The Present and Future of Sarcopenia Diagnosis and Exercise Interventions: A Narrative Review

Abstract

The aim of this review was to harmonize major consensus statements (European Working Group on Sarcopenia in Older People 2; Asian Working Group for Sarcopenia 2019; Foundation for the National Institutes of Health Sarcopenia Project operational criteria) into a stage- and setting-stratified algorithm. It maps diagnostic strata to dose-defined resistance and combined training, integrates multimodal and technology-enabled options (whole-body electrical muscle stimulation, whole-body vibration, virtual reality, AI-assisted telerehabilitation) with safety cues, and embeds nutrition (≥1.2 g/kg/day protein, vitamin D, key micronutrients) and education to sustain adherence. Sarcopenia is a consequential geriatric syndrome linked to falls, loss of independence, hospitalization, mortality, and psychosocial burden, yet translation to practice is hindered by heterogeneous definitions, diagnostics, and treatment guidance. Literature searches via PubMed/MEDLINE, EBSCO, SciELO, and Google Scholar (January 2000 to August 2025) yielded 354 records; after screening and deduplication, 132 peer-reviewed studies were included. We summarize tools for screening, strength, muscle mass, and function (e.g., Sarcopenia Five-Item Questionnaire, grip strength, dual-energy X-ray absorptiometry, gait speed) and identify resistance exercise as the cornerstone, with aerobic, balance, and flexibility training adding functional and metabolic benefits. Clinic-ready tables and figures operationalize a stepwise program across primary to severe sarcopenia and across acute or iatrogenic to community settings. Early screening plus structured, exercise-centered care, augmented by targeted nutrition and education, offers pragmatic, scalable benefits.

1. Introduction

The aging global population is accelerating owing to longer life expectancies and falling birth rates. These trends are reshaping national demographics and creating a worldwide challenge. People aged ≥65 accounted for ~870 million (≈10%) in 2023 and are projected to exceed 16% by 2050 [1].

As the population ages, health profiles generally become more complex. Very often, older adults experience functional decline and have a higher risk of chronic conditions (e.g., hypertension, diabetes, cardiovascular and respiratory diseases, osteoarthritis, dementia, cancer, depression, kidney disease, sensory impairment) [2]. Multimorbidity is common. A meta-analysis of ~15.4 million adults across 54 countries reported the estimated prevalence of multimorbidity to be 37.2% overall and 51.0% among those aged ≥60 years, complicating care and straining resources [3].

Sarcopenia is defined as the progressive loss of skeletal muscle mass and function. The condition is a key driver of frailty, limiting strength, power, gait, balance, and postural control [4]. Moreover, patients with sarcopenia have an increased risk of falls, fractures, disability, hospitalization, and mortality. The condition also exacerbates chronic diseases and diminishes quality of life (QoL) [5]. The clinical relevance of sarcopenia was formalized with the ICD-10-CM code M62.84 in 2016 [6]. Recent meta-analyses estimate a prevalence of 10–27% in adults ≥ 60 years of age, with severe sarcopenia at 2–9%, implying a growing socioeconomic burden in super-aged societies [7].

Research and practice are hampered by inconsistent definitions, diagnostic criteria, and measurement tools. Furthermore, heterogeneous study populations and designs have yielded widely varying prevalence estimates and limited translational utility [8,9,10].

Among the strategies available for the management of sarcopenia, exercise is supported by the most consistent evidence [4]. Resistance and multicomponent programs can improve muscle mass and functional outcomes, such as strength, gait speed, and balance [11]. A recent expert consensus by Moretti et al. [12] proposed stage-tailored sessions combining resistance, aerobic, balance, and flexibility training. However, internationally standardized prescriptions for intensity, frequency, and duration remain controversial. Consequently, clinical and policy uptake are compromised [12].

Early detection and effective management of sarcopenia are essential not only for individual health, but also for societal sustainability, especially in super-aged contexts. This study synthesized contemporary statistics and evidence on the etiology and diagnosis of sarcopenia and integrated the findings on stepwise, type-specific exercise-centered intervention strategies. The study aimed to clarify current knowledge, foreground the role of exercise, and provide practical clinical guidance to reduce health complications and social burden associated with sarcopenia.

2. Methods

This narrative review synthesized contemporary evidence on sarcopenia, including definitions, etiological factors, diagnostic criteria, clinical implications, and intervention strategies. The review also explicitly incorporated recommendations from major working groups and consensus reports: European Working Group on Sarcopenia in Older People 2 (EWGSOP2); Asian Working Group for Sarcopenia 2019 (AWGS 2019); and Foundation for the National Institutes of Health (FNIH) Sarcopenia Project (2014) operational criteria. Literature searches were conducted via PubMed/MEDLINE, EBSCO, SciELO, and Google Scholar for publications from January 2000 to August 2025. Only studies written in English or Korean were eligible, and this language restriction was applied during the screening stage. Search strategies combined controlled vocabulary (MeSH terms) and free-text terms, with keyword groupings such as “sarcopenia,” “aged/older adults,” “resistance training,” “aerobic exercise,” “muscle strength,” “muscle mass,” “physical function,” “diagnosis,” and “prevention.” For example, in PubMed, combinations such as “sarcopenia” AND (“older adults” OR “aged”) AND (“exercise” OR “resistance training”) AND (“muscle strength” OR “muscle mass”) were used. Equivalent keyword clusters were adapted to other databases.

Eligible evidence included peer-reviewed original studies, randomized controlled trials, systematic reviews/meta-analyses, consensus statements, clinical guidelines, and selected mechanistic or methodological papers directly relevant to sarcopenia assessment or physiology. Exclusion criteria were (1) non-peer-reviewed materials, (2) studies where sarcopenia or muscle-related outcomes were not a primary focus—operationalized as unclear relevance to sarcopenia—and (3) studies on general aging phenomena without functional or clinical outcomes. References published before 2000 were consulted to provide a historical background on sarcopenia.

Evidence was organized across four domains: (1) definition and conceptual development; (2) pathophysiology and risk factors; (3) intervention evidence, exercise, nutrition, and education; and (4) synergistic effects and clinical implications of the combined exercise and nutrition strategies. A total of 354 records were identified across databases (PubMed, EBSCO, SciELO, and Google Scholar). After removing 94 duplicates, 260 studies underwent title/abstract screening. Four non-English/Korean records were excluded based on the language restriction, leaving 256 full texts assessed for eligibility. Of these, 124 were excluded owing to irrelevant or ineligible design/outcomes. In total, 132 peer-reviewed articles were included in the narrative synthesis. This study followed a structured narrative approach; therefore, no formal quality assessment of the included studies was performed (Figure 1). Study screening, eligibility assessment, and narrative synthesis were conducted by two authors, and all decisions were finalized through discussion and consensus. This review was not conducted as a systematic review and therefore does not adhere to PRISMA guidelines; instead, it follows a structured narrative format with transparent search, screening, and synthesis procedures. Critical appraisal was incorporated narratively by comparing methodological features, diagnostic heterogeneity, prevalence differences, and consistency of findings across included studies rather than performing a formal risk-of-bias assessment.

3. Results

3.1. Definition of Sarcopenia

Sarcopenia is derived from the Greek sarx (“flesh, body”) and penia (“loss, deficiency”). Rosenberg first used this term in 1989 to describe age-related loss of muscle mass [13]. Momentum grew in 1998 when Baumgartner et al. proposed the dual-energy X-ray absorptiometry (DXA)-based index of appendicular skeletal muscle mass adjusted for height squared (ASM/height²) and a −2 SD cutoff [14].

The definition of sarcopenia has expanded from loss of muscle mass to a condition encompassing reduced muscle strength and physical performance. In 2010, the European Working Group on Sarcopenia in Older People (EWGSOP) introduced a comprehensive diagnostic algorithm that considered strength, function, and mass [15]. The Asian Working Group for Sarcopenia (AWGS) followed in 2014 with criteria and cutoffs tailored to East and Southeast Asian populations. Subsequent updates by European Working Group on Sarcopenia in Older People 2 (EWGSOP2, 2018) and Asian Working Group for Sarcopenia 2019 (AWGS 2019) reflect accumulated evidence [4,16].

This subsection synthesizes evidence from 5 key sources, primarily comprising consensus statements and foundational definition papers. Collectively, these documents demonstrate a clear evolution from a mass-centered definition toward a strength-based, functionally oriented conceptualization of sarcopenia.

3.2. Etiology

Sarcopenia is a pathological condition that goes beyond normal aging. The condition is characterized by a decline in muscle strength and physical performance that impairs activities of daily living (ADL). The contributing etiological factors include aging, inactivity, nutritional insufficiency, and chronic disease/inflammation [4,5,17]. Aging drives the loss and atrophy of muscle fibers (especially type II fibers). Reduced protein synthesis, mitochondrial dysfunction, impaired satellite cell regeneration, and neuromuscular alterations (motor neuron loss and neuromuscular junction degeneration), along with increased oxidative stress/inflammation and lower anabolic hormone levels, all play a part [13,18,19]. Physical inactivity—such as bed rest—can depress muscle protein synthesis, increase breakdown and myosteatosis, and reduce insulin sensitivity. The least-active older adults showed ~2.8× higher odds of sarcopenia than other older adults [20,21].

Nutritional deficiencies, including insufficient protein, essential amino acids, and vitamin D levels can reduce muscle protein synthesis and mass. Older adults are prone to primary and disease-related malnutrition, fostering intramuscular fat, inflammation, and poor recovery. Importantly, the prevalence of sarcopenia is significantly higher in patients with a poor nutritional status [22,23,24]. Endocrine–metabolic factors also contribute: age-related declines in testosterone, estrogen, growth hormone (GH), and insulin-like growth factor-1 (IGF-1) lower muscle protein synthesis, worsen insulin sensitivity, and promote intramuscular fat. Excess thyroid hormone or chronic glucocorticoid exposure also accelerates muscle loss [25,26,27,28]. In addition, chronic diseases (diabetes, cardiovascular disease, chronic kidney disease, cancer, and liver disease) drive systemic inflammation and oxidative stress, shifting the balance toward proteolysis, blunting regeneration, and inactivity. Furthermore, undernutrition and long-term medications (e.g., glucocorticoids) amplify the risk [29].

Finally, neurological and genetic factors are implicated: motor neuron loss and neuromuscular junction degeneration precede clinical weakness. Neurological disorders (e.g., Parkinson’s disease, stroke) and genetic predispositions (e.g., muscular dystrophies and risk polymorphisms) can further limit muscle use and regeneration, and exacerbate lifestyle and hormonal factors [19].

Overall, 16 studies underlie this subsection and support a multifactorial pathophysiology of sarcopenia. Neuromuscular, inflammatory, metabolic, nutritional, endocrine, and genetic factors appear to interact, although most of the available evidence is observational or mechanistic.

3.3. Clinical Implications

Sarcopenia, a representative geriatric syndrome, affects older adults beyond the loss of muscle mass, and is linked to falls and fractures, loss of independence, higher hospitalization and mortality, cognitive and emotional problems, and worsening chronic diseases [4,30]. Drawing on 10 clinical and observational studies, this subsection highlights how sarcopenia independently contributes to adverse functional and medical outcomes in older adults. Lower limb weakness, impaired balance, neuromuscular junction degeneration, and reduced proprioception increase fall and fracture risk, leading to prolonged hospitalization and institutionalization; declines in gait and ADL, especially lower limb power, impair tasks (such as chair rise), and predict future loss of independent living capacity [31,32]. Compromised immune and metabolic functions, and reduced recovery capacity, increase the risk of postoperative complications, length of hospital stay, and short-term mortality [4,33].

As an endocrine/metabolic organ, muscle influences brain health via myokines and related pathways; reduced cerebral perfusion and neuroplasticity contribute to cognitive decline, and low activity plus social isolation exacerbate depression [34,35]. Sarcopenia independently worsens outcomes in diabetes, cardiovascular disease, chronic kidney disease, and cancer because skeletal muscle mediates 70–80% of whole-body glucose disposal. Loss of muscle mass promotes insulin resistance and metabolic syndrome, and intramuscular fat and inflammation aggravate hypertension, dyslipidemia, and obesity [36,37,38].

3.4. Clinical Assessment and Diagnostic Tools

Various clinical tools are used to diagnose sarcopenia according to international guidelines (screening, strength, muscle mass, and physical function). Each tool is selected for its diagnostic accuracy and its efficacy in evaluating severity, planning follow-up, and monitoring the effectiveness of interventions. This subsection draws on 21 studies evaluating the reliability, validity, and clinical utility of commonly used assessment tools. Tools vary in the ease of measurement, accessibility, reliability, and clinical utility. Ensuring the appropriate use of these clinical tools according to the population and purpose is essential. The types of tools, measurement methods, interpretation criteria, and clinical strengths and weaknesses of representative tools for each stage are discussed below.

3.4.1. Screening Tools

Screening tools for sarcopenia consist primarily of self-reported questionnaires and brief assessments, including physical measurements.

• Sarcopenia-five-item questionnaire (SARC-F) is a self-report questionnaire for the rapid screening and includes five items: muscle strength, assistance with walking, getting out of a chair, climbing stairs, and falling experience. Each item is scored on a 0–2 scale (total score = 10), with a score of 4 or higher indicating the need for further evaluation. SARC-F is quick, inexpensive, and useful for large-scale screening. However, the limitations include self-report-related subjectivity, low sensitivity, and the lack of direct assessment of muscle mass, which lead to underdiagnosis of the mild cases [39].
• SARC-F questionnaire and calf circumference (SARC-CalF), developed by Barbosa-Silva et al. [40] in Brazil, aims to compensate for the low sensitivity of the SARC-F by adding calf circumference (CC). For CC of <34 cm for men and <33 cm for women, the SARC-F total score is added to the CC score (0–10 to produce a total score, and a score of ≥11 generally indicates a high risk for sarcopenia). However, CC is subject to errors due to edema, measurement location, etc., and needs to be standardized [40].

These tools for sarcopenia screening, each with different assessment modalities and characteristics, are used selectively in clinical practice depending on the patient’s condition and the setting. As a part of first-stage diagnosis, these tools play an important role in identifying high-risk individuals quickly and efficiently.

3.4.2. Assessing Strength

A decrease in muscle strength often precedes muscle mass loss, making early diagnosis and intervention important [4,41]. In clinical practice, muscle strength can be quantified using grip strength (GS), the five-time sit-to-stand test (FTSST), and knee extension (KE) strength. These assessments are used to objectively monitor diagnosis and treatment progress.

• GS is highly correlated with upper extremity strength as well as with total body strength and muscle mass, meaning that weakness in the hand is likely to be accompanied by weakness in the muscles of the entire body [41].
• The FTSST is a simple and reliable method to assess lower body strength, mobility, and physical decline. The test is quick and easy to perform without any equipment and is widely used as a strength assessment tool in clinical and community settings [4].
• KE strength is a representative quantitative indicator of quadriceps strength in the lower limbs. KE strength is closely associated with lower limb weakness, functional limitations, and diagnosis of sarcopenia, making it a core metric in functional assessment [4].

3.4.3. Assessing Muscle Mass

Muscle mass assessment using various measurement tools plays an important role in diagnosing sarcopenia and analyzing body composition.

• DXA uses radiation to simultaneously and accurately measure total body and site-specific muscle mass, body fat, and bone density. The technique is the gold standard in clinical research [42]. However, cost, accessibility, and radiation exposure are drawbacks, and alternative methods are being developed [43].
• Bioelectric impedance analysis (BIA) is a non-invasive method for estimating muscle mass using differences in the electrical properties of tissues, such as water, fat, and muscle in the body. It is widely used in clinical and large epidemiological studies owing to its simplicity, short test time, lack of radiation exposure, and low cost. However, the results can vary depending on the body hydration status, food intake, device type, and measurement environment. Furthermore, standardized conditions for conducting BIA are required and care must be taken when interpreting the results [44,45].
• Medical imaging, such as magnetic resonance imaging (MRI) and computed tomography (CT), is the most precise imaging method for evaluating muscle quality, including muscle mass and intramuscular fat deposition (myosteatosis). It is used as a reference for research and precision diagnosis because it can quantify muscle volume and cross-sectional area through cross-sectional images and the degree of fat deposition (CT radiation attenuation, MRI fat fraction, etc.). However, cost and access challenges relating to MRI and the radiation exposure limitations of CT, these medical imaging technologies are mainly used for research and advanced clinical evaluation, and not for routine screening [4,46].
• Musculoskeletal ultrasound is a noninvasive method for assessing muscle thickness, cross-sectional area, and structure in real time. It has been increasingly used in clinical and research studies due to its low cost and lack of radiation exposure. The limitations include large differences in measurement results depending on the examiner’s skill level, and the need for standardization of the method [4,47].

3.4.4. Assessing Physical Function

Physical function assessments reflect real-world performance and mobility of individuals living with sarcopenia. These assessments can identify functional limitations that are difficult to identify using strength and muscle mass assessments alone [31]. Moreover, these assessments are strongly correlated with clinical outcomes, such as the ability to perform ADL, risk of falls, and ability to live independently. The assessments provide important information, not only for diagnosing sarcopenia, but also for planning patient-specific interventions [48].

• Gait speed (4 m, 6 m, 10 m) is measured by asking the subject to walk a certain distance naturally. It is the most widely used physical function indicator in clinical practice and research due to its simplicity and short testing time [4,16,49].
• Short Physical Performance Battery (SPPB) is a composite index comprising balance ability, gait speed, and FTSST to provide a multifaceted assessment of overall lower-body function in older adults [4,16,50].
• Timed up and go (TUG) measures the time taken to get up from a seated position, walk a certain distance, and then sit down again. It can simultaneously assess mobility and balance, making it useful for screening for fall risk among older adults and measuring the effectiveness of rehabilitation [4,50].
• The 6-Minute walk test (6MWT) assesses endurance and functional exercise capacity by measuring the maximum distance traveled in a limited amount of time (6 min). It is used as a surrogate marker of total body endurance, cardiorespiratory capacity, and the ability to perform ADL [50].
• The 400 m walk test assesses the ability to complete a certain distance (400 m) and reflects long-distance walking ability and endurance. It has been reported as a marker strongly associated with long-term health outcomes in older adults in large cohort studies [51].

3.4.5. Sarcopenia Assessment Tool for Psychological Factors

Sarcopenia is primarily defined as a decline in strength, muscle mass, and physical function. In clinical practice, mental and psychological factors, such as cognition, emotion, and health-related QoL, play an important role in overall health and prognosis [34,52]. The muscle–brain axis (such as myokines) and social factors can interact to reinforce the vicious cycle of physical limitations, isolation, depression, and cognitive decline in older adults [34].

• The Geriatric Depression Scale and Center for Epidemiologic Studies Depression Scale are widely used for assessing psychological factors in older adults. Studies have repeatedly reported that sarcopenia and depressive symptoms are independent but mutually reinforcing risk factors [53].
• Quality of Life Assessment The Sarcopenia and Quality of Life (SarQoL) Questionnaire is a tool developed specifically for patients with sarcopenia that quantifies multidimensional QoL, including physical functioning, mental health, and social engagement. This reflects the clinical impact of the disease from a patient-centered perspective [54].
• The Mini-Mental State Examination and Montreal Cognitive Assessment, among others, have been used to assess cognitive decline and an increased risk of dementia [55].

3.5. Diagnostic Criteria

Sarcopenia is typically diagnosed by screening for strength, muscle mass, and physical function. International guidelines (e.g., EWGSOP2, AWGS 2019, and FNIH criteria; provide indicators and cut-offs for each stage of the condition and are widely used in clinical and research settings. However, specific cutoffs and assessment items vary by region owing to population characteristics, healthcare context, and measurement access [56,57,58]. In response, several countries have developed standards that reflect the older population in their region. Comparative epidemiological analyses confirm these discrepancies. In large community-dwelling cohorts, the prevalence of sarcopenia has been shown to vary substantially depending on the diagnostic criteria applied, ranging from 1.4% to 5.2% in men and 1.6% to 7.2% in women. Agreement between definitions is generally low, with overall agreement rates of 1.5–55.3% and corresponding κ coefficients of 0.01–0.23, indicating no or only minimal agreement across standards. Notably, negative agreement rates were ≥ 95%, underscoring that individuals classified as “non-sarcopenic” by one system are almost universally classified the same by others, whereas positive case identification differs markedly across guidelines [59]. Below, we compared international and national criteria and summarized the implications of this diversity, the need for standardization, and recent harmonization efforts (

Table 1. Diagnostic criteria for sarcopenia.

Working Group	Screening	Assessment (Tests & Cut Offs)	Diagnosis (Criteria & Stages)	Remarks
EWGSOP2 (2018) [4]	Clinical suspicion or SARC-F ≥ 4	Muscle strength: GS < 27 kg (male), <16 kg (female); FTSST > 15 s Muscle mass: ASMI < 7.0 (male), <5.5 (female) by DXA (BIA/CT/MRI acceptable) Physical performance: gait speed ≤ 0.8 m/s; 400 m walk: non-completion or ≥6 min; SPPB ≤ 8; TUG ≥ 20 s;	Probable: low muscle strength Confirmed: probable + low muscle mass Severe: confirmed + poor physical performance	Three-step algorithm (Find–Assess–Confirm/Severity); widely used in Europe
AWGS 2019 (2019) [16]	SARC-F ≥ 4 or SARC-CalF ≥ 11 or CC < 34 cm (male), <33 cm (female)	Muscle strength: GS < 28 kg (male), <18 kg (female) Physical performance: gait speed < 1.0 m/s; SPPB ≤ 9; FTSST ≥ 12 s Muscle mass: ASMI < 7.0 (male), <5.4 (female) by DXA, or <7.0 (male), <5.7 (female) by BIA	Sarcopenia: low ASM + low muscle strength, or low physical performance Severe sarcopenia: low ASM + low muscle strength and low physical performance	Asian-specific cut-offs Includes SARC-CalF for case finding
FNIH Sarcopenia Project operational criteria (2014) [51]	No formal case finding specified	GS: <26 kg (male), <16 kg (female) Muscle mass: ALM/BMI < 0.789 (male), <0.512 (female)	Sarcopenia: low GS and low lean mass	Pooled n = 26,625 Emphasizes BMI-adjusted muscle mass No ‘severe’ category

Abbreviations: SARC-F, Sarcopenia-Five-item questionnaire; SARC-CalF, SARC-F with calf circumference; ASMI, appendicular skeletal muscle mass/height²; ALM, appendicular lean mass; BMI, body mass index; DXA, dual-energy X-ray absorptiometry; BIA, bioelectrical impedance analysis; SPPB, Short Physical Performance Battery; TUG, timed up and go; FTSST, five times sit to stand test; CC, calf circumference; GS, grip strength.

).

3.6. Exercise Rehabilitation

Currently, exercise prescription based on an accurate diagnosis remains challenging. Despite interventions that can effectively slow the progression of sarcopenia, physical exercise is one of the most promising ways to reduce age-related loss of muscle mass and strength [13,60]. International clinical practice guidelines for sarcopenia (ICFSR) emphasize that exercise should be a key intervention in sarcopenia management [50].

3.6.1. Ideal Sarcopenia Rehabilitation

• Resistance exercise (RE)

RE is the effective way to increase muscle mass and strength in older adults with sarcopenia and has been reported to improve balance, endurance, as well as improve muscle mass, and strength [61,62].

RE can prevent age-related muscle loss in physically frail older adults because it not only promotes anabolic activity but also enhances specific metabolic and myoprotein synthesis through morphological muscle adaptations [63]. In particular, resistance exercise has been reported to significantly increase GH levels in both men and women, and increase IGF-1 expression in skeletal muscles with satellite cell activation [64,65]. These positive effects are due to the anabolic and anti-inflammatory effects of resistance exercise, which activate anabolic signaling pathways, such as the Protein Kinase B/mammalian target of rapamycin (Akt/mTOR) pathway, inhibiting muscle loss and alleviating the pro-inflammatory state common in patients with sarcopenia [66].

Weight training, a popular form of resistance exercise, is also an effective way to improve the health of older adults with sarcopenia [67]. Kettlebell resistance training, a type of weight training, involves more complex and dynamic full-body movements than traditional barbell or dumbbell training [68]. A previous study reported significant increases in the sarcopenia index, GS, muscle power, and peak expiratory flow rate in older women with sarcopenia who participated in 8 weeks of training [68]. Elastic band exercises are also important for older adults due to their stability and lower risk of injury and are effective for building muscle mass and strength [69]. RE with elastic bands has been shown to prevent cardiovascular disease through weight loss and BMI reduction, and reduced pulse wave velocity [70].

• Combined exercise

RE is effective in improving sarcopenia, and greater overall benefits are reported when combined with aerobic exercise (AE) [71]. AE induces mitochondrial adaptation (increases ATP production and function), which contributes to body fat loss, metabolic regulation, and improved cardiovascular function. A combination of the two (RE and AE) has been reported to provide additional benefits in these metrics [72].

Considering AE, 30–60 min/day of moderate intensity exercise 5 days/week or 20–30 min/day of high-intensity exercise 3 times/week with 2 days of rest are recommended. In contrast, for RE, targeting 8–10 major muscles of the body and using the principle of progressive overload to 70% of 1RM (high intensity) for 8–12 repetitions, 1–3 sets, and performed twice a week (with 48 h of rest) consecutively is recommended [53]. The World Health Organization (WHO) and American College of Sports Medicine recommend 150–300 min of moderate aerobic activity or 75–150 min of vigorous activity (or equivalent combination) per week for people aged 65 years and older, with muscle-strengthening RE at least 2 days per week. Balance-improving activities are recommended at least 3 days per week for those at a high risk of falls [73,74].

3.6.2. Stepwise Systematic Approach

When managing patients with sarcopenia, individualized intervention strategies based on the patient’s disease stage and functional status are most effective. Exercise response varies greatly depending on age, comorbidities, and physical functioning. Therefore, a one-size-fits-all prescription may not be sufficiently effective and may even have adverse effects. Several studies have also emphasized the importance of considering the patient’s clinical context and severity when planning interventions [12,75,76,77]. In other words, exercise and nutrition strategies for sarcopenia should be differentiated based on disease severity (e.g., probable–primary–severe) and the treatment setting (hyperacute–convalescent). Synthesizing the relevant literature, we conceptualized this as an “stage-specific structured approach” and summarized the suggested exercise and nutrition strategies for each stage of sarcopenia (

Table 2. A step-by-step systemic approach to exercise intervention strategies.

Stage	Source	Exercise Prescription	Key Notes/Features
Probable sarcopenia	Ferrero et al. (2023) [77]	40–60% 1RM; power vs. multicomponent training; emphasis on balance	Early phase, muscle strength decline only, safety and feasibility prioritized
Primary sarcopenia	Moretti et al. (2025) [12]	60–70 min session; 50–70% 1RM RE (10 exercises × 2 sets × 10 reps); ≥30 min/day moderate AE; balance & flexibility	Full structured session, functional improvement beyond muscle mass
Severe sarcopenia	Moretti et al. (2025) [12]	50–55 min session; 30–60% 1RM RE (8 exercises, chair-based); 15 min low-intensity AE; balance-focused	Safety prioritized, reduced load and duration, fall prevention focus

Abbreviations: 1RM, one-repetition maximum; RE, resistance exercise; AE, aerobic exercise.

).

• Guidelines based on sarcopenia severity [12]

The expert consensus report by Moretti et al. [12] provided specific structured exercise sessions based on the severity of sarcopenia (primary vs. severe). In the primary sarcopenia stage, sessions last approximately 60–70 min and included RE (10 exercises × 2 sets × 10 repetitions) at 50–70% of 1RM intensity, moderate-intensity AE (at least 30 min per day), and balance and flexibility training. In contrast, in the severe sarcopenia phase, the consensus recommends shortening sessions to 50–55 min, reducing RE intensity to 30–60% of 1RM, prioritizing safety by including chair-based exercises, limiting AE to low intensity (15 min or less), and focusing on balance training to prevent falls and maintain basic mobility. Consensus was one of the first recommendations to categorize people with sarcopenia according to severity and to detail the intensity, duration, and form of exercise.

• Specific prescription guidelines for RE [76]

Hurst et al. [76] proposed some pragmatic RE guidelines: ≥2 sessions/week; begin at ~40–60% 1RM (RPE 3–5) and progress to 70–85% (RPE 6–8); 1–3 sets of 6–12 reps for ≥12 weeks; and prioritize lower-body functional compound movements (e.g., squats, leg press, sit-to-stand). Combined with progressive overload, these principles provide a safe and effective prescription for improving physical functeion in older adults.

• Iatrogenic sarcopenia and a step-by-step nutrition and exercise integration approach [75]

While primary sarcopenia is related to aging, iatrogenic sarcopenia is associated with medical factors, such as hospitalization, surgery, and prolonged immobility. Kakehi et al. [75] proposed a stepwise management model that incorporated nutrition and exercise in these situations. In the hyperacute–acute phase, early standing, in-bed bicycle exercises, and electrical stimulation are used to minimize proximal atrophy. As the patient progresses to the subacute–convalescent phase, RE and AE combined with protein supplementation can be used to promote muscle mass and functional recovery. Importantly, differentiated interventions based on the clinical situation may delay progression of sarcopenia and promote early recovery.

• Probable sarcopenia and early intervention strategies [77]

Probable sarcopenia, the earliest stage of sarcopenia, is characterized by a decrease in strength but not a confirmed loss of muscle mass. Ferrero et al. [77] designed an randomized controlled trial comparing power training with multicomponent training in this population. In the probable stage, low-intensity interventions that prioritize safety and acceptability over excessive loading are recommended, and programs that combine resistance training at 40–60% 1RM intensity with balance training may be effective. These practical strategies can contribute to fall prevention and functional maintenance during the early stages of strength decline.

3.6.3. Multimodal Sarcopenia Rehabilitation Program

Traditional RE remains foundational, but does not fully address balance, flexibility, and psychosocial needs. Multimodal programs combine apparatus-based training, mind–body approaches, rhythmic activities, and digital technology to complement RE and improve adherence (Table 3).

• Adaptations of Traditional RE

Modifications and apparatus-based methods extend the benefits beyond strength to balance, core stability, and endurance. Sling exercises enhance proprioception and neuromuscular coordination while improving strength, flexibility, endurance, and balance [78,79,80]. Total body resistance exercise (TRX) uses body weight in an unstable environment to increase hypertrophy and core stability and promote neuromuscular coordination [81,82]. Elastic band exercise increases muscle mass and strength at low loads, is suitable for older adults, and may aid in weight control and cardiometabolic health [69,70]. Squat and power training target rapid force production and help maintain bone density in postmenopausal women [83]. Swiss-ball training activates core musculature and proprioception via unstable surface stimuli and is affordable and safe for older adults [84,85,86]. Plyometrics leverages the stretch–shortening cycle to develop elastic recoil and explosive forces, improving muscle size and strength even over short programs [87,88].

• Aerobic and rhythmic exercise

Music- and group-based aerobic/rhythmic formats improve cardiorespiratory endurance, gait speed, functional mobility, balance, and social engagement, and address fall risk factors such as rhythm, step control, and reactivity [89,90]. Modified Javanese traditional dance, combining music and rhythm for aerobic stimulation, shows improvements in muscle mass and walking speed, potentially via enhanced circulation and protein synthesis from mitochondrial biogenesis [91,92]. The strength and lean mass gains are relatively small; therefore, these modes are best combined with RE. Individuals at risk of dizziness, balance loss, or cardiovascular events require aids/supervision and intensity/heart rate monitoring when exercising [93,94,95].

• Blood flow restriction training

Low-load blood flow restriction (LLBFR) mobilizes type II fibers and increases metabolic stress at low mechanical loads, improving strength and function and providing a lower joint burden than high-intensity RE [96,97]. The pragmatic template suggests 2–3 sessions/week for 8–12 weeks (20–30% 1RM, 40–80% personal limb occlusion pressure (LOP), and 30-15-15-15 repetitions). Screening and monitoring for contraindications, such as thrombosis, peripheral vascular disease, and uncontrolled hypertension is important [97].

• Integrative mind–body exercise

Breath- and awareness-based training supports stress control and autonomic stabilization while improving flexibility, balance, and QoL. Yoga downregulates the hypothalamic–pituitary–adrenal (HPA) axis and sympathetic activity with benefits for flexibility, balance, circulation, and self-awareness [98,99]. Pilates promotes lumbo-pelvic stabilization and core activation through controlled breathing and slow movements [100,101]. Tai Chi, a moderate-intensity AE, improves balance and gait, and may reduce proinflammatory cytokine levels [102,103].

• Innovative and technology-enabled interventions

Innovative and technology-enabled approaches may provide complementary options for older adults who cannot easily participate in conventional high-load resistance exercise. Whole-body electrical muscle stimulation (WB-EMS) can simultaneously activate multiple muscle groups and has been reported to produce small-to-moderate improvements in muscle strength and appendicular mass in short-term trials, offering a time-efficient alternative when traditional resistance training is difficult [104]. Whole-body vibration (WBV) has likewise been associated with gains in lower-extremity strength and modest improvements in mobility (e.g., TUG), gait, balance, and SPPB scores in older adults [105]. Evidence for AI- and digitally supported interventions is also emerging: virtual reality (VR) can facilitate repetitive, task-oriented training in immersive environments and may improve mobility, balance, strength, and selected cognitive or executive functions, while AI-assisted telerehabilitation has shown functional outcomes that are broadly comparable to those of in-person programs in early studies, enabling feedback-driven home or community-based training [106,107,108]. Recent mixed reality (MR)-based RCTs in older adults with sarcopenia further suggest potential benefits; for example, a 12-week MR intervention demonstrated significantly greater improvements in quadriceps muscle thickness compared with a conventional program (p = 0.001), along with gains in balance confidence and ADL functioning, although these findings remain preliminary due to small sample size and short follow-up duration [109]. A recent meta-analysis of digital-based interventions in older adults additionally reported modest improvements in handgrip strength, usual gait speed, five-times sit-to-stand performance, and 30-s chair stand tests [110]. However, effect sizes were small, study quality varied, and the overall certainty of evidence was rated low, warranting cautious interpretation.

Table 3. Integrated sarcopenia rehabilitation programs.

Category	Representative Types	Key Effects	Pros	Cons
Adaptations of Traditional RE [69,70,78,79,80,81,82,83,84,85,86,87,88]	Sling, TRX, elastic bands, squats & power training, Swiss ball, plyometrics	↑ Strength/power, ↑ hypertrophy; ↑ balance & proprioception, ↑ core stability, some ↑ bone density, mixed aerobic-resistance options	Diverse, cost-effective tools, adaptable to setting, low-load options for older adults, multidimensional functional gains	Device/setup variability → standardization needed, high-velocity/power & plyometrics may raise fall/joint load → gradual progression/supervision, adjust dose during pain/inflammation flares [111]
Aerobic and Rhythmic Exercise [91,92,93,94,95]	Dance sports, traditional rhythmic dance (e.g., Javanese), group rhythm-based AE	↑ Cardiorespiratory fitness, ↑ gait speed, ↑ functional mobility/balance, addresses fall-risk factors, social bonding	Enjoyment & interaction → adherence ↑, complements fall-prevention components	Modest gains in strength/lean mass when used alone; monitoring/supervision for dizziness/balance or cardiovascular risk
Blood Flow Restriction Training [96,97]	LLBFR (20–30% 1RM, 40–80% LOP, 30-15-15-15)	↑ Strength & function, favorable signals on some metabolic/cardiovascular markers, ↓ joint load	Low joint strain, bridge to capacity building in early rehab, effective short sessions	Screen for contraindications (thrombosis, PVD, uncontrolled hypertension, etc.); high-intensity RE may better maximize hypertrophy—select by goal
Integrative Mind–Body Exercise [98,99,100,101,102,103]	Yoga, Pilates, Tai Chi	Autonomic stabilization & stress reduction, ↑ balance/postural control, ↑ core activation	Mind–body benefits, QoL gains, reinforces fall-prevention components	Low external load → limited standalone gains in strength/power → combine with RE, faulty technique may cause pain/minor injuries → instruction/correction needed [71,112]
Innovative & Technology-Enabled [104,105,106,107,108]	WB-EMS, WBV, VR/AR exercise, AI telerehabilitation (3D pose estimation)	↑ Lower-limb strength, ↑ mobility, ↑ balance, better functional scores (TUG/SPPB), and possible QoL gains → use as low-intensity, supervised adjuncts to RE	Low-load, time-efficient (WB-EMS), suitable for very old adults (WBV), immersive/task-oriented engagement (VR), feedback-rich remote delivery (AI)	Manage device-specific contraindications (WB-EMS with implanted devices, WBV in epilepsy/PVD/neuropathy/diabetic complications, VR for cybersickness/falls). Practical barriers: digital literacy, device/network access, data privacy/security [113,114,115,116,117]

Abbreviations: 1RM, one-repetition maximum; AE, aerobic exercise; AI, artificial intelligence; WB-EMS, whole-body electrical muscle stimulation; LLBFR, low-load blood-flow restriction; LOP, limb occlusion pressure; PVD, peripheral vascular disease; QoL, quality of life; RE, resistance exercise; SPPB, short physical performance battery; TUG, timed up-and-go; VR/AR, virtual/augmented reality; WBV, whole-body vibration; TRX, total body resistance exercise.

Table 3. Integrated sarcopenia rehabilitation programs.

Category	Representative Types	Key Effects	Pros	Cons
Adaptations of Traditional RE [69,70,78,79,80,81,82,83,84,85,86,87,88]	Sling, TRX, elastic bands, squats & power training, Swiss ball, plyometrics	↑ Strength/power, ↑ hypertrophy; ↑ balance & proprioception, ↑ core stability, some ↑ bone density, mixed aerobic-resistance options	Diverse, cost-effective tools, adaptable to setting, low-load options for older adults, multidimensional functional gains	Device/setup variability → standardization needed, high-velocity/power & plyometrics may raise fall/joint load → gradual progression/supervision, adjust dose during pain/inflammation flares [111]
Aerobic and Rhythmic Exercise [91,92,93,94,95]	Dance sports, traditional rhythmic dance (e.g., Javanese), group rhythm-based AE	↑ Cardiorespiratory fitness, ↑ gait speed, ↑ functional mobility/balance, addresses fall-risk factors, social bonding	Enjoyment & interaction → adherence ↑, complements fall-prevention components	Modest gains in strength/lean mass when used alone; monitoring/supervision for dizziness/balance or cardiovascular risk
Blood Flow Restriction Training [96,97]	LLBFR (20–30% 1RM, 40–80% LOP, 30-15-15-15)	↑ Strength & function, favorable signals on some metabolic/cardiovascular markers, ↓ joint load	Low joint strain, bridge to capacity building in early rehab, effective short sessions	Screen for contraindications (thrombosis, PVD, uncontrolled hypertension, etc.); high-intensity RE may better maximize hypertrophy—select by goal
Integrative Mind–Body Exercise [98,99,100,101,102,103]	Yoga, Pilates, Tai Chi	Autonomic stabilization & stress reduction, ↑ balance/postural control, ↑ core activation	Mind–body benefits, QoL gains, reinforces fall-prevention components	Low external load → limited standalone gains in strength/power → combine with RE, faulty technique may cause pain/minor injuries → instruction/correction needed [71,112]
Innovative & Technology-Enabled [104,105,106,107,108]	WB-EMS, WBV, VR/AR exercise, AI telerehabilitation (3D pose estimation)	↑ Lower-limb strength, ↑ mobility, ↑ balance, better functional scores (TUG/SPPB), and possible QoL gains → use as low-intensity, supervised adjuncts to RE	Low-load, time-efficient (WB-EMS), suitable for very old adults (WBV), immersive/task-oriented engagement (VR), feedback-rich remote delivery (AI)	Manage device-specific contraindications (WB-EMS with implanted devices, WBV in epilepsy/PVD/neuropathy/diabetic complications, VR for cybersickness/falls). Practical barriers: digital literacy, device/network access, data privacy/security [113,114,115,116,117]

Abbreviations: 1RM, one-repetition maximum; AE, aerobic exercise; AI, artificial intelligence; WB-EMS, whole-body electrical muscle stimulation; LLBFR, low-load blood-flow restriction; LOP, limb occlusion pressure; PVD, peripheral vascular disease; QoL, quality of life; RE, resistance exercise; SPPB, short physical performance battery; TUG, timed up-and-go; VR/AR, virtual/augmented reality; WBV, whole-body vibration; TRX, total body resistance exercise.

3.7. Nutrition and Education

In the absence of effective drug therapy for sarcopenia, nutrition and education combined with exercise are key strategies. In practice, diet adherence is often low in older adults; therefore, behavioral change programs and education beyond simple dietary supplementation are essential. In total, 24 studies underpin this subsection and generally support protein optimization and structured education as effective adjuncts to exercise, although adherence and long-term sustainability remain major challenges.

3.7.1. Nutritional Therapy

Skeletal muscle mass reflects the balance between protein synthesis (anabolism) and breakdown (catabolism) [118]. Aging shifts this balance by reducing synthesis, impairing protein turnover, and accelerating functional decline [118,119]. Moreover, insulin resistance suppresses insulin synthesis and promotes sarcopenia [120]. Adequate dietary protein is important for amino acids synthesis. In a previous study of 3236 adults ≥ 65 years, low energy/protein intake increased the risk of sarcopenia by >1.5-fold [121,122]. Notably, AWGS 2019 recommends ≥1.2 g/kg/day protein for older adults, with higher targets under catabolic stress [16].

Vitamin D supports synthesis and cell growth and reduces inflammation via muscle cell receptors [123,124,125], while vitamins B6–B12 support neuromuscular function. In contrast, vitamin D deficiency elevates parathyroid hormone and intracellular Ca²⁺, inhibiting synthesis and promoting degradation, leading to proximal weakness, type II fiber atrophy, and higher sarcopenia risk [126,127,128,129], while vitamin B6-B12 deficiency causes weakness and paresthesia. Vitamin supplementation may assist in upregulating muscle growth–related genes [130,131]. Furthermore, calcium and magnesium regulate contractile signaling and enzyme activity, and omega-3 fatty acids act via anti-inflammatory and protein synthesis pathways [122,132,133,134,135,136,137,138].

3.7.2. Educational Programs

RE is a well-established exercise. As exercise alone cannot overcome poor adherence or dietary imbalance, nutrition education and lifestyle management should be combined to maximize and sustain the benefits. Real-world data show that frail groups have lower supplement use and label awareness, more activity limitations, and lower physical activity than non-frail groups. In the Korean healthy-eating index analyses, a higher total score, indicative of balanced energy intake, especially in women, was associated with better health status, suggesting that late-life dietary education may lower sarcopenia risk by improving diet quality [139].

Internationally, the AWGS 2019 recommends early identification of “possible sarcopenia” in primary care and immediate initiation of combined exercise–nutrition interventions and education in the absence of medication [16]. Consistent with this, integrated community programs that combine exercise, protein supplementation, dietary education, and chronic-disease, oral, and mental-health care are being implemented (e.g., the “I” Health Center’s Aging Prevention Management Project), with effectiveness monitored via basic and functional assessments; after the first half-year program in 2024. The second half recruited additional participants, indicating an ongoing, scalable model [140].

Thus, exercise-based management, augmented by nutritional and educational support, is required. Protein/leucine-enriched diets, together with vitamin and mineral supplementation can aid in muscle protein synthesis and function, while education improves awareness and long-term adherence. Future studies that aim to refine the optimal dosing, evaluate different combinations, and test sex- and age-specific educational strategies are warranted.

4. Discussion

4.1. Key Findings and Clinical Implications

This narrative review synthesized contemporary evidence on the definition, mechanisms, diagnostic criteria, and intervention strategies for sarcopenia. Current diagnostic frameworks emphasize muscle strength as the primary criterion, with muscle mass and physical performance added to determine severity. Exercise remains the most consistently effective intervention, with resistance training producing robust improvements in muscle strength, functional performance, and metabolic health in older adults. Aerobic, balance, flexibility, and multimodal programs provide complementary benefits, particularly when adapted to functional status, comorbidities, and care settings. Nutrition—especially adequate protein intake, vitamin D, and other micronutrients—enhances the effects of exercise and supports long-term muscle health.

Sarcopenia is a multidimensional clinical condition with consequences extending to falls, loss of independence, hospitalization, mortality, cognitive decline, and psychosocial burden. Early screening with validated questionnaires and objective strength and function measures is critical for timely identification. Resistance exercise should serve as the core treatment, progressed safely according to individual capacity, while combined modalities (including aerobic, balance, flexibility, and mind–body or rhythmic activities) can further improve function and adherence. Technology-enabled options (e.g., WB-EMS, WBV, VR-based training, AI-assisted telerehabilitation) may increase accessibility for community-dwelling older adults, but careful attention to safety, feasibility, and monitoring is required. At the systems level, harmonized diagnostic thresholds and standardized assessment batteries can facilitate consistent case finding, referral, and outcome tracking across clinical and community settings.

4.2. Future Directions

Despite substantial progress in sarcopenia research, current evidence remains fragmented, with most studies focusing on isolated intervention types or short-term physiological outcomes. To advance toward clinically actionable and scalable models of care, future research must address several strategic priorities. Furthermore, future investigations should prioritize longitudinal, multicenter, and diverse-population cohorts to overcome limitations in generalizability and to establish clinically meaningful thresholds that are applicable across settings. Harmonized methodological standards, especially for technology-enabled assessments and multimodal interventions, will be essential to reducing heterogeneity and improving comparability across studies.

Future research should move beyond enumeration of intervention types and instead define precise parameters that guide clinical decision-making. Key directions include:

• Dose–response relationships for resistance, aerobic, balance, and multimodal training in diverse older adults [141].
• Integrated intervention models, such as combined exercise–nutrition–education packages, evaluated on hard clinical outcomes (e.g., falls, fractures, hospitalization, mortality) [142].
• Personalization strategies tailored by sex, age, functional status, multimorbidity patterns, and anabolic resistance [4,16].
• Rigorous evaluation of technology-enabled interventions (WB-EMS, WBV, VR, AI-assisted telerehabilitation), including safety, feasibility, digital access, and privacy [110].
• Real-world implementation and scale-up, including cost-effectiveness, resource requirements, and long-term adherence strategies [143].
• Development of digital or sensor-based biomarkers for monitoring muscle quality, gait dynamics, and exercise response [144].

A structured research agenda in these areas will improve precision, safety, and accessibility of sarcopenia management.

5. Conclusions

Sarcopenia is a complex condition that affects physical, metabolic, and psychosocial health in aging populations. Early screening, strength-focused diagnostics, and progressive resistance exercise form the foundation of effective management, supported by multimodal training, adequate nutrition, and sustained education. Harmonizing diagnostic criteria and advancing personalized, scalable intervention models will be essential for improving outcomes. Through integration of evidence-based exercise, nutrition, and technology-supported strategies, sarcopenia care can be more effectively embedded into routine clinical practice to support healthy longevity. As this narrative review did not perform a formal risk-of-bias or quality assessment, the strength of the synthesized recommendations should be interpreted with caution.