercise groups experienced improvements in physical performance, body weight, VO₂ peak, and strength, with specific benefits varying by exercise type. Jung et al.30) implemented a circuit-training program in older women with sarcopenia, showing gains in body composition (BMI, fat-free mass, and fat mass), muscle mass, strength, and balance after 12 weeks of training.

Table 2.

FITT principle to improve muscle strength and physical function in older adults with and without sarcopenia

KQ3. What exercises are effective for improving both muscle mass and strength?

Table 3 shows a study that evaluated exercise methods that are effective for enhancing muscle mass and muscle strength.7,33,34) Resistance training effectively enhances muscle mass and strength in older adults with and without sarcopenia. In sarcopenic older adults, moderate-to-high-intensity machine-based resistance exercises improved grip strength and leg extension strength over durations of 12 weeks to 18 months, with sessions lasting 30–50 minutes, 2–3 times per week, at intensities of 65%–85% of 1RM.7,33) Kemmler et al.7) noted a more pronounced decline in muscle mass and strength after an 18-month resistance training period during detraining than in controls. In healthy older adults without sarcopenia, low-intensity (20% maximal power) eccentric ergometer resistance training for 20 minutes twice a week over 12 weeks also effectively improved muscle mass and strength.34) Resistance exercises ranging from low- to high-intensity, including eccentric ergometer- and machine-based training up to 85% of 1RM, consistently improved muscle mass, grip strength, and leg strength.7,33) Both sarcopenic and healthy older adults should typically perform resistance training for 50–60 minutes per session, with gradual increases in time for those with sarcopenia. For optimal gains in muscle mass and strength, resistance training at 50%–85% of 1RM or rate of perceived exertion (RPE) 12–16, for 30–60 minutes per session, at least twice a week for 12 weeks, is recommended. Long-term progressive training is particularly beneficial for individuals with sarcopenia.

Table 3.

FITT principle to improve muscle mass and muscle strength in older adults with and without sarcopenia

KQ4. What types of exercises are effective for improving both muscle mass and physical performance?

Table 4 presents a study that evaluates exercise methods effective in improving muscle mass and physical function.35-38) Both resistance and aerobic exercises are effective in enhancing muscle mass and physical function in older adults with sarcopenia and Parkinson’s disease. Sixteen trials examined the effects of various exercise modalities, often paired with nutritional supplementation, in older adults with and without sarcopenia. Monti et al.35) reported that a 2-year, thrice-weekly multicomponent program for sarcopenic adults, including aerobic, resistance, and balance exercises, maintained muscle architecture and neuromuscular junction (NMJ) stability, with greater physical performance improvements than controls. Liao et al.36,37) showed that elastic band resistance exercises in adults with sarcopenia and obesity improved muscle mass, physical capacity, balance, body composition, and quality of life. Kim et al.38) examined older adults with Parkinson’s disease, showing that high-intensity interval training three times a week for 24 weeks improved lean muscle mass, ASM mass, and walking distance, while moderate-intensity continuous training improved chair-stand test performance. For optimal improvements in muscle mass and physical function, resistance training should be performed twice weekly for at least 12 weeks at an exertion level of 12–14 on the Borg RPE scale using body weight or elastic bands. Aerobic activities such as walking and cycling at moderate intensity (60% of the maximum aerobic power) are recommended three times weekly for 60 minutes over 24 weeks for older adults with sarcopenia and Parkinson’s disease.

Table 4.

FITT principle to improve muscle mass and physical function in older adults with and without sarcopenia

KQ5. What exercises are effective for improving overall muscle mass, strength, and physical performance?

Table 5 summarizes research evaluating the effectiveness of various exercise interventions on muscle mass, strength, and physical function.39-46) Both resistance and aerobic exercises have been shown to be effective in improving muscle mass, strength, and physical function in older adults with and without sarcopenia. In older adults with sarcopenia, moderate- to high-intensity resistance exercise using elastic bands or body weight, even when guided by personal subjective measures, such as RPE, leads to significant improvements in muscle mass and strength as measured by grip strength, leg press, and physical function as assessed by gait speed.39,40) These improvements were observed with an exercise duration of at least 8 weeks, typically extending to ≥12 weeks, when exercise was performed for at least 30 minutes per day, typically 60 minutes, 2–3 times per week.41) In healthy older adults without sarcopenia, the effects were observed at varying levels for each FITT principle. In resistance exercises, improvements in lean mass, grip strength, and physical functions such as muscle power, gait speed, and balance have been demonstrated across various intensities. These range from bodyweight exercises such as squats and medium-intensity exercises using elastic bands to power training at intensities of up to 80% of 1RM.41,42) Among the FITT elements, there was no difference in the exercise frequency between healthy older adults and those with sarcopenia. However, the exercise time for healthy older adults was generally >1 hour per day, indicating that they can sustain longer exercise sessions than those with sarcopenia.43) Healthy older adults typically engaged in combined exercises that included resistance training along with various aerobic activities such as walking and bench stepping.44-46)

Table 5.

FITT principle to improve muscle mass, strength and physical function in older adults with and without sarcopenia

Comprehensive Exercise Recommendations Based on FITT Principles

Table 6 summarizes the final exercise guidelines based on the FITT principle for improving and preventing sarcopenia in older adults with and without sarcopenia. To enhance muscle mass, resistance training should be performed more than three times a week for 24 weeks at moderate or high intensity (60%–80% 1RM). Each session should include 10–15 repetitions per machine for 2–3 sets, lasting at least 30 minutes, using machines or free weights. This guideline is substantiated by level I evidence with a grade of A. For augmenting muscle strength, resistance training should occur more than twice a week for 12 weeks, at a moderate or higher intensity (40%–60% 1RM). Each session should last at least 20 minutes and use machines or free weights, as supported by level I evidence and grade A. The results showed that it is effective to combine resistance training and aerobic exercise to improve physical function. Resistance training was performed at least twice a week for 12 weeks at moderate or high intensity for at least 20 minutes per session. In addition, aerobic exercise (e.g., walking), performed 3–5 times a week for 12 weeks at moderate or high intensity for at least 30–50 minutes, improved physical function. This recommendation is supported by level II evidence of grade B.

Table 6.

Exercise guideline based on FITT principle for improving sarcopenia

Physiological Basis for Resistance Training Recommendations

Our review results suggest that resistance training is recommended to improve muscle mass and strength. After 3–6 months of proper resistance training, muscle strength increased by an average of 40%–150%, depending on the individual’s characteristics and the intensity of the program; the total lean body mass increased by 1–3 kg, and the muscle fiber area increased by 10%–30%.47,48) Therefore, even in old age, adaptations to muscle loading can induce neural, metabolic, and structural changes in the muscles, which help compensate for strength loss and age-related atrophy.49) Resistance training is widely recommended to improve muscle mass, strength, and physical function; however, each has differences in the FITT. Muscle mass training requires longer periods (24 weeks) and higher weekly frequencies to reflect the time required to achieve significant muscle hypertrophy in older adults. In contrast, strength and physical function may improve in a shorter period (12 weeks) with lower-frequency sessions. A slight difference was observed in intensity. Muscle growth requires considerable mechanical tension; therefore, resistance training requires a higher intensity (60%–80% of 1RM). However, the intensity (40%–60% of 1RM) for enhancing muscle strength is slightly lower than the intensity required to improve muscle mass, suggesting that it is beneficial for improving muscle strength. Muscle hypertrophy depends on muscle protein synthesis (MPS), and muscles grow through the damage and regeneration of muscle fibers; therefore, repetitive stimulation over a long period of time is required.50,51) High-intensity training is required to produce sufficient mechanical tension. This tension activates the mammalian target of rapamycin (mTOR) signaling pathway, which is important for promoting MPS and satellite cell activation.52) This is important for older adults as they have anabolic resistance, a state in which MPS is less responsive to exercise stimuli. In addition, increases in muscle mass require the activation of fast-twitch (Type II) fibers, which are activated during high-intensity exercise and have a higher potential for increasing muscle size.53) In addition, muscle strength improvement depends on the efficient activation of both the fast and slow muscles and mainly on neurological adaptation, and therefore, it can be effective even in a relatively short period of time and at a slightly lower intensity.54)

Rationale for Combined Exercise Approaches

The difference between exercise to improve physical function and exercise to increase muscle mass and strength is the combined approach of resistance training and aerobic exercise such as walking, which involves the entire body. It is well known that aerobic exercise can help prevent the loss of essential physical abilities, such as muscle strength, mobility, balance, and endurance, which are necessary for older adults to safely carry out daily activities.55,55) Moreover, it was found that combining aerobic exercise with resistance exercises had more benefits than a single exercise,57-59) and such combined exercise had a more significant effect on the physical performance of older adults than single exercise.58,60) This is because combined exercises engage more factors involved in physical performance, resulting in more comprehensive and effective outcomes than single exercises.61)

Integrated Approach for Comprehensive Sarcopenia Management

Finally, a combined approach of resistance and aerobic exercise is recommended to increase muscle mass and improve strength and physical function. Resistance training should be performed 3–5 times per week for 12 weeks at moderate to vigorous intensity (60%–80% of 1RM) for a minimum of 30 minutes per session. Additionally, aerobic exercise, such as walking, is recommended at least three times per week for 12 weeks, with each session lasting 30–50 minutes in total (Level I, Grade A). According to a previous review, although the level of evidence for resistance training alone in improving muscle mass, strength, and physical performance in older adults with sarcopenia is moderate, the strongest evidence supports combined or multimodal training programs that include resistance training, aerobic exercise, and balance.62) Additionally, the frequency of resistance training in this review ranged from a minimum of 2 days to a maximum of 5 days, with most studies recommending 3 days per week.62) The intensity of resistance training ranged from 20%–79% of 1RM.62) In another previous study, the intensity ranged from 40%–80% of 1RM or a somewhat difficult12-14) RPE in frail older adults.63) Aerobic exercise was performed 2–5 times per week as part of a multicomponent exercise intervention.62) For older adults with sarcopenia, the intensity of aerobic exercise ranged from 50%–70% of the maximum heart rate or corresponded to an RPE of 7–17.62) This is consistent with the American College of Sports Medicine/American Heart Association guidelines, which recommend moderate- to vigorous-intensity aerobic exercises for older adults.64) The international exercise recommendations for older adults include moderate-to-high-intensity resistance and power training 2–3 times a week to prevent frailty and sarcopenia.65)

In addition to combined exercise modalities, several studies included in this review incorporated nutritional supplementation—such as protein, amino acids, or vitamin D—in conjunction with physical training. Rather than considering nutrition as a confounding variable, we acknowledge that these multimodal interventions closely reflect current clinical practices in sarcopenia management. Accumulating evidence suggests that the co-administration of exercise and targeted nutritional support may exert synergistic effects by enhancing MPS, modulating anabolic pathways, and facilitating neuromuscular adaptation.66) This study emphasizes the clinical importance of an integrated approach that combines nutritional strategies with exercise prescriptions to optimize improvements in muscle mass, strength, and physical function.

Clinical Implications and Future Directions

This guideline provides the first evidence-based exercise recommendation in Korea based on the KWGS algorithm for older adults with and without sarcopenia. This highlights the importance of tailoring exercise programs according to specific goals such as muscle mass, strength, or physical function by adjusting the FITT principles. Resistance training is central to improving muscle mass and strength, whereas a combination of resistance and aerobic exercises is the most effective for enhancing physical function. The alignment of exercise prescriptions with the KWGS diagnostic categories enables clinicians to develop targeted interventions based on individual sarcopenia phenotypes (sarcopenia, severe sarcopenia, or functional sarcopenia), potentially improving therapeutic efficiency and patient outcomes (Fig. 2). These findings support the implementation of structured goal-specific exercise interventions in clinical and community settings to prevent and manage sarcopenia in older adults.

Fig. 2.

Algorithm for exercise prescription based on FITT for improving sarcopenia. R1 indicates resistance exercise type 1; R2, resistance exercise type 2; A, aerobic exercise. FITT, frequency- intensity-time-type; 1RM, one-repetition maximum.

This study has several limitations. It included randomized controlled trials conducted in both community and clinical settings, and therefore, participant homogeneity may have been disrupted. Participants recruited from these different environments are likely to differ in baseline health status, prevalence of comorbidities, degree of physical frailty, and responsiveness to exercise interventions. Such heterogeneity may have influenced the observed outcomes and limited the internal consistency of the evidence base. Nevertheless, to ensure the relevance of the findings to the Korean context, we adopted the sarcopenia diagnostic algorithm proposed by the KWGS, which reflects the unique characteristics of the Korean older population. In line with this approach, we intentionally included both community-based and clinically recruited populations to better represent the heterogeneity encountered in real-world practice. This strategy aims to ensure that the exercise recommendations are applicable not only to healthy older adults living independently but also to vulnerable individuals receiving clinical care. By doing so, we enhance the generalizability and external validity of the findings across diverse healthcare settings.

Future research should focus on optimizing exercise protocols for specific sarcopenia subtypes, evaluating the cost-effectiveness of these interventions in various healthcare settings, and investigating the integration of digital health technologies to enhance adherence and monitoring. Additionally, exploring the interactions between exercise and nutritional interventions, particularly protein supplementation and vitamin D, may provide insights into synergistic approaches for comprehensive sarcopenia management in the Korean elderly population.