Four-Step Co-Designing of the Reablement Strategies Targeting Sarcopenia (ReStart-S): An Exercise-Based Multicomponent Program for Older Adults Residing in Long-Term Care Settings

Figures & data

Table 1 Summarization of the Responses from the Workshop Conducted to Co-Design a ReStart-S

Question No.	Question Discussed	Participants Response	Theme Generated	Investigator Action
Question 1	Do you know anything about the condition of Sarcopenia?	Never heard of the term sarcopenia	Lack of knowledge	The condition was introduced to the participants.
Question 2	What do you think about exercise?	Improvement in strength Improves ability to walk Improves flexibility Ease in carrying out activities Feels active	Appreciate the importance of exercise	Additional benefits of doing exercise were discussed.
Question 3	How many days a week do you like to exercise?	Three (n=3): 7 times/week One (n=1) each for 2, 3, 5, and 6 times/week	Willingness	The investigator introduced the concept of Frequency (part of the FITT principle)
Question 4	What should be the intensity of the exercise?	Four (n=4): Tailored as per person’s fitness level Three (n=3): 5 on a scale of 0 to 10 and stepwise progress	Capacity	Explained about the Intensity (part of the FITT principle) The participants were asked to rate the exercise intensity on a scale of zero (nil) to ten (maximum intensity).
Question 5	How long should the exercise session be in a day?	Four (n-=4): 30 minutes/day, 1–3 times/day Two (n=2): start with 30 minutes and progress to 60 minutes	Duration	Participants responses about the time/day of exercise (including different modes and rest periods)
Question 6	What kind of exercises should be there in the training, in your opinion?	Strengthening exercises Aerobic exercises Balance exercises Stretching exercises	Type of exercise	The investigator displayed photographs of a few exercises to the participants to help them understand the question.
Question 7	What motivates you to exercise?	Reduce dependency on tablets To be active and feel better Decrease tiredness	Self-determination	The investigator noted the responses
Question 8	What are the challenges/difficulties you face that prevent you from exercising?	Stones Uneven walkway Pets	Barrier	Discussed solutions/alternatives
Question 9	What are your thoughts on doing exercise in a group?	Group	Positivity	The investigator noted the responses
Question 10	Fun-based physical activity should be included in an exercise program. What is your opinion?	Two (n=2): Throwing a ball Reasoning and mental abilities Two (n=2): Dance Two (n=2): games plus exercise One (n=1): laughing	Exercise is fun; do not consider it a burden	The investigator noted the responses
Question 11	What are the safety concerns while doing exercise?	Two (n=2): Tiredness Three (n=3): joint pain One (n=1): blood pressure fluctuations One (n=1): headaches	Safety concerns	The investigator noted the responses
Question 12	What is the most suitable time to do exercise?	Morning	Preference	The investigator noted the responses
Question 13	What do you think we should keep in mind while designing the exercise program?	Age Surgical history Fear of fall Acute exacerbation of medical condition Fear of group (some inmates show hesitancy to take part in a group)	Thoughts	The investigator noted the responses

Figure 1 Flow chart of the Delphi process.

Table 2 Demographic, Clinical, and Performance Characteristics of the Participants (n = 8)

Domain	Values
Age (Years)	78.25 ± 8.35
Gender	Male= 2 (25%)
	Female= 6 (75%)
Weight (Kg)	55.44 ± 10.31
Body mass index (Kg/m^2)	23.81 ± 4.12
Education level	Primary level= 5 (62.5%)
	Secondary level= 1 (12.5)
	Higher level= 2 (25%)
Hand dominance	Right= 8 (100%), Left= 0
Years of stay	Less than one year= 2 (25%)
	Two to three years= 1 (12.5%)
	More than three years= 5 (62.5%)
Marital status	Married= 3 (37.5%)
	Widow= 5 (62.5%)
Family visits	Yes= 6 (75%)
	No= 2 (25%)
Frequency of visits (in a year)	1.63 ± 1.41
History of falls (in the last two years)	Yes= 2
	No= 6
History of hospitalization (in the last two years)	Yes= 1
	No= 7
History of comorbidities (in the last two years)	Yes= 6
	No= 2
Comorbidities (in the last two years)	Hypertension= 5 (62.5%) Diabetes and hypertension= 2 (25%) Hypertriglyceridemia= 1 (12.5%)
History of medication (in the last two years)	Antihypertensive drugs= 2 (25%)
	Diabetic drugs= 1 (12.5)
	Sedatives= 1 (12.5%)
	Antihypertensive and diabetes drugs= 2 (25%)
	No medication= 2 (25%)
Sarcopenia status	Possible sarcopenia= 1 (12.5%)
	Sarcopenia= 3 (37.5%)
	Severe sarcopenia= 4 (50%)
Skeletal muscle index (Kg/m^2)	5.22 ± 1.09
Males	6.18 ± 0.47
Females	4.89 ± 1.05
Hand Grip Strength (Kg)	17.10 ± 7.23
Males	27.95 ± 5.58
Females	13.48 ± 2.04
Short physical performance battery score	8.38 ± 2.13
Males	10.50 ± 2.12
Females	7.66 ± 1.75
Katz index	6.00 ± 0.00

Figure 2 Flowchart of the participant in the pilot study (step 4) to test ReStart-S feasibility among sarcopenic older adults residing in LTCS.

Table 3 Proposed ReStart-S Program for Severe Sarcopenics

Week Wise Progression	Frequency/Week	Intensity	Volume & Progression	Duration (min)/Session	Exercises
Resistance exercise components of the ReStart-S program for severe sarcopenics
1st week	2/week	Low-moderate (6–8 RPE)	1 set with 5–7 repetitions/set	10 min	Dynamic quads, ball squeeze, sitting heel raise, biceps curls using thera band
2nd week	2/week	Low-moderate (6–8 RPE)	2 sets with 5–7 repetitions/set	10 min	1st week + biceps curls with dumbbells, dynamic quads with sandbag
3rd week	2/week	Moderate-somewhat high (9–10 RPE)	2 sets with 8–10 repetitions/set	20 min	2nd week
4th week	2/week	Moderate-somewhat high (9–10 RPE)	3 sets with 8–10 repetitions/set	20 min	3rd week + sitting hip abductor using thera band, shoulder flexion with dumbbells
5th week	2/week	Somewhat high-high (11–12 RPE)	3 sets with 10–12 repetitions/set	30 min	4th week + sitting knee raises, horizontal shoulder abduction using thera band
6th week	2/week	Somewhat high-high (11–12 RPE)	3 sets with 12–15 repetitions/set	30 min	5th week
Aerobic & endurance exercise components of the ReStart-S program for severe sarcopenics
1st week	2/week	Low-moderate (6–8 RPE)	30 sec self-paced walking 2–4 times	1–2 min	Self-paced walking
2nd week	2/week	Low-moderate (6–8 RPE)	50 sec self-paced walking 2–4 times	3–4 min	Week 1
3rd week	2/week	Moderate-somewhat high (9–10 RPE)	50 sec self-paced walking 5–6 times	4–5 min	Week 2
4th week	2/week	Moderate-somewhat high (9–10 RPE)	60 sec self-paced walking 7–8 times and 5 repetitive stepping in anterior direction 10 sec 2 times	6–12 min	Week 3 + anterior/lateral/posterior stepping
5th week	2/week	Somewhat high-high (11–12 RPE)	70 sec self-paced walking 9–10 times and repetitive stepping anterior + lateral 10 sec 2 times for each direction	11–15 min	Week 4
6th week	2/week	Somewhat high-high (11–12 RPE)	80 sec self-paced walking 11–12 times and repetitive stepping 15 sec 2 times for each direction	16–20 min	Week 5
Balance exercise components of the ReStart-S program for severe sarcopenics
1st week	2/week	Low-moderate (6–8 RPE)	Stand in the position for 20 sec and repeat it 3 times	1min/session	Broad base standing
2nd week	2/week	Low-moderate (6–8 RPE)	Stand with feet together with the support of one finger 10 sec and repeat it for 6 times, followed by without support 5 sec and repeat it for 3 times	2–3 min	1st week + feet together
3rd week	2/week	Moderate-somewhat high (9–10 RPE)	Week 2	3–4 min	2nd week
4th week	2/week	Moderate-somewhat high (9–10 RPE)	Stand with the side of the heel of one foot touching the big toe of the other foot for about 10 seconds, 2 times	4–6 min	3rd week + semi tandem
5th week	2/week	Somewhat high-high (11–12 RPE)	Stand with the heel of one foot in front of and touching the toes of the other foot for about 10 seconds, 2 times	6--8 min	4th week + tandem
6th week	2/week	Somewhat high-high (11–12 RPE)	Week 5	6–8 min	5th week
Stretching exercise components of the ReStart-S program for severe sarcopenics
1st week	2/week	Low-moderate (6–8 RPE)	1 set, repeat 2 times, 10–12 sec hold	1 min	Wrist flexor/extensor stretch, sitting plantar/dorsi flexors stretch
2nd week	2/week	Low-moderate (6–8 RPE)	1 set, repeat 2 times, 13–15 sec	1–2 min	1st week + neck extensor stretch
3rd week	2/week	Moderate-somewhat high (9–10 RPE)	2 set, repeat 2 times, 13–15 sec	2–3 min	2nd week + sitting lateral stretch of the trunk musculature
4th week	2/week	Moderate-somewhat high (9–10 RPE)	Week 3	3–4 min	3rd week + neck rotators stretch
5th week	2/week	Somewhat high-high (11–12 RPE)	2 set, repeat 3 times, 13–15 sec	4–5 min	4th week + biceps and triceps stretch
6th week	2/week	Somewhat high-high (11–12 RPE)	3 set, repeat 3 times, 13–15 sec	5–6 min	5th week + shoulder abductor stretches, neck lateral flexor stretch

Table 4 Proposed ReStart-S Program for Sarcopenics

Week Wise Progression	Frequency/Week	Intensity	Volume & Progression	Duration (min)/Session	Exercises
Resistance exercise components of the ReStart-S program for sarcopenics
1st week	2/week	Low-moderate (6–8 RPE)	1 set with 5–7 repetitions/set	10 min	Standing shoulder abduction with the dumbbell, sitting chest press, sitting abdominal crunch, standing back extension
2nd week	2/week	Low-moderate (6–8 RPE)	2 sets with 5–7 repetitions/set	10 min	1st week+ Standing hip abduction with support, standing flexion/extension
3rd week	2/week	Moderate-somewhat high (9–10 RPE)	2 sets with 8–10 repetitions/set	20 min	2nd week + hip abduction with sandbags, triceps extension and seated row
4th week	2/week	Moderate-somewhat high (9–10 RPE)	3 sets with 8–10 repetitions/set	20 min	3rd week + standing knee bend (hamstring) with support, heel raise with the support
5th week	2/week	Somewhat high-high (11–12 RPE)	3 sets with 10–12 repetitions/set	30 min	4th week + squatting with support, knee bend with support with a sandbag, sit to stand
6th week	2/week	Somewhat high-high (11–12 RPE)	3 sets with 12–15 repetitions/set	30 min	5th week + wall pushups, standing knee raise
Aerobic & endurance exercise components of the ReStart-S program for sarcopenics
1st week	2/week	Low-moderate (6–8 RPE)	5 sec steps marching 2–3 times	1–4 min	Step marching with support
2nd week	2/week	Low-moderate (6–8 RPE)	10 sec steps marching 2–3 times	5–7 min	Week 1
3rd week	2/week	Moderate-somewhat high (9–10 RPE)	10 sec steps marching 4–5 times	8–10 min	Week 2
4th week	2/week	Moderate-somewhat high (9–10 RPE)	20 sec 1–2 times	11–13 min	3rd Week + stationary cycling
5th week	2/week	Somewhat high-high (11–12 RPE)	20 sec 2–3 times	14–16 min	Week 4
6th week	2/week	Somewhat high-high (11–12 RPE)	30 sec 3–4 times	16–20 min	Week 5
Balance exercise components of the ReStart-S program for sarcopenics
1st week	2/week	Low-moderate (6–8 RPE)	Hold position for 10 sec, 6 times	1 min	Heel raise with support, toe raise with support, single leg standing with support
2nd week	2/week	Low-moderate (6–8 RPE)	Hold position for 10 sec, 3 times each exercise	2–3 min	1st week + heel raise/toe raise without support, standing on foam
3rd week	2/week	Moderate-somewhat high (9–10 RPE)	Hold and walk 10 sec, 3 times each exercise	4–6 min	2nd week+ standing reach out, heel walking with support, tandem walk with support forward/backwards
4th week	2/week	Moderate-somewhat high (9–10 RPE)	Walk for 10 sec, 4 times each exercise	7–8 min	3rd week + figure of 8 walk, heel walk without support
5th week	2/week	Somewhat high-high (11–12 RPE)	Walking and clearing hurdles	8–10 min	4th week + tow walking with support, obstacle clearance
6th week	2/week	Somewhat high-high (11–12 RPE)	Toe walks and climbing stairs	10–13 min	5th week + toe walk without support, stair climbing
Stretching exercise components of the ReStart-S program for sarcopenics
1st week	2/week	Low-moderate (6–8 RPE)	1 set, repeat 2 times, 10–12 sec hold	1 min	Sitting arm stretch
2nd week	2/week	Low-moderate (6–8 RPE)	1 set, repeat 2 times, 13–15 sec	1–2 min	1st week + standing lateral muscles of trunk stretch
3rd week	2/week	Moderate-somewhat high (9–10 RPE)	2 set, repeat 2 times, 13–15 sec	2–3 min	2nd week
4th week	2/week	Moderate-somewhat high (9–10 RPE)	Week 3	3–4 min	3rd week + sitting trunk rotator stretch
5th week	2/week	Somewhat high-high (11–12 RPE)	2 set, repeat 3 times, 13–15 sec	4–5 min	4th week + sit to reach
6th week	2/week	Somewhat high-high (11–12 RPE)	3 set, repeat 3 times, 13–15 sec	5–6 min	5th week + standing Achilles stretch with support

Table 5 Proposed ReStart-S Program for Possible Sarcopenics

Week wise progression	Frequency/Week	Intensity	Volume & Progression	Duration (min)/Session	Exercises
Resistance exercise components of ReStart-S program for possible sarcopenics
1st week	2/week	Low-moderate (6–8 RPE)	1 set with 5–7 repetitions/set	10 min	Lunges with support, standing pelvic tilt
2nd week	2/week	Low-moderate (6–8 RPE)	2 sets with 5–7 repetitions/set	10 min	1st week + sitting leg press
3rd week	2/week	Moderate-somewhat high (9–10 RPE)	2 sets with 8–10 repetitions/set	20 min	2nd week + double arm pulls down
4th week	2/week	Moderate-somewhat high (9–10 RPE)	3 sets with 8–10 repetitions/set	20 min	3rd week + forward bend row
5th week	2/week	Somewhat high-high (11–12 RPE)	3 sets with 10–12 repetitions/set	30 min	4th week + latissimus dorsi pull-down
6th week	2/week	Somewhat high-high (11–12 RPE)	3 sets with 12–15 repetitions/set	30 min	5th week + supine chest press
Aerobic & endurance exercise components of ReStart-S program for possible sarcopenics
1st week	2/week	Low-moderate (6–8 RPE)	5 sec steps marching 2–3 times	1–4 min	Step marching without support
2nd week	2/week	Low-moderate (6–8 RPE)	10 sec steps 2–3 times	5–8 min	Week 1
3rd week	2/week	Moderate-somewhat high (9–10 RPE)	10 sec slow running 1–2 times	9–11 min	Week 2 + slow running
4th week	2/week	Moderate-somewhat high (9–10 RPE)	10 sec slow running 2–3 times	11–14 min	Week 3
5th week	2/week	Somewhat high-high (11–12 RPE)	One time each in forward and sideward	14–17 min	Week 4 + agility ladder
6th week	2/week	Somewhat high-high (11–12 RPE)	2 times each in a forward and sideward direction	18–20 min	Week 5
Balance exercise components of ReStart-S program for possible sarcopenics
1st week	2/week	Low-moderate (6–8 RPE)	Object clearance 2 set, 10 times/set	1–2 min	Crossing obstacle
2nd week	2/week	Low-moderate (6–8 RPE)	10 sec walks with backward counting	2–3 min	1st week + cognitive task while walking
3rd week	2/week	Moderate-somewhat high (9–10 RPE)	10 sec walks, 2 times, manual task with walk	4–6 min	2nd week + manual task while walking
4th week	2/week	Moderate-somewhat high (9–10 RPE)	Forward walk on ramp, 5 sec, 2 times	6–8 min	3rd week + upward ram walking
5th week	2/week	Somewhat high-high (11–12 RPE)	Backward walk on the ramp, 5 sec, 2 times	8–10 min	4th week + downward ramp walking
6th week	2/week	Somewhat high-high (11–12 RPE)	2 times front, sideways	8–10 min	5th week + quick direction change exercise
Stretching exercise components of ReStart-S program for possible sarcopenics
1st week	2/week	Low-moderate (6–8 RPE)	1 set, repeat 2 times, 10–12 sec hold	1 min	Standing trunk rotator stretch
2nd week	2/week	Low-moderate (6–8 RPE)	1 set, repeat 2 times, 13–15 sec	1–2 min	1st week
3rd week	2/week	Moderate-somewhat high (9–10 RPE)	2 set, repeat 2 times, 13–15 sec	2–3 min	2nd week + seated Achilles stretch using a towel
4th week	2/week	Moderate-somewhat high (9–10 RPE)	Week 3	3–4 min	3rd week + pectoral muscle wall stretches
5th week	2/week	Somewhat high-high (11–12 RPE)	2 set, repeat 3 times, 13–15 sec	4–5 min	4th week + With support quadriceps stretch
6th week	2/week	Somewhat high-high (11–12 RPE)	3 set, repeat 3 times, 13–15 sec	5–6 min	5th week