Effect of the Resistance-cognitive Dual-task Training on Frailty Status and Cognitive Function in Frail Community-dwelling Older Adults With Chronic Musculoskeletal Pain: A Pilot Randomized Controlled Trial
Phase: NA
Conditions: Chronic Musculoskeletal Pain, Frailty
Sponsor: The Hong Kong Polytechnic University

Official title:  
Effect of the resistance-cognitive dual-task training on frailty status and cognitive function in 
frail community-dwelling older adults with chronic musculoskeletal pain: A pilot randomized 
controlled trial  
NCT number: NCT07035327  
Document date: 30 July 2025  
 
 

Effect of the resistance-cognitive dual-task training on frailty status and cognitive 
function in frail community-dwelling older adults with chronic musculoskeletal pain: A 
pilot randomized controlled trial  
 
Abstract 
Background: The increasing prevalence of frailty among the ageing population poses 
significant health challenges, including heightened vulnerability to stressors and adverse 
outcomes such as falls, hospitalization, and chronic musculoskeletal pain (CMP). CMP 
significantly contributes to functional disability. Studies indicate a strong association between 
pain severity and frailty, with a high prevalence of chronic pain among older adults. Cognitive 
decline correlates with frailty and CMP, affecting perception speed, memory, and verbal 
fluency.  
While physical activity is effective in improving physical functions and reducing pain, hence 
it may improve physical frailty, its impact on cognitive improvement is limited. Current 
research lacks comprehensive interventions targeting cognitive frailty. Dual-task training 
(DTT), which integrates motor and cognitive tasks, has shown promise in enhancing physical 
and cognitive functions in populations with neurological conditions and cognitive 
impairments. This study explores the potential of DTT to improve cognitive functions and 
frailty status in frail individuals with CMP. 
Methods: This is a pilot randomized controlled trial of around 38 community-dwelling older 
adults with chronic musculoskeletal pain and frailty. They will be randomly assigned to either 
the intervention (n=19) or control group (n=19). The intervention group will receive 
resistance training and cognitive tasks simultaneously, while the control group will perform 
resistance exercises only. Both groups will perform exercises (twice/week) under supervision 
for 10 weeks.  
Outcome measures and data analysis: Feasibility and acceptability of the programme will 
be assessed at the end of the training programme. Outcome measures of frailty status, 
cognitive function, pain level, and health-related quality of life will be assessed at the initial 
and the last sessions. To examine preliminary efficacy, within-group and between-group 
changes in pain and functional measures will be analysed.  
Expected results: We expect DTT will be feasible and well-accepted, and participants 
receiving DTT will gain greater improvement in frailty status, physical and cognitive 
performances, reduction in pain, and enhancement in health-related quality of life when 
compared to conventional resistance training. 
 
Keywords: Frailty, Chronic musculoskeletal pain, Exercise, Dual-task training 
 
 

Introduction 
Frailty is a state shown by a regression in ageing individuals’ reserves and the chief reason for 
the vulnerability to various stressors (Cesari et al., 2017). With the rising trend of the ageing 
population, the prevalence of frailty is expected to grow simultaneously. This brings about the 
increased risk of unfavourable outcomes like falls, hospitalization, disability, or comorbidity 
(Pandey et al., 2019). With deterioration in multiple physiological systems, frail individuals 
may suffer from negative health-related effects, and chronic musculoskeletal pain (CMP) is a 
major one. On the other hand, CMP may also be a leading cause of frailty since the severity of 
musculoskeletal pain has a direct effect on individual functions, like mobility (Blyth & 
Noguchi, 2017). Therefore, managing both frailty and CMP with interventions aimed at 
slowing down the deterioration is the key. CMP is a chief culprit for the functional disability. 
It has a large impact on older people’s physical activity level, depression, cognitive 
impairment, and even frailty level (Blyth & Noguchi, 2017). Study shows that pain severity 
was associated with frailty, with 99% of frail individuals (n=176), classified using the FRAIL 
questionnaire, having moderate or severe CMP (i.e. ≥4 on the pain numeric rating scale 
[NRS]) (Chaplin et al., 2023). In the same study, people who transited from non-frail to frail 
status had greater baseline pain levels (mean NRS:  6.4) than those who remained non-frail 
(mean NRS: 4.7). This shows that CMP has a positive correlation to frailty. A systematic 
review of 23 studies showed that approximately 45% of frail community-dwelling older 
adults had chronic pain, and its prevalence could reach as high as 70% in prefrail or frail older 
people (Otones Reyes et al., 2019). Frailty could lead to the degeneration of the peripheral 
and central nervous system, causing nociceptive issues, pain modulation and expression 
(Blyth & Noguchi, 2017). 
In addition to physical deterioration, the rise of cognitive problems is prevalent in frail 
individuals. A cross-sectional study shows that among the community-dwelling older people 
over 65 years old, 39% of the frail ones showed cognitive impairment compared to 22% and 
16% of pre-frail and normal elderly, respectively (Macuco et al., 2012). The cognitive 
functions of perception speed, episodic and semantic memory, and verbal fluency showed 
declined performance in frail elderly (Brigola et al., 2015). Another review also found that 
there was a strong correlation between CMP and cognitive decline (Alcon et al., 2023). These 
show that cognitive impairment is a subject of concern in the older population with frailty and 
CMP. 
Physical activity has been the main intervention in treating the frail elderly, and it has been 
proven effective in reducing physical frailty. Additionally, physical exercise can induce 
endogenous analgesia, which supports the use of exercise therapy in subjects with CMP 
(Daenen et al., 2015). However, a meta-analysis showed that physical activity alone had no 
significant effect on improving cognition (Negm et al., 2019). There are still limited studies 
about the effect of intervention specifically targeting cognitive frailty, and not a clear flow 
from the comprehensive assessment to the multimodal interventions to counter cognitive 
frailty (Sugimoto et al., 2021). Dual-task training (DTT), which combines motor tasks and 
cognitive tasks, is an intervention that has been proven effective in enhancing the physical 
capabilities like gait speed and postural stability (Ghai et al., 2017) of older adults in general 
and those with neurological diseases, like stroke or Parkinson’s disease (Varela-Vásquez et 
al., 2020). General cognitive functions like memory and attention can also be improved by 
DTT in cognitively healthy populations, or patients with cognitive impairment and 
Alzheimer’s disease (AD) (Pereira Oliva et al., 2020). Since cognitive deficits are present in 
older people with frailty and CMP as mentioned, DTT may be one of the feasible 
interventions to improve both physical and cognitive functions, targeting this group of people 
with physical deficits and cognitive impairment effectively. We would like to see whether a 
similar effect will be obtained on frail individuals with CMP. The study aims to provide 
insight into how we provide intervention to enhance cognitive and physical functions, which 
may possibly pave the way for how we treat the problems of frailty clinically. 

Objectives 
1. To assess the feasibility and acceptability, and investigate the effect of a 10-week 
resistance-cognitive DTT program on frailty status in community-dwelling older adults 
with frailty and CMP compared to conventional resistance training. 
2. To investigate the effect of the resistance-cognitive DTT program on cognitive function, 
pain levels and health-related quality of life in community-dwelling older adults with 
frailty and CMP compared to conventional resistance training. 
We hypothesize that 
1. The 10-week resistance-cognitive DTT program is feasible and well accepted, and can 
improve frailty status greater in community-dwelling older adults with frailty and CMP 
compared to conventional resistance training. 
2. Resistance-cognitive DTT program can improve cognitive function, pain levels and health-
related quality of life in community-dwelling older adults with frailty and CMP to a 
greater extent, compared to conventional resistance training. 
 
Research Plan and Methodology 
Study design and setting 
It will be a pilot randomized controlled trial on a 10-week resistance-cognitive DTT 
programme. 38 subjects will be recruited from the general public in Hong Kong. Potential 
participants will also be identified from another ongoing cross-sectional study 
(ChiCTR2400089069) that investigates the prevalence of frailty in community-dwelling older 
adults with CMP. The program will last for 10 weeks with assessments conducted at the initial 
and final sessions. The assessment overview and overall flow of the study can be found in 
Appendices 1 and 2. Subjects will receive assessments and training in the Hong Kong 
Polytechnic University under supervision. 
 
Methods 
Recruitment 
To recruit subjects with frailty, recruitment posters will be posted on the notice boards of the 
Hong Kong Polytechnic University. Invitation posts and stories will also be posted on social 
media like Facebook and Instagram. Potential subjects will also be identified from another 
cross-sectional study (ChiCTR2400089069) with a similar target population. Eligibility 
criteria will be screened by online questionnaires. Eligible subjects will undergo face-to-face 
objective assessments after getting the written consent for participation. Participants will be 
randomized into the intervention and control groups after the initial assessment. 
 
Randomization and allocation 
Randomization and group assignment will be performed by an investigator not involved in 
recruitment or assessment. After participants’ eligibility for enrolment is confirmed, a 
researcher will use a computer to automatically generate a random sequence using Excel 
software (Microsoft Corporation, Redmond, USA) to generate random integers, with odd 
numbers being the experimental group and even numbers being the control group. The 
grouping information will be stored in a separate folder. Participants will undergo the 
corresponding exercise program which will be supervised by the researcher. 
 
Treatment 
The entire program will be scheduled to span 10 weeks, with exercise sessions occurring 
twice per week on non-consecutive days. The exercise frequency will be established based on 
the American College of Sports Medicine’s guidelines (Liguori et al. 2022), in which 
resistance exercise is recommended for at least two days per week.   
 
(i) Intervention group 

Participants in the intervention group will engage in a DTT training program, in which 
resistance training will be incorporated with cognitive tasks. Ten-minute warm-up and 
cool-down sessions will precede and follow each exercise session. 
- Resistance training:  
Participants will be instructed to perform the following exercises with proper form: (1) 
squat to chair, (2) seated unilateral hip flexion, (3) seated unilateral knee extension, (4) 
standing unilateral knee flexion and (5) bilateral calf raise. The lower limb exercises will 
be followed by four upper limb exercises: (6) seated elbow flexion, (7) twisting a towel, 
(8) seated horizontal opening of arms and elbow, (9) seated diagonal opening of arm and 
elbow. The procedures of these exercises are described in Appendix 3. The modified 
BorgCR-10 scale will be adopted to determine the intensity of exercise (Borg, 1998). 
During the initial two-week familiarization period, one set of 10-15 repetitions at an 
intensity of 4-5 will be performed. From the third to the twelfth week, participants will 
perform two sets of 8-12 repetitions at an intensity of 5-6 for each exercise (Liguori et 
al., 2022). A two-minute rest period will be allowed between sets. Participants will be 
instructed to execute the concentric and eccentric phases over approximately 2.5 seconds 
to enhance muscle strength and power. Loads will be adjusted using ankle and wrist 
weights for exercises (1) to (6), and elastic bands with different resistance for exercises 
(8) and (9). A standard towel will be used for exercise (7), and subjects will be asked to 
twist and squeeze the towel with maximal force for 10 repetitions if the pain level is not 
increased (Izquierdo et al., 2017; Coelho-Júnior & Uchida, 2021). 
In normal situations, exercising painful muscles will not change pain sensitivity either in 
the exercising muscle or at distant locations. However, in some patients with 
dysfunctional endogenous analgesia and the presence of central sensitization, there may 
be a risk that participants may experience an increase in pain during the initial weeks of 
the program (Daenen et al., 2015). If participants experience an increase in pain that 
surpasses their usual levels during resistance training, they will switch to alternative non-
painful resistance exercises before resuming the exercise that initially causes discomfort. 
They will also be reminded to ensure adequate rest following the exercise session 
(Daenen et al., 2015). In subsequent sessions, these participants will be instructed to 
perform the resistance exercises at a reduced volume and intensity, with their pain levels 
closely monitored. 
- Cognitive task:  
Among different aspects of cognitive functions, verbal fluency has been chosen as a 
cognitive task in the training since it can serve as a predictor of cognitive decline, 
providing valuable insight into the potential need for early intervention (Frankenberg et 
al., 2021). Additionally, working memory has been selected owing to its critical role in 
cognitively demanding daily activities, such as problem-solving and reading 
comprehension (Matysiak et al., 2019).  
Subjects will be asked to perform a verbal fluency task simultaneously with the 
resistance training exercises. The verbal fluency task will require participants, during the 
concentric action of the exercise, to say aloud as many words as possible within a given 
category for each exercise set. Each month, the task's difficulty will be increased by 
altering the word categories, progressing from general to specific, while semantic 
categories (such as animals and colours) will be varied in each exercise set. Participants 
will be asked to avoid repeating words and generate new ones (Castaño et al., 2022). 
Apart from the verbal fluency task, subjects will also be asked to perform mental 
arithmetic tasks which require sufficient working memory (Nascimbeni et al., 2015). 
This task requires subjects to count backwards from a certain integer. Subjects will 
initially start by counting backwards by one beginning with two pre-determined 
numbers: 378 or 283. Subjects will then progress to counting backwards by four and 
seven (Winser et al., 2019). They will progress once they are managed to complete the 

task without making mistakes in one session.  A three-digit odd number will be randomly 
generated by the computer as a starting number to ensure participants will not rely on the 
memorized sequence but actively process each number. 
There will be no specific combination of cognitive tasks and resistance exercises, it will 
be selected randomly upon each resistance exercise. However, each participant should 
perform each cognitive task for a similar number of times in one session. 
 
(ii) Control group: 
Subjects in the control group will perform the resistance exercises only without receiving 
any cognitive training. Ten-minute warm-up and cool-down sessions will precede and 
follow each exercise session. Subjects will be instructed to maintain their usual physical 
activity level throughout the program. 
 
Inclusion and exclusion criteria 
Adults, of either sex, aged 60 years or above, living in Hong Kong, being able to read and 
communicate verbally, screened frail using the Tilburg Frailty Indicator (TFI) (total score ≥5) 
with report of memory problems (question 9) (Gobbens et al., 2010), experiencing any CMP 
with a pain level higher or equal to 4 in the numerical pain rating scale over a consecutive 3-
month period will be recruited.  
Any individuals with either of the following will be excluded: absence of frailty; surgical 
procedure in the lower limbs or the vertebral column; wheelchair bound or inability to walk 
for five minutes; severe balance impairment; uncompensated cardiac or vascular condition; 
acute inflammatory musculoskeletal conditions; ongoing cancer; dementia; neurological 
diseases such as stroke, Parkinson’s disease, cerebellar disease, myelopathy, and peripheral 
neuropathy; mental illnesses such as schizophrenia, bipolar, psychosis, borderline personality 
disorder; illiteracy. 
 
Sample size consideration 
As this is a pilot study, the study has been designed to generate data that will be used for 
setting up future larger randomised controlled trials. The sample size has been selected to 
evaluate the feasibility, safety and preliminary efficacy of the intervention. An exploratory 
sample size of 30 participants will be recruited in this study, in which 15 of them will be 
randomly allocated to the intervention group performing DTT, and the control group. To 
anticipate a 20% loss, the sample size will increase to 38. All results from the pilot study will 
be helpful in sample size calculations for the future large study. 
 
Outcome measures 
(i) Primary outcome  
- Feasibility and acceptability 
Feasibility will be evaluated through recruitment and compliance rates of the program. 
Recruitment rate will be defined as the total number of participants recruited out of the 
total number of participants screened. Treatment compliance will be defined as the 
proportion of scheduled sessions attended in each group. Acceptability will be assessed 
by a six-question post-program questionnaire based on the barriers to engaging in 
physical activity (Tiecker et al., 2024). Participants will be asked about (1) their 
perceived importance of physical exercise, (2) their acceptability and satisfaction of the 
exercises, (3) the pain or discomfort during the exercises, (4) how challenging it was to 
perform the exercises, (5) exercise duration, (6) whether the exercises could assist in 
activities of daily living. All questions will be asked to rate from a 5-point Likert scale 
from ‘Strongly disagree’ to ‘Strongly agree’ (Appendix 4). Participants will be asked to 
justify all questions to let the researchers understand their difficulties. The questionnaire 
will be administered at the last session of this program. For descriptive interpretation, 
these thresholds ( ≥70% of participants attending ≥70% of supervised sessions and ≥70% 

reporting satisfaction) will be regarded as indicative of good feasibility and acceptability. 
 
- Frailty status: 
To assess the frailty status of participants, three assessment tools will be used since there 
is currently no gold standard in assessing frailty (Dent et al., 2017): the Tilburg Frailty 
Indicator (TFI) (Gobbens et al., 2010), the Fried Frailty Phenotype (FFP) (Fried et al., 
2001) and the Short Physical Performance Battery (SPPB) (Ramírez-Vélez et al., 2021). 
TFI consists of 4 parts, including physical, social and psychological components, and 
determinants of frailty (not scored and not subjected to change in this study), which 
provide us with information on the multifaceted nature of frailty other than physical 
deficits (Gobbens et al., 2010). Other than frailty determinants that are not scored, there 
are 15 items in total, with a score of 0 or 1 on each item. A total score of ≥5 has a validity 
of 0.86 to determine the frailty status of the community-dwelling older Chinese 
population (Dong et al., 2017). FFP consists of 5 components in assessing the severity of 
fraily, including weight loss, weakness, exhaustion, slowness and low physical activity 
(Fried et al., 2001). The frailty score is calculated and the status is categorized into robust 
(0), pre-frail (1-2) and frail (3-5) (Auyeung et al., 2014; Fried et al. 2001). The SPPB is 
an assessment tool for participants’ physical function. It includes 3 components: standing 
balance, 4-m gait speed, and five-repetition sit-to-stand motion (Ramírez-Vélez et al., 
2021). Each component has a score of 0-4. It can be used to show the physical frailty of 
the participants. A total score of <9 is regarded as frail, with a high sensitivity (79.7-
92%) and specificity (73.8-80%) (da Câmara et al., 2013; Perracini et al., 2020; Ramírez-
Vélez et al., 2021). 
 
(ii) Secondary outcome 
There are four secondary outcome measures: a) cognitive function, b) pain level, c) quality 
of life, and d) acceptability towards the programme  
- Cognitive function  
To assess the cognitive status of participants, three assessment tools will be used: the 
Montreal Cognitive Assessment (MoCA) (Nasreddine et al., 1995), the forward digit 
span test (Wechsler, 2008) and the Cognitive Failures Questionnaire (CFQ) (Broadbent et 
al., 1982). The MoCA is a well-established 30-point test that assesses various aspects, 
like attention, memory and fluency. The Hong Kong version (HK-MoCA) will be used 
(Wong et al., 2009). A higher score indicates better cognitive function. A score of 25 or 
below may indicate the presence of mild cognitive impairment (Nasreddine et al., 1995). 
The digit span test is a measure of working memory. Participants will be presented with a 
random series of digits and be asked to repeat them in the order presented (Wechsler, 
2008). If the participant responds correctly, the next trial presents a longer sequence. The 
task will terminate when participants respond incorrectly on three occasions. The 
participant’s span will be the longest number of sequential digits that can be accurately 
remembered. A longer span indicates better working memory with high internal 
reliability (70-90%) (Conway et al., 2005). The CFQ is a self-report measure to assess 
individual forgetfulness, distractibility, and false triggering in everyday life (Rast et al., 
2009). It has 25 items (0-4 points) scored by the client or significant other (Broadbent et 
al., 1982). The total score is 100 points. A higher point indicates fewer cognitive 
difficulties in daily life, with a high test-retest reliability of 0.71 (Bridger, 2013). A valid 
and reliable Chinese version of the CFQ will be used in this study (Zhou et al.,2016). 
 
- Pain score 
The average pain score will be assessed by the numerical pain rating scale (NPRS). 
Participants will be asked to rate the average pain level on a scale from 0 (no pain) to 10 

(maximal pain). It has a high test-retest reliability of 0.95 (Ferraz et al., 1990). 
 
- Health-related quality of life 
The health-related quality of life will be assessed by the EQ-5D-5L questionnaire. It has 
a validated Hong Kong Chinese version (Wong et al., 2019). The questionnaire consists 
of 5 dimensions of health, including mobility, self-care, usual activities, pain/discomfort 
and anxiety/depression. Each dimension will be rated from 1 (no problem) to 5 (extreme 
problems). It also has an EQ-VAS scale to self-rate the overall health perception from 0 
(worst health) to 100 (best health). The questionnaire will be administered before and 
after the intervention programme. 
 
Sociodemographic data will also be collected, including age, gender, body mass index, 
marital status, living status, mobility status, educational level, employment status, lifestyle 
variables (exercise habit, smoking, alcohol intake), number of self-reported comorbidities, 
and any presence of polypharmacy (i.e. concurrent use of ≥5 drugs) in the baseline 
assessment. 
 
Statistical analysis 
Descriptive statistics with means (SDs) or medians (IQRs) for continuous variables, and 
counts (percentages) for categorical variables will be reported for the demographics of the 
participants. Shapiro-Wilk test will be used to check data for normality. The recruitment, 
compliance and acceptability rates will be presented as percentages with 95% confidence 
intervals (95% CIs) to describe the feasibility and acceptability of the program. For the first 
and second objectives, independent t-tests for parametric statistics or Mann-Whitney U Test 
for non-parametric statistics will be used to compare baseline statistics between the 
intervention and control groups. Mixed ANOVA will be used to show the differences of 
change in outcome measures between both groups, and post-hoc tests will be used to check 
for differences in the outcomes between pre- and post-intervention in both groups. Statistical 
analyses will be performed using SPSS software version 29 (IBM, New York, USA). The 
level of significance will be set at p<0.05. 
 
Ethical considerations 
The researcher will explain the risks and benefits of the study to the participants. Written 
informed consent will be obtained from the participants. Participants may withdraw from the 
project without prejudice. Data will be kept confidential in secure offices of the Department 
of Rehabilitation Sciences. Only group data will be published. Approval for the project will 
be obtained from The Hong Kong Polytechnic University Institutional Review Board. The 
study will adhere to the local laws, the Declaration of Helsinki, and institutional policies. This 
study will be registered with the Chinese Clinical Trials Registry before the first participant is 
recruited. 
 
 

References 
Alcon, C., Bergman, E., Galli, F., Humphrey, J., Patel, R. M., & Wang-Price, S. (2023). The 
relationship between pain catastrophizing and cognitive function in chronic 
musculoskeletal pain: A scoping review. Pain Research & Management, 2023, 
5851450. https://doi.org/10.1155/2023/5851450 
Auyeung, T. W., Lee, J. S., Leung, J., Kwok, T., & Woo, J. (2014). The selection of a 
screening test for frailty identification in community-dwelling older adults. The 
Journal of Nutrition, Health & Aging, 18(2), 199–203. 
https://doi.org/10.1007/s12603-013-0365-4 
Blyth, F. M., & Noguchi, N. (2017). Chronic musculoskeletal pain and its impact on older 
people. Best Practice &amp; Research Clinical Rheumatology, 31(2), 160–168. 
https://doi.org/10.1016/j.berh.2017.10.004 
Borg, G. (1998). Borg’s Perceived Exertion and Pain Scales. Champaign, IL: Human 
Kinetics. 
Bridger, R. S., Johnsen, S. Å., & Brasher, K. (2013). Psychometric Properties of the cognitive 
failures questionnaire†. Ergonomics, 56(10), 1515–1524. 
https://doi.org/10.1080/00140139.2013.821172  
Brigola, A. G., Rossetti, E. S., Santos, B. R., Neri, A. L., Zazzetta, M. S., Inouye, K., & 
Pavarini, S. C. (2015). Relationship between cognition and frailty in elderly: A 
systematic review. Dementia & Neuropsychologia, 9(2), 110–119. 
https://doi.org/10.1590/1980-57642015dn92000005 
Broadbent, D. E., Cooper, P. F., FitzGerald, P., & Parkes, K. R. (1982). The Cognitive 
Failures Questionnaire (CFQ) and its correlates. British Journal of Clinical 
Psychology, 21(1), 1–16. https://doi.org/10.1111/j.2044-8260.1982.tb01421.x  
Castaño, L. A. A., Castillo de Lima, V., Barbieri, J. F., de Lucena, E. G. P., Gáspari, A. F., 
Arai, H., Teixeira, C. V. L., Coelho-Júnior, H. J., & Uchida, M. C. (2022). Resistance 
Training Combined With Cognitive Training Increases Brain Derived Neurotrophic 
Factor and Improves Cognitive Function in Healthy Older Adults. Frontiers in 
psychology, 13, 870561. https://doi.org/10.3389/fpsyg.2022.870561 
Cesari, M., Calvani, R., & Marzetti, E. (2017). Frailty in older persons. Clinics in Geriatric 
Medicine, 33(3), 293–303.  
https://doi.org/10.1016/j.cger.2017.02.002 
Chaplin, W. J., McWilliams, D. F., Millar, B. S., Gladman, J. R., & Walsh, D. A. (2023). The 
bidirectional relationship between chronic joint pain and frailty: Data from the 
investigating Musculoskeletal Health and Wellbeing cohort. BMC Geriatrics, 23(1). 
https://doi.org/10.1186/s12877-023-03949-4 
Coelho-Júnior, H. J., & Uchida, M. C. (2021). Effects of Low-Speed and High-Speed 
Resistance Training Programs on Frailty Status, Physical Performance, Cognitive 
Function, and Blood Pressure in Prefrail and Frail Older Adults. Frontiers in 
medicine, 8, 702436. https://doi.org/10.3389/fmed.2021.702436 
Conway, A. R., Kane, M. J., Bunting, M. F., Hambrick, D. Z., Wilhelm, O., & Engle, R. W. 
(2005). Working memory span tasks: A methodological review and user’s guide. 
Psychonomic Bulletin & Review, 12(5), 769–786. https://doi.org/10.3758/bf03196772  

Daenen, L., Varkey, E., Kellmann, M., & Nijs, J. (2015). Exercise, not to exercise, or how to 
exercise in patients with chronic pain? Applying science to practice. The Clinical 
journal of pain, 31(2), 108-114. 
da Câmara, S.M.A., Alvarado, B.E., Guralnik, J.M., Guerra, R.O. and Maciel, Á.C.C. (2013), 
Using the Short Physical Performance Battery to screen for frailty in young-old adults 
with distinct socioeconomic conditions. Geriatrics & Gerontology International, 13, 
421-428. https://doi.org/10.1111/j.1447-0594.2012.00920.x 
Dent, E., Lien, C., Lim, W. S., Wong, W. C., Wong, C. H., Ng, T. P., Woo, J., Dong, B., de la 
Vega, S., Hua Poi, P. J., Kamaruzzaman, S. B., Won, C., Chen, L.-K., Rockwood, K., 
Arai, H., Rodriguez-Mañas, L., Cao, L., Cesari, M., Chan, P., … Flicker, L. (2017). 
The asia-pacific clinical practice guidelines for the management of frailty. Journal of 
the American Medical Directors Association, 18(7), 564–575. 
https://doi.org/10.1016/j.jamda.2017.04.018  
Dong, L., Liu, N., Tian, X., Qiao, X., Gobbens, R. J. J., Kane, R. L., & Wang, C. (2017). 
Reliability and validity of the Tilburg Frailty Indicator (TFI) among Chinese 
community-dwelling older people. Archives of Gerontology and Geriatrics, 73, 21–
28. https://doi.org/10.1016/j.archger.2017.07.001  
Ferraz, M. B., Quaresma, M. R., Aquino, L. R., Atra, E., Tugwell, P., & Goldsmith, C. H. 
(1990). Reliability of pain scales in the assessment of literate and illiterate patients 
with rheumatoid arthritis. The Journal of Rheumatology, 17(8), 1022–1024. 
Frankenberg, C., Weiner, J., Knebel, M., Abulimiti, A., Toro, P., Herold, C. J., Schultz, T., & 
Schröder, J. (2021). Verbal fluency in normal aging and cognitive decline: Results of 
a longitudinal study. Computer Speech & Language, 68, 101195-. 
https://doi.org/10.1016/j.csl.2021.101195 
Fried, L. P., Tangen, C. M., Walston, J., Newman, A. B., Hirsch, C., Gottdiener, J., Seeman, 
T., Tracy, R., Kop, W. J., Burke, G., McBurnie, M. A., & Cardiovascular Health 
Study Collaborative Research Group (2001). Frailty in older adults: evidence for a 
phenotype. The Journals of Gerontology. Series A, Biological Sciences and Medical 
Sciences, 56(3), M146–M156. https://doi.org/10.1093/gerona/56.3.m146 
Ghai, I., Ghai, S., & Effenberg, A. O. (2017). Effects of dual tasks and dual-task training on 
postural stability: A systematic review and meta-analysis. Clinical Interventions in 
Aging, 12, 557–577. https://doi.org/10.2147/CIA.S125201 
Gobbens, R. J. J., van Assen, M. A. L. M., Luijkx, K. G., Wijnen-Sponselee, M. Th., & 
Schols, J. M. G. A. (2010). The Tilburg Frailty Indicator: Psychometric properties. 
Journal of the American Medical Directors Association, 11(5), 344–355. 
https://doi.org/10.1016/j.jamda.2009.11.003  
Izquierdo, M., Casas-Herrero, A., Zambom-Ferraresi, F., Martínez-Velilla, N., Alonso-
Bouzón, C., & Rodriguez-Mañas, L. (2017). A practical guide for prescribing a 
multi-component physical training program to prevent weakness and falls in people 
over 70. Multi-component physical exercise program VIVIFRAIL. 
https://vivifrail.com/wp-content/uploads/2019/11/VIVIFRAIL-ENG-Interactivo.pdf 
Liguori, G., Feito, Y., Fountaine, C. (Charles J., & Roy, B. (Eds.). (2022). ACSM’s guidelines 
for exercise testing and prescription (Eleventh edition.). Wolters Kluwer. 
Macuco, C. R., Batistoni, S. S., Lopes, A., Cachioni, M., da Silva Falcão, D. V., Neri, A. L., & 
Yassuda, M. S. (2012). Mini-mental state examination performance in frail, pre-frail, 

and non-frail community dwelling older adults in Ermelino Matarazzo, São Paulo, 
Brazil. International Psychogeriatrics, 24(11), 1725–1731. 
https://doi.org/10.1017/s1041610212000907 
Matysiak, O., Kroemeke, A., & Brzezicka, A. (2019). Working Memory Capacity as a 
Predictor of Cognitive Training Efficacy in the Elderly Population. Frontiers in Aging 
Neuroscience, 11, 126–126. https://doi.org/10.3389/fnagi.2019.00126 
Nascimbeni, A., Caruso, S., Salatino, A., Carenza, M., Rigano, M., Raviolo, A., & Ricci, R. 
(2015). Dual task-related gait changes in patients with mild cognitive impairment. 
Functional Neurology, 30(1), 59–65. https://doi.org/10.11138/FNeur/2015.30.1.059 
Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., 
Cummings, J. L., & Chertkow, H. (2005). The Montreal Cognitive Assessment, 
MOCA: A brief screening tool for mild cognitive impairment. Journal of the 
American Geriatrics Society, 53(4), 695–699. https://doi.org/10.1111/j.1532-
5415.2005.53221.x  
Negm, A. M., Kennedy, C. C., Thabane, L., Veroniki, A.-A., Adachi, J. D., Richardson, J., 
Cameron, I. D., Giangregorio, A., Petropoulou, M., Alsaad, S. M., Alzahrani, J., 
Maaz, M., Ahmed, M. M., Kim, E., Tehfe, H., Dima, R., Sabanayagam, K., Hewston, 
P., Abu Alrob, H., & Papaioannou, A. (2019). Management of Frailty: A systematic 
review and network meta-analysis of randomized controlled trials. Journal of the 
American Medical Directors Association, 20(10), 1190–1198. 
https://doi.org/10.1016/j.jamda.2019.08.009 
Otones Reyes, P., García Perea, E., & Pedraz Marcos, A. (2019). Chronic pain and frailty in 
community-dwelling older adults: A systematic review. Pain Management Nursing, 
20(4), 309–315. https://doi.org/10.1016/j.pmn.2019.01.003 
Pandey, A., Kitzman, D., & Reeves, G. (2019). Frailty is intertwined with heart failure. 
JACC: Heart Failure, 7(12), 1001–1011. https://doi.org/10.1016/j.jchf.2019.10.005 
Pereira Oliva, H. N., Mansur Machado, F. S., Rodrigues, V. D., Leão, L. L., & Monteiro-
Júnior, R. S. (2020). The effect of dual-task training on cognition of people with 
different clinical conditions: An overview of systematic reviews. IBRO Reports, 9, 
24–31. https://doi.org/10.1016/j.ibror.2020.06.005 
Perracini, M. R., Mello, M., de Oliveira Máximo, R., Bilton, T. L., Ferriolli, E., Lustosa, L. 
P., & da Silva Alexandre, T. (2020). Diagnostic accuracy of the short physical 
performance battery for detecting frailty in older people. Physical Therapy, 100(1), 
90–98. https://doi.org/10.1093/ptj/pzz154 
Ramírez-Vélez, R., López Sáez De Asteasu, M., Morley, J. E., Cano-Gutierrez, C. A., & 
Izquierdo, M. (2021). Performance of the short physical performance battery in 
identifying the frailty phenotype and predicting geriatric syndromes in community-
dwelling elderly. The Journal of Nutrition, Health and Aging, 25(2), 209–217. 
https://doi.org/10.1007/s12603-020-1484-3  
Rast, P., Zimprich, D., Van Boxtel, M., & Jolles, J. (2008). Factor structure and measurement 
invariance of the cognitive failures questionnaire across the adult life span. 
Assessment, 16(2), 145–158. https://doi.org/10.1177/1073191108324440  
Salse-Batán, J., González-Devesa, D., Duñabeitia, I., Bidaurrazaga-Letona, I., Ayán-Pérez, C., 
& Sanchez-Lastra, M. A. (2025). Effects of stretching exercise on walking 
performance and balance in older adults: A systematic review and meta-analysis. 
Geriatric Nursing (New York), 61, 479–490. 
https://doi.org/10.1016/j.gerinurse.2024.12.018 

Simão, R., Lemos, A., Salles, B., Leite, T., Oliveira, É., Rhea, M., & Reis, V. M. (2011). The 
Influence of Strength, Flexibility, and Simultaneous Training on Flexibility and 
Strength Gains. Journal of Strength and Conditioning Research, 25(5), 1333–1338. 
https://doi.org/10.1519/JSC.0b013e3181da85bf 
Sugimoto, T., Arai, H., & Sakurai, T. (2021). An update on cognitive frailty: Its definition, 
impact, associated factors and underlying mechanisms, and interventions. Geriatrics 
& Gerontology International, 22(2), 99–109. https://doi.org/10.1111/ggi.14322 
Tiecker, A. P., Cadore, E. L., Izquierdo, M., Zmuda, G. G. O., Aguirre, F. B., & Bós, Â. J. G. 
(2024). Acceptability of a home-based multicomponent exercise program (Vivifrail®) 
for the oldest-old via videoconferencing during the Covid-19 pandemic. Revista 
Brasileira de Geriatria e Gerontologia., 27. https://doi.org/10.1590/1981-
22562024027.230089.en 
Varela-Vásquez, L. A., Minobes-Molina, E., & Jerez-Roig, J. (2020). Dual-task exercises in 
older adults: A structured review of current literature. Journal of Frailty, Sarcopenia 
and Falls, 05(02), 31–37. https://doi.org/10.22540/jfsf-05-031 
Wechsler, D. (2008). Wechsler Adult Intelligence Scale--fourth edition. PsycTESTS Dataset. 
https://doi.org/10.1037/t15169-000  
Winser, S., Pang, M. Y. C., Rauszen, J. S., Chan, A. Y. Y., Chen, C. H., & Whitney, S. L. 
(2019). Does integrated cognitive and balance (dual-task) training improve balance 
and reduce falls risk in individuals with cerebellar ataxia? Medical Hypotheses, 126, 
149–153. https://doi.org/10.1016/j.mehy.2019.03.001 
Wong, A., Xiong, Y. Y., Kwan, P. W., Chan, A. Y., Lam, W. W., Wang, K., Chu, W. C., 
Nyenhuis, D. L., Nasreddine, Z., Wong, L. K., & Mok, V. C. (2009). The validity, 
reliability and clinical utility of the Hong Kong Montreal Cognitive Assessment (HK-
MoCA) in patients with cerebral small vessel disease. Dementia and geriatric 
cognitive disorders, 28(1), 81–87. https://doi.org/10.1159/000232589 
Wong, E. L., Cheung, A. W., Wong, A. Y., Xu, R. H., Ramos-Goñi, J. M., & Rivero-Arias, O. 
(2019). Normative Profile of Health-Related Quality of Life for Hong Kong General 
Population using Preference-Based Instrument EQ-5D-5L. Value in Health, 22(8), 
916–924. https://doi.org/10.1016/j.jval.2019.02.014 
Zhou, Y., Chen, J., Liu, Y., Wang, P., Zhu, L., & Yan, T. (2016). 认知失败问卷中文版测评大
学生样本的效度和信度[Validity and Reliability of the Chinese Version of the 
Cognitive Failures Questionnaire in a University Student Sample]. Chinese and 
reliability of the Chinese version of the cognitive failure questionnaire in a sample of 
college students, 24(3), 438-443. 
 
 

Appendix 1. Assessments overview and sample of outcome measures 
 
Assessment  
Baseline (Day 0) Intervention period End of intervention 
Enrolment  
 
Eligibility screen  
X 
 
 
Informed consent  
X 
 
 
Demographic data  
X 
 
 
Comorbidity data  
X 
 
 
Treatment 
 
 
Intervention group: resistance 
training, cognitive tasks 
X 
 
Control group: resistance 
exercise 
 
X 
 
Outcomes  
 
 
Feasibility and acceptability 
 
 
X 
Frailty level 
 
 
 
- TFI 
X 
 
X 
- FFP 
X 
 
X 
- SPPB 
X 
 
X 
Cognitive function 
 
 
 
- MoCA 
X 
 
X 
- Forward digit span test 
X 
 
X 
- CFQ 
X 
 
X 
Pain intensity: NPRS 
X 
 
X 
Health-related quality of life: 
EQ-5D-5L 
X 
 
X 
TFI, Tilburg Frailty Indicator; FFP, Fried Frailty Phenotype; SPPB, Short Physical 
Performance Battery; MoCA, Montreal Cognitive Assessment; CFQ, Cognitive Failures 
Questionnaire; NPRS, Numerical Pain Rating Scale 
 
 

Appendix 2. CONSORT Flow Diagram  
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Appendix 3. Description of exercises 
Resistance exercises 
(1) Squat to chair 
Subjects sit in a firm chair with arms, supporting their feet well 
on the ground, and stand up without using the arms of the chair. 
In the standing position, subjects lower their body down until 
their buttocks touch the chair and immediately return to standing. 
(2) Seated unilateral 
hip flexion 
Subjects sit in a firm chair with arms and slowly lift one knee 
towards their chest as high as is comfortable with the knee bent, 
keeping the foot off the ground. They then lower the foot back to 
the floor, returning to the starting position. 
(3) Seated unilateral 
knee extension 
Subjects horizontally extend one leg, trying to keep it as straight 
as possible, and repeat with the other leg once they have finished 
the recommended sets. 
(4) Standing unilateral 
knee flexion 
Subjects stand up and, if necessary, support their arms on a firm 
chair or table. With their back straight, they flex the knee, 
keeping the foot back, and return to the initial position. They 
repeat with the other leg once the sets indicated have been 
finished. 
(5) Bilateral calf raise 
Subjects stand in front of a table or chair back with their feet 
separated and aligned with their shoulders. They get on their 
tiptoes until they are as high as possible, then go down gradually 
until their heels are on the floor. If they lose balance, they support 
themselves on the table or chair; they do not do so if they can 
keep their balance well. 
(6) Seated elbow 
flexion 
Subjects sit with their arms stretched across their body with a 
weight in each hand. They bend the elbows towards the chest, 
moving the weights towards the shoulders. 
(7) Twisting a towel 
Subjects roll up a small towel into the shape of a tube, grab the 
towel by the ends, and use both hands to make a movement 
similar to wringing out a soaking towel. They tighten gradually 
but as strong as they can. 
(8) Seated horizontal 
opening of arms 
and elbow 
Subjects hold an elastic band by the ends and roll it appropriately 
to prevent injury. They stretch the band at the height of their chest 
and separate the arms to fully extend the elbows. 
(9) Seated diagonal 
opening of arm and 
elbow 
Subjects hold an elastic band by the ends and roll it appropriately 
to prevent injury. They begin to separate the arms diagonally to 
extend the elbows at the height of the knees. 
 
 
 

Appendix 4. Acceptability Questionnaire 
Criteria 
Strongly 
disagree 
Disagree 
Neutral 
Agree 
Strongly 
agree 
Importance of 
engaging in the 
proposed exercises 
 
 
 
 
 
Acceptability and 
satisfaction of the 
exercises 
 
 
 
 
 
Discomfort felt 
when performing 
the exercises 
 
 
 
 
 
Difficulty in 
performing the 
exercises 
 
 
 
 
 
Duration of 
exercises 
 
 
 
 
 
Can the exercises 
help with activities 
of daily living? 
 
 
 
 
 
(Adpoted from Tiecker et al., 2024)