FrailtyTrack – Teaching & Reference Tool
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Dieses Tool dient der Ausbildung und Wissensvermittlung. Es ist kein Medizinprodukt und ersetzt keine klinische Beurteilung durch Fachpersonen. Bitte keine echten Patientendaten eingeben.

Background: Frailty & Sarcopenia

Two related but distinct age-associated syndromes that physiotherapy is uniquely positioned to detect and address. This tab is the landing page of FrailtyTrack: it first orients new users to what the tool offers (overview card below), then to the conceptual framework FrailtyTrack is built on, and walks through the scientific evidence behind the SARC-F screening questionnaire as the worked example. For deeper conceptual positions see the Position Statements & Consensus section in the About tab; for the full reference list see the bibliography in About.

Was FrailtyTrack bietet — auf einen Blick

Identität · Inhalt · Zielgruppe · Workflow · Was es nicht tut · Schnellstart
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In einem Satz

FrailtyTrack ist ein Lehr- und Referenzwerkzeug für die Physiotherapie-Ausbildung und -Weiterbildung — keine Medizinprodukt-Software, keine Diagnose-Hilfe für reale Patientinnen und Patienten. Die App läuft vollständig lokal im Browser; keine Cookies, kein Server, keine Patientendaten verlassen das Gerät.

1. Was drin ist

  • Test-Protokoll-Katalog — strukturierte Karten zu Gangtests, Sit-to-Stand-Tests, Gleichgewicht und Stepping, Sarkopenie und Ernährung, Sturzrisiko, Kognition, Depression sowie Selbstauskunfts-Fragebögen, jeweils mit Protokoll, normativen Daten und klinischer Interpretation.
  • 8 Demo-Fälle — literaturbasierte Patientenvignetten mit longitudinalen Verlaufsdaten, abgeleitet aus publizierten klinischen Studien sowie aus den drei Fall-Vignetten des BFH-Frailty-Workshop-Skripts (Frau M.K. pre-frail HFpEF, Herr H.K. frail+MCI+Sturzanamnese, Frau B.S. post-Pneumonie HAD).
  • Berechnungs-Engines — relative STS-Power nach Alcazar, Perzentil-Lookup gegen NAKO/Coelho-Junior/Strassmann/Morbach/Bohannon-Normdaten, Fried-Phänotyp-Scoring, automatische SARC-F → SARC-CalF-Ableitung mit sex-spezifischen Wadenumfang-Cut-offs.
  • Verlaufsverfolgung — Sitzung-zu-Sitzung-Vergleiche aller Metriken inklusive MCID-Markierungen, Radar-Charts und Trendlinien.
  • Excel-Import/Export — herunterladbare Vorlage, Speichern und Laden von Sitzungs-Daten als XLSX, ohne Server-Kontakt.
  • Zweisprachige Oberfläche — Deutsch (Standard) mit validierten DACH-Übersetzungen klinischer Instrumente (u. a. Braun 2018 PRISMA-7/FRAIL/GFI, Drey 2020 SARC-F, Dalhousie CFS v2.0, Hautzinger & Bailer 2012 ADS, DZHK-SOP-K-04 6MWT, Cramer 2020 GVMBT, Scherfer 2006 BBS); Englisch über den Topbar-Schalter.

2. Für wen

  • Physiotherapie-Studierende — als interaktives Nachschlagewerk neben dem Lehrbuch.
  • Klinische Lehrpersonen und Dozierende — als Demo-Werkzeug im Unterricht.
  • Praktizierende Physiotherapeut:innen in geriatrischer und rehabilitativer Versorgung — als Referenz für Cut-offs, Normdaten und MCID-Werte.
  • Teilnehmer:innen des BFH-Frailty-Workshops 2026 — die Demo-Fälle und Protokoll-Karten sind auf das Workshop-Skript abgestimmt.

3. Typischer Arbeitsablauf

Die Tab-Reihenfolge (ab v9.5.0) ist auf eine konzept-zuerst-Lernreise ausgelegt:

  1. 📚 Hintergrund — was Frailty ist und warum Früherkennung zählt (diese Seite).
  2. 🧪 Demo-Fälle — acht ausgearbeitete Patientenbeispiele mit Verlaufsdaten ansehen.
  3. 📋 Testprotokolle — Cut-offs, Normdaten und Durchführungsanleitungen für die einzelnen Instrumente nachschlagen.
  4. ✏️ Übungsfall-Erfassung — einen eigenen Übungsfall anlegen, Werte eingeben und automatisch auswerten lassen.
  5. 📊 Lernresultate — die kombinierte Auswertung mit Frailty-Status, Perzentilen und Risiko-Bändern lesen.
  6. 📈 Verlaufsvergleich — bei Folge-Sitzungen Veränderungen über die Zeit verfolgen, einschliesslich MCID-Markierungen.

4. Was FrailtyTrack nicht tut

  • Kein Medizinprodukt. FrailtyTrack ist keine zugelassene Diagnose-Software und ersetzt keine klinische Beurteilung durch Fachpersonen.
  • Keine Diagnose und keine Therapie-Entscheidung an realen Patient:innen. Die Eingabe-Felder sind für didaktische Übungsfälle gedacht; bitte keine echten Patientendaten eingeben.
  • Keine Datenpersistenz. Es gibt keinen Server-Kontakt; alles bleibt lokal im Browser. Beim Schliessen des Tabs sind die Eingaben weg, sofern nicht vorher per Excel-Export gespeichert.
  • Kein Ersatz für klinisches Urteil. Die Cut-offs und MCIDs sind populationsspezifische Schwellenwerte aus der Literatur — die klinische Interpretation bleibt Aufgabe der Therapeut:in.

5. Schnellstart

Direktlinks zu den nächsten Schritten:

1. Frailty — Conceptual Framework

Definition · Models · Why early detection matters · FrailtyTrack assessment pathway
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Bottom line in one paragraph

Frailty is an age-associated clinical syndrome of reduced physiological reserve and impaired stress response. It is a pre-disability state — it precedes disability, predicts it more strongly than any other modifiable factor, and is itself dynamic and potentially reversible. Two operational models dominate: the Fried physical phenotype (5 dichotomous criteria: weight loss, exhaustion, low activity, slow gait, weak grip) and the Rockwood deficit accumulation Frailty Index (proportion of accumulated health deficits). The two are complementary, not interchangeable. Targeted intervention — multicomponent exercise plus nutritional optimisation — has consistent RCT evidence (SPRINTT, LIFE-P, Tarazona-Santabalbina 2016, MID-Frail). Physiotherapy is uniquely positioned at the intersection of detection (gait, strength, balance, power) and intervention (the same domains as exercise prescription targets). Early detection at the pre-frail stage gives the greatest intervention leverage.

1.1 What frailty is — the syndrome and its physiology

Frailty is best understood as a clinical syndrome rather than a single disease. The defining feature is a heterogeneous decline in functional reserve across multiple organ systems, accompanied by impaired homeostasis and a reduced capacity to respond to stressors.Clegg 2013Fried 2001Hoogendijk 2019Dent 2025 A minor stressor that an unfrail older adult would absorb without consequence — a urinary tract infection, a brief hospital admission for a non-major procedure, a course of corticosteroids — can in a frail patient precipitate cascading functional decline, hospital-acquired delirium, mobility loss, and disability that persists long after the original stressor has resolved. This vulnerability is what frailty captures and what makes it a distinctive clinical concept.

Underlying the syndrome is a complex pathophysiology that is not yet fully understood: chronic low-grade inflammation (the «inflammaging» phenomenon), dysregulated nutrient sensing, mitochondrial dysfunction, cellular senescence, sarcopenia, neuro-endocrine dysregulation (HPA axis, autonomic nervous system, sex hormones), and altered intercellular communication all play roles.Álvarez-Bustos 2026 Importantly, the syndrome's clinical expression is downstream of these biological processes — which is why frailty is assessed clinically through observable functional changes (walking speed, grip strength, fatigue, activity level, body weight) rather than directly through biomarkers.

1.2 Why early detection matters

Three reasons make early detection of frailty — particularly at the pre-frail stage — clinically valuable.

  1. Reversibility window. Pre-frailty (1–2 of the Fried criteria, or an intermediate frailty-index score) is the window where targeted intervention has the greatest chance of reversing the trajectory. Once severe frailty and disability have set in, reversibility is «highly compromised and complex».Álvarez-Bustos 2026 Travers 2019, in a systematic review of primary-care interventions, found multicomponent exercise to consistently delay or reverse frailty in community settings.Travers 2019
  2. Strong outcome predictor. Frailty independently predicts falls, fractures, hospitalisation, prolonged length of stay, post-operative complications, institutionalisation, and mortality — over and above chronological age, comorbidity, and disability scores. Some studies identify it as the main modifiable factor associated with mortality in older adults.Hoogendijk 2019Álvarez-Bustos 2026Dent 2025 Identifying frailty changes the prognostic conversation and informs care intensity decisions.
  3. Effective interventions exist. The SPRINTT RCT (n=1,519, 11 European countries, evaluator-blinded) demonstrated that a multicomponent intervention (physical activity + nutritional counselling) prevented mobility disability in older adults with physical frailty and sarcopenia at the SPPB 8–9 stratum.Bernabei 2022 The LIFE-P, MID-Frail, and Tarazona-Santabalbina 2016 trials show converging evidence. Detection without intervention is incomplete; detection plus exercise plus nutrition is where the evidence sits.

1.3 Two operational models — phenotype vs deficit accumulation

There are two well-established operational definitions of frailty in the literature, and they conceptualise the syndrome in different ways.Buta 2016Clegg 2013

Dimension Fried physical phenotype Rockwood deficit accumulation (Frailty Index)
Origin Fried 2001 — Cardiovascular Health Study cohort Mitnitski 2001 / Rockwood 2007 — Canadian Study of Health and Aging
Construct Frailty as a biological syndrome: 5 dichotomous criteria capturing a phenotype of energy depletion / dysregulation Frailty as deficit burden: the more accumulated health deficits an individual has, the frailer they are
Items 5 criteria: unintentional weight loss, exhaustion (CES-D items), low physical activity, slow gait speed, weak grip strength Variable (typically 30–70) deficits drawn from CGA: diseases, signs, symptoms, lab abnormalities, functional impairments
Score 0–5; categorical: Robust 0 / Pre-frail 1–2 / Frail ≥3 0–1 continuous (proportion of deficits present); cut-points typically >0.25 frail, 0.10–0.25 pre-frail
Strength Mechanism-anchored, fast to administer (~10 min), validated against clinical outcomes in the original CHS cohort and many derivative studies Fine-grained, captures gradient of risk, derivable from electronic health records (eFI), useful in research
Limitation Dichotomous criteria reduce sensitivity to subtle changes; requires gait speed measurement and dynamometer; population-adapted cut-offs needed Items not standardised across studies; can include disability items (which CIBERFES considers an error of construct); less mechanism-anchored
Best use Diagnosis — especially when physiotherapy intervention is being considered Risk stratification across settings, electronic-record-driven case-finding, research

The two models do not measure the same thing and may be complementary.Álvarez-Bustos 2026 The Clinical Frailty Scale (CFS, Rockwood 2005), built on the deficit-accumulation tradition but validated as a 1–9 visual scale for clinician judgement, sits as a third widely-used pragmatic tool. FrailtyTrack uses Fried's phenotype as the primary diagnostic construct and includes the CFS card for cross-referencing; the Frailty Trait Scale-5 (FTS5; García-García 2020García-García 2020) is on the roadmap as a complement to address Fried's dichotomy limitations — this is also CIBERFES's recommended approach (bibliography entry added in v9.7.1; full instrument card scheduled for v9.8). The full deficit-accumulation Frailty Index is not currently in FrailtyTrack as a primary instrument.

1.4 Pre-frailty — the intervention window

Pre-frailty denotes the intermediate state with one or two Fried phenotype criteria present, but not yet meeting the ≥3-criterion frailty threshold. Up to half of community-dwelling older adults meet pre-frailty criteria.Álvarez-Bustos 2026 Pre-frailty is associated with substantially increased risk of progression to frailty, falls, and disability over 1–3 years — but it is also the stage at which intervention has the greatest leverage. The combination of high prevalence, increased risk, and intervention reversibility makes pre-frailty the prime target for case-finding programmes in primary care, outpatient physiotherapy, and community geriatric services.

Important caveat. CIBERFES 2026 explicitly notes that there remains no consensus on the operational definition of pre-frailty: cut-off points, clinical relevance, and prognostic implications all require further research. The pragmatic approach is to treat pre-frailty as a high-yield trigger for full assessment and exercise/nutrition counselling, while remaining cautious about labelling and over-medicalising the state.

1.5 How FrailtyTrack supports the assessment pathway

FrailtyTrack implements the two-step screening → diagnosis pathway recommended by ADVANTAGE (the European Joint Action on frailty), the Spanish Ministry of Health's Frailty Working Group, the ICFSR Primary Care guidelines, and CIBERFES.Álvarez-Bustos 2026Hoogendijk 2019 Each construct corresponds to a section in the Test Protocols tab.

Step Purpose Recommended instruments — FrailtyTrack cards
1. Screening Rapid case-finding in primary care, outpatient settings, or community programmes. Few minutes per patient. Goal: flag candidates for fuller assessment. SPPB (S1) · Gait speed 4MGS (G1) · FRAIL Scale (Questionnaires tab, 5-item self-report). PRISMA-7 and Groningen FI also implemented for comparison.
2. Diagnosis Confirm frailty status, characterise the syndrome's expression in this individual, and inform intervention planning. 20–30 min. Fried phenotype (Frailty construct, primary instrument) — HGS for grip, gait speed for slowness, ADS/CES-D items for exhaustion, Activity questionnaire for physical activity, weight-loss self-report. Plus CFS for clinician overall judgement.
3. Powerpenia marker Sit-to-stand muscle power declines earlier and faster than muscle size or strength — making it a sensitive marker. 5xSTS power and 30s STS power cards (Strength & Power construct), with Coelho-Junior 2024 normative data (n=12,864) and the Alcázar 2021 power equation. Garcia-Aguirre 2025 longitudinal evidence supports STS power as a predictor of adverse outcomes.
4. Fall-risk assessment Frailty and fall risk are intertwined; the WFG 2022 guidelines explicitly cite frailty as a high-risk fall marker. Fall Risk construct with three frameworks: CDC STEADI (F0–F3), WFG 2022 (F4) + FES-I (F5), Swiss StoppSturz (S1–S3). Plus B4 Mini-BESTest, B5 Berg Balance Scale, OLS, FSST, DT-TUG.
5. Sarcopenia coexistence Sarcopenia and frailty often coexist (and the combination is necessary for full disability risk). Detection of one should prompt evaluation of the other. Sarcopenia construct — SARC-F screen, HGS, calf circumference, gait speed for the EWGSOP2 case-finding pathway. See Section 2 of this Background tab for the in-depth SARC-F evaluation.

1.6 Common misunderstandings

  • «Frailty just means old.» No. Many older adults — including nonagenarians and centenarians — are not frail and never become frail. Frailty is age-associated but not synonymous with aging.Álvarez-Bustos 2026
  • «Frailty is the same as sarcopenia.» No. Sarcopenia is a neuromusculoskeletal disease where muscle (the target organ) loses size and function. Frailty is multisystemic. The two often coexist (and the coexistence is necessary for some adverse outcomes), but each can be present without the other.Álvarez-Bustos 2026 See Section 2 of this Background tab for the sarcopenia-specific evaluation.
  • «Frailty is just a different word for disability.» No. Frailty is a pre-disability state — it precedes disability, predicts it, and is itself dynamic. CIBERFES specifically argues that disability items should not be part of frailty scales, on the construct grounds that confusing predictor with outcome empties the concept of clinical use. (The Tilburg Frailty Indicator, Groningen Frailty Indicator, and electronic Frailty Index are critiqued on these grounds.)
  • «Frailty is irreversible — once a patient is frail, that's it.» No. Pre-frailty and mild frailty are dynamic and respond to multicomponent intervention.Bernabei 2022Travers 2019 Severe frailty with established disability is much harder to reverse, but even there functional gains are achievable in many cases.
  • «Frailty assessment requires specialist geriatricians.» No. The recommended screening instruments (SPPB, gait speed, FRAIL) are designed for primary care, nursing, and physiotherapy use. Comprehensive Geriatric Assessment for further characterisation is appropriate when available, but the entry assessment can and should be done at the first point of contact with the older adult.Hoogendijk 2019Álvarez-Bustos 2026
  • «The label 'frail' will harm patients.» A real concern but not a reason to avoid assessment. Stigma management is recognised by CIBERFES and the World Falls Guidelines — the right response is destigmatisation and patient-centred communication, not concealment of the clinical state. The terminology choice (e.g. avoiding the German Gebrechlichkeit in favour of the English Frailty) is one practical way to manage this. See the Position Statements & Consensus section in About for a fuller discussion.

1.7 Why physiotherapy is central to frailty care

Physiotherapy sits at a unique intersection in frailty care. The clinical features used to detect frailty are physical-functional — gait speed, grip strength, balance, sit-to-stand power, fatigue during activity. These are exactly the domains physiotherapists routinely measure. The interventions with the strongest RCT evidence — multicomponent exercise (strength + power + balance + gait + aerobic) — are exactly the domains physiotherapists routinely prescribe and supervise.Bernabei 2022Izquierdo 2025 ICFSR The treatment dose, the progression logic, the safety considerations, the adherence work — all are physiotherapy core competencies.

In the Swiss context, this is operationalised through the StoppSturz Vorgehen Physiotherapie (Frehner 2021) for fall prevention — with explicit prescription pathways and tariff-position structures. The Vivifrail program (vivifrail.com), endorsed by ICFSR, provides a tested capacity-tailored exercise prescription anchored to the patient's functional status. The combination of a frailty diagnosis + a Vivifrail or equivalent prescription + nutritional counselling (≥1.2 g/kg/day protein, Mediterranean dietary pattern, vitamin D where deficient) constitutes the current standard-of-care multicomponent intervention.

The pedagogical implication for physiotherapy education: learning to detect frailty and prescribe its interventions is no longer specialist-only knowledge. It is a core competency for any physiotherapist working with older adults, in any setting. FrailtyTrack is built to support this learning by tying every clinical instrument card to its source evidence, normative data, and population-specific cut-offs — so the user develops not just procedural fluency but a sense of why a given threshold exists and where it does and does not apply.

1.8 Key references used in this section

All references are live-fetched and verified per the project's Rule 1 protocol; full citation strings with DOI links are in the Primary References section of the About tab. Highlights:

  • Fried 2001 — original Fried phenotype paper, Cardiovascular Health Study; doi:10.1093/gerona/56.3.M146
  • Mitnitski 2001 — original deficit-accumulation Frailty Index; doi:10.1100/tsw.2001.58
  • Rockwood 2005 — Clinical Frailty Scale (CFS); doi:10.1503/cmaj.050051
  • Clegg 2013 — canonical Lancet review «Frailty in elderly people»; doi:10.1016/S0140-6736(12)62167-9
  • Buta 2016 — systematic characterisation of frailty assessment instruments; doi:10.1016/j.arr.2015.12.003
  • Hoogendijk 2019 — Lancet review on clinical and public-health implications; doi:10.1016/S0140-6736(19)31786-6
  • Travers 2019 — primary-care interventions for delaying/reversing frailty; doi:10.3399/bjgp18X700241
  • Bernabei 2022 SPRINTT — multicomponent intervention RCT; doi:10.1136/bmj-2021-068788
  • Álvarez-Bustos 2026 (CIBERFES) — current European consensus document; doi:10.1016/j.jnha.2026.100793
  • Izquierdo 2025 ICFSR — global exercise consensus; doi:10.1016/j.jnha.2024.100401
  • Dent 2025 — Lancet Commission on Frailty programme announcement; doi:10.1016/S0140-6736(25)01101-8

1.9 Frailty as a public-health priority — the Lancet Commission's reframing

In June 2025 The Lancet announced a new Commission on Frailty (Dent, Clegg, Roller-Wirnsberger, Vetrano & Hoogendijk, Lancet 2025;405(10497):2265–2266), building on the 2013 Lancet Seminar (Clegg et al.) and the 2019 Lancet Series (Hoogendijk et al. / Dent et al.). The Commission's stated goal is to "globally reorient healthcare and public policy to prevent the development and progression of frailty across the life-course".Dent 2025 For physiotherapy education and practice, three aspects of the Commission's framing are particularly worth surfacing.

(a) Prevalence and equity. The Commission reaffirms a community prevalence of 12–24% in adults aged ≥65 (depending on operationalisation), drawing on the O'Caoimh 62-country meta-analysis. It explicitly highlights that frailty disproportionately affects women, populations from culturally and linguistically diverse backgrounds, those experiencing socioeconomic disadvantage, and residents of low- and middle-income countries.Dent 2025 For Swiss outpatient physiotherapy this means: frailty is not an exotic geriatric-ward phenomenon but a routine concern across general practice referrals, and equity considerations should inform case-finding effort across populations.

(b) Four priority areas. The Commission's programme covers (i) frailty as an actionable target across the life-course, (ii) early detection and a diagnostic framework correlated with WHO ICD/ICF, (iii) optimal management as frailty becomes a prognostic indicator across cardiology, oncology, orthopaedics, neurology, endocrinology, surgery and emergency medicine, and (iv) wider adoption of frailty into national public-health policies for ageing.Dent 2025 Priority (iii) in particular signals that frailty assessment is no longer specialist-only knowledge — it is becoming a core competency across medical and allied-health specialties. This is the Commission's clearest pedagogical implication for physiotherapy education: frailty literacy belongs in every adult-orthopaedic, neurological, surgical and oncological rehabilitation curriculum, not only the geriatric one.

(c) Policy alignments. The Commission grounds its work in the UN Decade of Healthy Ageing 2021–2030, the WHO World Report on Ageing and Health, and the World Health Assembly's primary-care reorientation.Dent 2025 This positions frailty assessment and intervention as core primary-care infrastructure rather than specialist-only activity — consistent with the FrailtyTrack design (no-server, no-cookie, double-clickable) supporting use across primary-care, outpatient physiotherapy, and community geriatric services.

The Commission's substantive report has not yet been published — the 2025 Comment is the programme announcement. Operational recommendations on instruments, cut-offs, intervention protocols and care pathways are not yet available from this Commission. Current operational guidance in FrailtyTrack therefore continues to draw on CIBERFES 2026 (Álvarez-Bustos), ICFSR 2025 (Izquierdo), WHO ICOPE, and the SPRINTT RCT evidence base. See the Position Statements & Consensus — Lancet Commission card in About for the full programme summary.

1.10 Pathophysiologie im Überblick — eine visuelle Zusammenfassung

Die folgende Abbildung aus dem CIBERFES-Konsensdokument 2026 (Álvarez-Bustos et al.) fasst die Hauptpfade der Frailty-Pathophysiologie zusammen, die in den Abschnitten 1.1–1.9 besprochen wurden. Sie zeigt das Zusammenspiel von Exposom (Lebensstil, Bewegung, Erkrankungen, Umwelt), alterungsbezogenen zellulären und molekularen Veränderungen, der Aktivierung von Stress-Antwort-Systemen mit Inflamm-Aging, Ernährung und Körperzusammensetzung sowie psychosozialen, ökonomischen und gesundheitssystem-bedingten Faktoren — alle konvergieren auf den Frailty-Zyklus nach L. P. Fried mit Sarkopenie als zentralem Substrat und enden im funktionellen Kontinuum von Robustheit über Pre-frailty und Frailty zu Disability.Álvarez-Bustos 2026

CIBERFES 2026 Figure 1: schematic of the main pathways involved in the pathophysiology of frailty, showing exposome, aging-related cellular and molecular changes, stress-response systems activation/inflamm-aging, nutrition and body composition, psychosocial-economic-healthcare factors, and the L. P. Fried frailty cycle centred on sarcopenia, with the downstream functional continuum from robustness through pre-frailty, frailty, mild disability, severe disability, to death.
Abbildung 1. Hauptpfade der Frailty-Pathophysiologie. RAAS = Renin-Angiotensin-Aldosteron-System; ANS = autonomes Nervensystem; HPAA = Hypothalamus-Hypophysen-Nebennierenrinden-Achse; SASP = Senescence-associated secretory phenotype.

Quelle und Lizenz: Álvarez-Bustos A, Andres-Lacueva C, Ara I, et al. for the CIBERFES working group. Consensus document on frailty: conceptualization, detection, multidisciplinary management and future roadmap. The Journal of nutrition, health and aging. 2026;30:100793. Figur 1, S. 3. doi:10.1016/j.jnha.2026.100793 · Open Access · CC BY-NC-ND 4.0. Wiedergabe ohne inhaltliche Veränderung; grössen-angepasst für Webdarstellung (2000 px, JPEG q=90) entsprechend der CC-Format-Shifting-Erlaubnis. Verwendung in FrailtyTrack ausschliesslich zu nicht-kommerziellen Bildungszwecken. ✅ live-fetched v9.7.0 session (Verlags-DOI über Elsevier-Linking-Hub und digital.csic.es Open Repository bestätigt).

Für die physiotherapeutische Praxis besonders relevant ist der rechte untere Quadrant der Abbildung — der Frailty-Zyklus selbst: Sarkopenie führt zu reduzierter Kraft/Power, die zu reduzierter Ganggeschwindigkeit führt; reduziertes VO2max führt über Erschöpfung zu reduzierter körperlicher Aktivität und Disuse; reduzierte Kalorien-/Proteinaufnahme verschlimmert die Muskelsynthese und schliesst den Kreis. Genau diese Variablen — Ganggeschwindigkeit, Kraft, Power, Erschöpfung, körperliche Aktivität — sind diejenigen, die die FrailtyTrack-Instrumente messen, und es sind dieselben Variablen, die ein multikomponentielles Übungsprogramm (Vivifrail, ICFSR-Konsens) gezielt adressiert. Die Abbildung gibt der Frage «warum diese Tests, warum dieses Training» eine kausale Antwort.

2. Muscle and Frailty — Mass, Strength, and Power

Sarcopenia · Dynapenia · Power · The hierarchy that underwrites instrument choice
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Bottom line in one paragraph

Muscle is the most clinically actionable substrate of physical frailty, but its three measurable dimensions do not contribute equally. Mass (sarcopenia in the original sense) is the weakest functional signal — once strength is accounted for, lean-mass measurements add little independent prediction of disability or mortality. Strength (dynapenia, in the Clark & Manini reframe) declines two- to five-fold faster than mass and predicts function and mortality more strongly — which is why EWGSOP2 elevated grip strength and chair-rise time to gateway parameters in 2019. Power (force × velocity) declines steepest of all and discriminates mobility-limited from well-functioning older adults more sharply than either mass or strength alone. The clinical implication for FrailtyTrack: when muscle has to be probed in limited assessment time, instruments that capture strength and power (HGS, 5×STS-derived power, gait speed) should be prioritised over instruments that estimate mass alone.

2.1 Why frailty cannot be discussed without muscle — the epidemiological overlap

In community-dwelling adults aged 50 and above, frailty and sarcopenia co-occur far more often than chance: meta-analytic prevalence is approximately 13% for frailty (28 studies, n ≈ 95,036) and 14% for sarcopenia (9 studies, n ≈ 7,656).Almohaisen 2022 The two syndromes share the same biological substrate (age-related muscle decline, chronic inflammation, anabolic resistance) and overlap in their clinical signatures (weakness, slowness, fatigue, weight loss).

In hospitalised older adults the overlap becomes the rule rather than the exception: pooled prevalence is (pre-)frailty ≈ 84% and sarcopenia ≈ 37%, with frequent triple co-occurrence of frailty, sarcopenia, and malnutrition.Ligthart-Melis 2020 A patient admitted for a hip-fracture repair, an exacerbation of heart failure, or a community-acquired pneumonia therefore presents almost by default with a muscular deficit that the inpatient and post-discharge physiotherapist must recognise and address. Treating the index event without addressing the underlying muscular substrate predictably yields incomplete functional recovery and elevated re-admission risk.

2.2 Sarcopenia and physical frailty — two sides of the same coin

Cesari and colleagues argued in 2014 that physical frailty (the Fried phenotype operationalisation) and sarcopenia are not two distinct entities competing for clinical attention but two complementary readings of the same age-related muscular decline.Cesari 2014 The Fried phenotype captures the syndrome functionally — via slowness, weakness, weight loss, low activity, and exhaustion — whereas sarcopenia (originally Rosenberg's 1989 term, formalised by EWGSOP1 in 2010 and revised by EWGSOP2 in 2019) names the underlying tissue-level pathology of skeletal-muscle decline.Cruz-Jentoft 2019 The two constructs converge on the same patients in the SPRINTT trial inclusion criteria (physical frailty and sarcopenia at SPPB 8–9) and in the EWGSOP2 algorithm, where slow gait speed and weak grip strength are simultaneously diagnostic for sarcopenia and constituent for frailty.

For physiotherapy practice this convergence is practical, not just conceptual: the same instruments — gait speed, grip strength, chair-rise time — serve case-finding for both syndromes; the same intervention — multicomponent exercise with a resistance and power emphasis, plus protein-adequate nutrition — addresses both. There is no need to choose between a «frailty workup» and a «sarcopenia workup»; the muscle-related core of each is shared.

2.3 The hierarchy — from mass to strength to power

A central insight of the past two decades is that muscle's three measurable dimensions are not interchangeable proxies for one another. They differ in (i) how steeply each declines with age, (ii) how strongly each predicts function and mortality, and (iii) how easily each can be measured in clinical practice.

Dimension What it captures Age-related decline Functional signal Field-test feasible?
Mass (sarcopenia) Skeletal-muscle quantity (DXA-ASM, BIA, ultrasound, MRI) ~0.5–1.0% per year from ~30y Modest; diminishes once strength is in the model No (DXA/BIA needed); calf circumference is a surrogate
Strength (dynapenia) Maximal force production (HGS, isokinetic KES, chair-rise time) ~1–3% per year — 2–5× faster than mass Strong; independent predictor of disability and mortality Yes (HGS, 5×STS time)
Power (powerpenia) Force × velocity (jump test, leg-press peak power, STS-derived power) ~3–4% per year — ~2× faster than strength Strongest; sharp discriminator of mobility limitation Yes (5×STS × Alcazar equation; jump tests in fitter cohorts)

The 2019 EWGSOP2 revision is the formal acknowledgement of this hierarchy at consensus level: strength replaces mass as the gateway parameter.Cruz-Jentoft 2019 A patient with low grip strength or prolonged chair-rise time is now classified as having «probable sarcopenia» before any imaging-based mass assessment is performed; mass measurement enters only at the confirmation step. The clinical rationale is that strength is the more proximate determinant of falls, disability, hospitalisation, and mortality, while mass acts largely through strength rather than independently of it.

2.4 Dynapenia — when strength loss outpaces mass loss

Clark and Manini coined the term dynapenia in 2008 to name an empirical observation that the original sarcopenia construct could not explain: in older adults, strength declines faster than mass, and the strength loss not attributable to mass loss is what predicts adverse outcomes.Clark & Manini 2008 Their argument was conceptual as well as terminological — calling age-related strength loss «sarcopenia» was a category error, since the underlying mechanisms (motor-unit remodelling, neuromuscular junction dysfunction, central activation deficits, fibre-type shifts) are largely neural and contractile-quality phenomena, not just tissue-quantity phenomena.

The 2012 update extended the case with longitudinal evidence: dynapenia predicts mobility limitations, falls, hospitalisation, and mortality more strongly than sarcopenia operationalised by mass alone, and resistance training improves strength substantially even when mass gains are modest.Manini & Clark 2012 The clinical message is that «strength» is not just a downstream consequence of «mass» but an independent therapeutic target — and one that responds to training across the older-adult age range, including in late life.

2.5 Power — the steepest decline and the strongest functional signal

The Skelton 1994 cross-sectional study (n=100, healthy adults aged 65–89) was an early demonstration that leg-extensor power declines faster than isometric knee-extensor or grip strength, and tracks functional ability (timed chair-rise, weighted-bag lift, step-up onto boxes) more closely than strength alone.Skelton 1994 Reid & Fielding's 2012 narrative review consolidated two decades of subsequent evidence: power declines roughly twice as fast as strength across the older-adult age span, and peak power is the more discriminant variable for the relationships between physiological impairment, functional limitation, and disability.Reid & Fielding 2012

The recent normative landscape has caught up with this insight. Coelho-Junior et al. (2024) provided sex- and age-specific centile values for lower-extremity muscle power in a large Italian community cohort across the 18–81+ age span, derived from the 5×STS test using the Alcazar equation; these centiles are now embedded in FrailtyTrack as the population-comparison reference for the 5×STS card.Coelho-Junior 2024 The Alcazar 2021 European cohort (n=9,320) supplied the operational cut-points (♂ <2.6 W/kg, ♀ <2.1 W/kg) that distinguish well-functioning from mobility-limited older adults. Together they make field-feasible muscle-power assessment a clinical reality in 2026 — no laboratory equipment required, no compromise on the strongest functional signal in the muscle hierarchy.

2.6 Quantitative anchors — how large is the contribution to adverse outcomes?

Beaudart et al. (2017) meta-analysed the health-outcome literature for sarcopenia and quantified what muscular decline costs older adults: pooled odds ratio for mortality 3.60 (95% CI 2.96–4.37) and for functional decline 3.03 (95% CI 1.80–5.12).Beaudart 2017 Effect sizes of this magnitude are unusual in geriatric epidemiology and place sarcopenia in the same prognostic tier as severe comorbid disease.

Two further anchors deserve attention. First, the SPRINTT RCT (Bernabei et al. 2022) demonstrated that a multicomponent exercise + nutrition intervention prevents mobility disability in older adults with co-incident physical frailty and sarcopenia at the SPPB 8–9 stratum — placing the muscular substrate squarely in the «modifiable» column rather than the «inevitable consequence of ageing» column. Second, «powerpenia» was recently proposed by Freitas et al. (2024) as a separate biomarker of healthy ageing because only 2 of 220 dynapenia studies between 2008 and 2023 actually measured power — the construct most strongly tied to function has been the least frequently measured.Freitas 2024 FrailtyTrack's inclusion of the 5×STS-derived muscle-power card with the Alcazar equation and the Coelho-Junior centiles is a direct response to that measurement gap.

2.7 What this means for FrailtyTrack — instrument-choice implications

The hierarchy described in this chapter is not an academic taxonomy; it determines which instruments the tool should privilege when assessment time is limited. Three concrete implications for the FrailtyTrack design follow.

  1. Strength and power instruments are first-line. Handgrip strength (HGS) and the 5×STS test (read both as a strength signal via raw time and as a power signal via the Alcazar equation) appear in the protocol catalogue before any mass-surrogate measure. Calf circumference is included for the SARC-CalF extension and as the MNA-SF F2 fallback, but it is positioned as a complement to — not a substitute for — HGS and 5×STS-derived power.
  2. Power normative comparison is a first-class output. The 5×STS card displays both the raw time and the Alcazar-derived relative power (W/kg), with on-screen comparison to Alcazar 2021 mobility-disability cut-points (♂ <2.6 W/kg, ♀ <2.1 W/kg) and the Coelho-Junior 2024 sex- and age-specific centile lookup. This makes the «steepest signal» visible at the same level of detail as the gait-speed and grip-strength outputs.
  3. The longitudinal radar shows muscle-related parameters together. HGS, 5×STS time, 5×STS power, and gait speed are all surfaced on the radar chart with their respective MCID flags, so a clinician can see at a glance whether re-assessment changes are clinically meaningful in the muscular axis specifically.

A complementary point of restraint: this chapter is a conceptual chapter, not a clinical-decision rule. It does not replace the consensus algorithms (EWGSOP2 for sarcopenia, Fried phenotype or CFS for frailty), and it is not an argument for abandoning mass assessment in settings where DXA or BIA is available. It is an argument for what to prioritise when only field tests are feasible — which is the typical outpatient-physiotherapy and primary-care reality across the DACH region.

2.8 Verified reference block (live-fetched v9.6.0)

Eleven references underpin this chapter. Each was live-fetched on PubMed and the publisher's record during the v9.6.0 session and confirmed for all five fields (authors, title, journal, volume/issue/pages, DOI). Cross-referenced with the structured refs/bibliography.json machine-readable bibliography. Full citation strings with DOI links are also in the Primary References — Muscle and Frailty (v9.6.0) block of the About tab.

  • Almohaisen 2022 — meta-analysis of community-dweller prevalence (frailty 13%, sarcopenia 14%); doi:10.3390/nu14081537 ✅
  • Ligthart-Melis 2020 — meta-analysis in hospitalised older adults ((pre-)frailty 84%, sarcopenia 37%); doi:10.1016/j.jamda.2020.03.006 ✅
  • Cesari 2014 — sarcopenia and physical frailty as «two sides of the same coin»; doi:10.3389/fnagi.2014.00192 ✅
  • Cruz-Jentoft 2019 (EWGSOP2) — revised European consensus, strength as gateway parameter; doi:10.1093/ageing/afy169 (erratum: 10.1093/ageing/afz046) ✅
  • Clark & Manini 2008 — coined «dynapenia»; doi:10.1093/gerona/63.8.829 ✅
  • Manini & Clark 2012 — dynapenia update, longitudinal evidence; doi:10.1093/gerona/glr010 ✅
  • Skelton 1994 — cross-sectional power vs strength decline ages 65–89 (n=100); doi:10.1093/ageing/23.5.371 ✅
  • Reid & Fielding 2012 — narrative review establishing power as critical determinant of physical functioning; doi:10.1097/JES.0b013e31823b5f13 ✅
  • Coelho-Junior 2024 — sex- and age-specific centiles for lower-extremity muscle power, Italian community cohort; doi:10.1002/jcsm.13301 ✅
  • Beaudart 2017 — meta-analysed health outcomes of sarcopenia (mortality OR 3.60; functional decline OR 3.03); doi:10.1371/journal.pone.0169548 ✅
  • Freitas 2024 — powerpenia as a separate biomarker (only 2 of 220 dynapenia studies actually measured power); doi:10.1186/s40798-024-00689-6 ✅

Self-audit (Rule 5): 11 references generated for this chapter. 11 live-fetched and five-field-verified in the v9.6.0 session. 0 flagged. Per Rule 4, no «all DOIs verified» blanket claim is made beyond this chapter; references in other chapters retain their last-session verification status as recorded in their respective audit blocks.

3. Sarcopenia — Scientific Evaluation of the SARC-F

Origin · Validation · Diagnostic accuracy · Consensus position · DACH version · Practice implications
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Comprehensive evidence-based evaluation of the SARC-F questionnaire and its position within the EWGSOP2 / AWGS 2019 / SCWD frameworks. All claims are anchored to references that were live-fetched and verified during the v8.21 session (13 references; all five fields confirmed: authors, title, journal, volume/issue/pages, DOI).

Bottom line in one paragraph

The SARC-F is a 5-item self-report questionnaire (Strength, Assistance walking, Rising from a chair, Climbing stairs, Falls) that takes under one minute, requires no equipment, and is reproducible across raters and time. Its diagnostic accuracy is consistent across the global literature: high specificity (≈80–90%) and low sensitivity (≈20–55%) against every consensus reference standard. This means the SARC-F is well suited to case-finding — flagging persons who warrant objective testing — but should not be used as the sole decision rule to rule out sarcopenia, particularly in higher-risk populations. EWGSOP2, AWGS 2019, the SCWD position paper, and the ICFSR clinical practice guidelines all recommend it as the entry step of their respective diagnostic algorithms, on this basis.

The eight collapsible sub-sections below (3.1–3.8) walk through the SARC-F's origin, validation history, diagnostic accuracy, structural reasons for its sensitivity profile, position in current consensus guidelines, the validated DACH-region German version, practical implications for physiotherapy practice, and the verified reference block.

3.1 Origin, Construct & Intended Purpose

Malmstrom & Morley 2013 · Editorial in JAMDA
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The SARC-F was introduced by Malmstrom and Morley in 2013 as a deliberately minimalist screening tool, designed by analogy with FRAX for osteoporosis: a brief, self-reportable instrument that could flag persons at risk of sarcopenia without requiring any equipment, body composition measurement, or clinical examination.Malmstrom 2013 The acronym names the five items — Strength, Assistance walking, Rising from a chair, Climbing stairs, Falls — each scored 0–2 (no/some/a lot of difficulty; or 0/1–3/≥4 for falls), giving a total of 0–10. A cut-off of ≥4 was proposed as predictive of sarcopenia and adverse functional outcomes.

Conceptual point — important to read carefully. The SARC-F does not measure sarcopenia. It measures the functional consequences of sarcopenia — the symptomatic phenotype most likely to be perceived by the patient. This single distinction explains both the strengths and the limitations that have emerged in the data accumulated since 2013.

3.2 Initial Validation in Three Large Cohorts

Malmstrom 2016 · AAH · BLSA · NHANES
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The first formal psychometric validation came from Malmstrom et al. in 2016, using three independent datasets — the African American Health (AAH) study, the Baltimore Longitudinal Study of Aging (BLSA), and NHANES.Malmstrom 2016 The instrument showed acceptable internal consistency (Cronbach's α), supportive factorial validity in principal components analysis, and construct validity that was strong but functional in nature: a SARC-F ≥4 was cross-sectionally and longitudinally associated with more IADL deficits, slower chair-stand times, lower grip strength, lower SPPB scores, recent hospitalisation, gait speed <0.8 m/s, and mortality.

What this validation actually demonstrated is that the SARC-F discriminates persons with poor functional outcomes — which is consistent with how it was designed. But that is not the same thing as discriminating low muscle mass plus low muscle strength as defined by EWGSOP, AWGS, IWGS, or FNIH. This is the central interpretive issue when reading SARC-F validation studies in different populations.

3.3 Diagnostic Accuracy Against Reference Standards

High specificity, low sensitivity — consistent across all consensus criteria
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This is where the literature has converged on a clear and consistent finding: the SARC-F has high specificity and consistently low sensitivity when measured against any of the consensus diagnostic criteria for sarcopenia.

The first community-level validation by Woo et al. in the Hong Kong Mr & Ms Os cohort (n = 4,000) compared SARC-F classification against EWGSOP, IWGS, and AWGS criteria and found "excellent specificity but poor sensitivity for sarcopenia classification," while the predictive power for 4-year physical limitation was comparable across all four classification approaches.Woo 2014

Pooled diagnostic accuracy across three meta-analyses

SourceStudies / nReference standardSensitivitySpecificity
Ida 20187 / 12,800EWGSOP0.21 (95% CI 0.13–0.31)0.90 (95% CI 0.83–0.94)
Lu 202120 / variableEWGSOP, EWGSOP2, AWGS, FNIH, IWGSvariable, generally lowconsistently high
Voelker 202129 / 21,855EWGSOP / EWGSOP2 / AWGS / FNIH / IWGS / SCWD28.9–55.3%68.9–88.9%
Woo 2014 (primary)1 / 4,000EWGSOP / IWGS / AWGSpoor (high spec, low sens)excellent

All four sources fully verified in v8.21 (DOI live-fetched). The 2018 meta-analysis by Ida, Kaneko, and Murata reported a diagnostic odds ratio of 2.47 (95% CI 1.64–3.74), which is modest, and concluded that the screening sensitivity is poor but the specificity is high — making the SARC-F suitable for ruling in candidates who should undergo further confirmatory testing rather than for ruling out sarcopenia in negative cases.Ida 2018

The reliability evidence in Voelker's review is more favourable: inter-rater reliability was good to excellent in all four studies that examined it, test–retest reliability was good in 5 of 6 studies, and internal consistency ranged from low to high across 8 studies.Voelker 2021 The instrument is reproducible — it is the diagnostic accuracy against muscle-based reference standards that is the problem, not the calibration.

3.4 Why Sensitivity Is Low — A Structural Issue, Not a Calibration Issue

Construct mismatch with muscle-mass-based definitions
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The reason for the SARC-F's modest sensitivity is not a calibration error but a structural one. Sarcopenia by all current consensus definitions includes a low muscle mass criterion. The SARC-F asks no question that is reliably correlated with muscle mass — its items are all functional (strength, mobility, falls), and a person can have low DXA-measured appendicular lean mass with preserved function, particularly early in the course of the disease. The instrument therefore systematically misses pre-clinical and asymptomatic sarcopenia — exactly the cases where intervention would arguably be most beneficial.

This is the rationale behind the SARC-CalF modification by Barbosa-Silva et al., who added calf circumference as a sixth item: in their original 2016 study (n = 179, EWGSOP reference, sarcopenia prevalence 8.4%), the AUC rose from 0.592 for SARC-F alone to 0.736 for SARC-F + CC, with sensitivity doubling from approximately 33% to 66% without compromising specificity.Barbosa-Silva 2016 Replication has been uneven: in Bahat et al.'s Turkish community sample (n = 207), adding calf circumference improved specificity (90–98%) and overall AUC, but did not improve sensitivity in that population, which the authors attributed to the low local prevalence of sarcopenia and population-specific calf circumference distributions.Bahat 2018

A larger Chinese community-based replication by Yang et al. in 2018 (n = 4,361, AWGS 2014 reference) confirmed the structural improvement: SARC-CalF sensitivity rose to 60.7% with specificity preserved at 94.7%, and the AUC rose from 0.89 to 0.92 (p = 0.003) compared with SARC-F alone.Yang 2018 A European confirmation followed in 2020 from Krzymińska-Siemaszko et al. in a Polish community-dwelling cohort (n = 260) using EWGSOP1, EWGSOP2, and modified-EWGSOP2 reference standards: SARC-CalF reached an AUC of 0.778 with sensitivity 57.8% and specificity 88.4%, compared with an AUC of approximately 0.62 for SARC-F alone — a substantial gain in a Central European population.Krzymińska-Siemaszko 2020 The pooled meta-analytic estimates from Voelker et al.'s 2021 systematic review converge on SARC-CalF sensitivity 45.9–57.2% and specificity 87.7–91.3% across EWGSOP, AWGS, FNIH, and IWGS reference standards — an approximately 15–25 percentage-point sensitivity gain at no meaningful loss of specificity.Voelker 2021

A persistent caveat across this literature is the cut-off question. The original Barbosa-Silva 2016 paper used a sex-pooled CC threshold of 31 cm; AWGS 2019 specifies sex-specific values (M <34 cm, F <33 cm); Bahat 2018 used a Turkish-validated 33 cm; and Lim et al. (2019) explicitly argued — in a letter to the editor of JNHA — that using the standard 31 cm cut-off without local validation impairs diagnostic performance and that population-specific cut-offs should be derived where prevalence and body composition differ.Lim 2019 For Central European practice this is an unresolved issue: there is no Swiss-validated or German-validated CC cut-off. The AWGS 2019 sex-specific values are used in this tool as the most defensible default, with the explicit acknowledgement that they are not population-validated for German-speaking practice.

Practical implication for FrailtyTrack users. If the screening question is "does this patient already show the symptomatic phenotype of sarcopenia?" — SARC-F is a reasonable, fast, free instrument for that. If the question is "does this patient have low muscle mass that we should address before symptoms develop?" — SARC-F will miss most of those patients, and direct measurement (handgrip strength ± DXA / BIA) is the appropriate first step. SARC-CalF (added v8.22) sits between the two: it is the SARC-F augmented with a single tape-measure muscle-mass proxy, recommended where calf circumference can be measured (most physiotherapy and rehabilitation settings). The implementation in FrailtyTrack treats SARC-F and SARC-CalF as parallel screens — see the SARC-CalF Optional Extension subsection in the Test Protocols tab for protocol, scoring, and cut-off details.

3.5 Position in the 2018–2020 Consensus Guidelines

EWGSOP2 · AWGS 2019 · SCWD · ICFSR
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Despite the diagnostic accuracy limitations, the SARC-F has been formally incorporated into all four major contemporary consensus frameworks:

  • EWGSOP2 (Cruz-Jentoft et al. 2019)Cruz-Jentoft 2019 recommends SARC-F as the entry step in case-finding ("Find"), to be followed by assessment of muscle strength ("Assess" — grip strength or chair-stand) for probable sarcopenia, then muscle quantity/quality ("Confirm" — DXA, BIA, CT, or MRI), and finally physical performance ("Severity" — gait speed, SPPB, TUG, or 400-m walk test). It is positioned not as a diagnostic test but as a way to elicit self-reported signs in persons who would benefit from formal testing. Note the published erratum (Age Ageing 2019;48(4):601, doi:10.1093/ageing/afz046), which corrects minor cut-off and table entries but does not alter the algorithm structure.
  • AWGS 2019 (Chen et al. 2020)Chen 2020 places the SARC-F (≥4), together with calf circumference (<34 cm in men, <33 cm in women) or SARC-CalF (≥11), at the case-finding step of separate community and hospital algorithms — explicitly to facilitate earlier identification of at-risk persons in primary care settings, with the new entity of "possible sarcopenia" enabling lifestyle intervention before full diagnostic confirmation.
  • SCWD position paper (Bauer et al. 2019)Bauer 2019 supports rapid screening with SARC-F as a first step, with formal diagnosis through grip strength or chair-stand combined with DXA-estimated appendicular muscle mass (height-indexed).
  • ICFSR clinical practice guidelines (Dent et al. 2018)Dent 2018 include the SARC-F as a recommended screening instrument among several options.

How this is reconciled. The consensus groups treat SARC-F as a case-finding instrument whose primary virtue is that it is essentially free, takes about a minute, requires no equipment, and identifies a subset of the population in whom further testing is warranted. The high specificity means a positive SARC-F is informative; the low sensitivity means a negative SARC-F is not sufficient to rule out sarcopenia, and therefore SARC-F should not be used as a sole gatekeeper in populations where the prior probability of sarcopenia is meaningful — for example, frail geriatric populations, post-surgical patients, oncology, COPD, and chronic kidney disease.

3.6 German-Language Version — Drey 2020

Relevant for German-speaking practice (DACH region)
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For German-speaking practice — the operating context for this tool — the validation by Drey et al. (Munich/Erlangen, 2020) followed a 7-step WHO-based translation and adaptation process, with two notable modifications:Drey 2020

  • The strength item's "10 lb" was converted to 5 kg, with the example "corresponds to carrying a water box with two hands or half a box with one hand".
  • The falls item received the explicit timeframe footnote "in the last 12 months" to remove ambiguity.

In 117 community-dwelling outpatients (mean age 79.1 ± 5.2 years; 80.4% female), against EWGSOP2 reference standards: 8 patients (6.8%) were sarcopenic, and 57 (48.7%) had probable sarcopenia. The German SARC-F showed excellent inter-rater reliability and good test–retest reliability, with acceptable internal consistency.

Drey 2020 — German SARC-F diagnostic accuracy

OutcomeSensitivitySpecificityRecommended use
Confirmed sarcopenia (EWGSOP2)63%47%Limited — high false-positive rate in this small sample
Probable sarcopenia (EWGSOP2)75%67%Recommended — case-finding for the EWGSOP2 "Assess" gate

The specificity for confirmed sarcopenia is notably lower than typical international SARC-F estimates, likely a consequence of the small sample and the selection effect (many participants scored ≥4 because of probable sarcopenia rather than confirmed sarcopenia). The figures for probable sarcopenia are clinically more useful and methodologically consistent with the EWGSOP2 algorithm: the SARC-F is a screen for the probable sarcopenia gate, not for the confirmed diagnosis.

3.7 Practical Implications for Physiotherapy Practice

Synthesis · Recommendations · Workflow
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Bringing the evidence together, the SARC-F is best characterised as follows:

  1. It is a rapid, equipment-free, self-administered screen with very high feasibility and good reliability.
  2. A positive screen (≥4) is reasonably specific and warrants further objective testing — handgrip strength and a chair-stand or 5×STS at minimum.
  3. A negative screen does not rule out sarcopenia and should not be used as a sole decision rule in higher-risk populations; in such settings, direct measurement of muscle strength (and ideally muscle mass) should be the first step rather than the second.
  4. The SARC-F is more accurately understood as a functional symptom score than as a sarcopenia detector. What it identifies well is patients in functional trouble, which in clinical physiotherapy practice is itself an important phenotype regardless of whether the underlying mechanism is sarcopenia, frailty, deconditioning, or comorbidity.
  5. In clinical workflows where calf circumference can be added with minimal effort, SARC-CalF is worth considering — the modest gain in sensitivity is consistent across most populations, even if the magnitude varies.Barbosa-Silva 2016

Recommended workflow in this tool's clinical context

  1. Screen with the German SARC-F (Drey 2020 wording) in any patient ≥65 y, or younger if there is a clinical reason (cardiopulmonary disease, oncology, postoperative, etc.).
  2. If SARC-F ≥4: proceed to handgrip strength (EWGSOP2 cut-offs M <27 kg / F <16 kg, or NAKO cut-offs M <29 kg / F <18 kgHuemer 2023) and 5×STS (cut-off ≥15 s).
  3. If SARC-F <4 but clinical suspicion is high (recent weight loss, unexplained falls, observed slow gait, recent decompensation): do not rely on the negative screen — proceed directly to objective measurement.
  4. If a positive screen + low strength is found: this is probable sarcopenia per EWGSOP2 — sufficient on its own to begin lifestyle intervention (resistance exercise, protein intake review, vitamin D status check, treating identifiable secondary contributors).
  5. Confirmatory imaging (DXA, BIA) is not required in primary-care physiotherapy to start intervention; it is required for the formal diagnostic label of "confirmed sarcopenia".

3.8 Verified Reference Block (live-fetched v8.21)

13 references · all five fields confirmed · 0 errors
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All 13 references cited in this Background tab were live-fetched on PubMed and the publisher's site during the v8.21 session, with all five fields (authors, title, journal, volume/issue/pages, DOI) confirmed for each. No memory-based references were retained. No unverified entries. No errors detected during the fetch pass. The full bibliography (with the same DOI links) is also reproduced in the About / References tab for tool-wide consistency.

  1. Malmstrom TK, Morley JE. SARC-F: a simple questionnaire to rapidly diagnose sarcopenia. J Am Med Dir Assoc. 2013;14(8):531–532. PMID: 23810110 ✅ doi:10.1016/j.jamda.2013.05.018
  2. Malmstrom TK, Miller DK, Simonsick EM, Ferrucci L, Morley JE. SARC-F: a symptom score to predict persons with sarcopenia at risk for poor functional outcomes. J Cachexia Sarcopenia Muscle. 2016;7(1):28–36. PMID: 27066316 ✅ doi:10.1002/jcsm.12048
  3. Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T, Cooper C, Landi F, Rolland Y, Sayer AA, Schneider SM, Sieber CC, Topinkova E, Vandewoude M, Visser M, Zamboni M; Writing Group for the European Working Group on Sarcopenia in Older People 2 (EWGSOP2). Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019;48(1):16–31. PMID: 30312372 ✅ doi:10.1093/ageing/afy169 · Erratum: Age Ageing. 2019;48(4):601. doi:10.1093/ageing/afz046 PMID: 31081853.
  4. Woo J, Leung J, Morley JE. Validating the SARC-F: a suitable community screening tool for sarcopenia? J Am Med Dir Assoc. 2014;15(9):630–634. PMID: 24947762 ✅ doi:10.1016/j.jamda.2014.04.021
  5. Ida S, Kaneko R, Murata K. SARC-F for Screening of Sarcopenia Among Older Adults: A Meta-analysis of Screening Test Accuracy. J Am Med Dir Assoc. 2018;19(8):685–689. PMID: 29778639 ✅ doi:10.1016/j.jamda.2018.04.001
  6. Barbosa-Silva TG, Menezes AMB, Bielemann RM, Malmstrom TK, Gonzalez MC; Grupo de Estudos em Composição Corporal e Nutrição (COCONUT). Enhancing SARC-F: Improving Sarcopenia Screening in the Clinical Practice. J Am Med Dir Assoc. 2016;17(12):1136–1141. PMID: 27650212 ✅ doi:10.1016/j.jamda.2016.08.004
  7. Chen LK, Woo J, Assantachai P, Auyeung TW, Chou MY, Iijima K, Jang HC, Kang L, Kim M, Kim S, Kojima T, Kuzuya M, Lee JSW, Lee SY, Lee WJ, Lee Y, Liang CK, Lim JY, Lim WS, Peng LN, Sugimoto K, Tanaka T, Won CW, Yamada M, Zhang T, Akishita M, Arai H. Asian Working Group for Sarcopenia: 2019 Consensus Update on Sarcopenia Diagnosis and Treatment. J Am Med Dir Assoc. 2020;21(3):300–307.e2. PMID: 32033882 ✅ doi:10.1016/j.jamda.2019.12.012
  8. Bahat G, Oren MM, Yilmaz O, Kılıç C, Aydin K, Karan MA. Comparing SARC-F with SARC-CalF to Screen Sarcopenia in Community Living Older Adults. J Nutr Health Aging. 2018;22(9):1034–1038. PMID: 30379299 ✅ doi:10.1007/s12603-018-1072-y
  9. Voelker SN, Michalopoulos N, Maier AB, Reijnierse EM. Reliability and Concurrent Validity of the SARC-F and Its Modified Versions: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc. 2021;22(9):1864–1876.e16. PMID: 34144049 ✅ doi:10.1016/j.jamda.2021.05.011
  10. Drey M, Ferrari U, Schraml M, Kemmler W, Schoene D, Franke A, Freiberger E, Kob R, Sieber C. German Version of SARC-F: Translation, Adaption, and Validation. J Am Med Dir Assoc. 2020;21(6):747–751.e1. PMID: 31980396 ✅ doi:10.1016/j.jamda.2019.12.011
  11. Lu JL, Ding LY, Xu Q, Zhu SQ, Xu XY, Hua HX, Chen L, Xu H. Screening Accuracy of SARC-F for Sarcopenia in the Elderly: A Diagnostic Meta-Analysis. J Nutr Health Aging. 2021;25(2):172–182. PMID: 33491031 ✅ doi:10.1007/s12603-020-1471-8
  12. Bauer J, Morley JE, Schols AMWJ, Ferrucci L, Cruz-Jentoft AJ, Dent E, Baracos VE, Crawford JA, Doehner W, Heymsfield SB, Jatoi A, Kalantar-Zadeh K, Lainscak M, Landi F, Laviano A, Mancuso M, Muscaritoli M, Prado CM, Strasser F, von Haehling S, Coats AJS, Anker SD. Sarcopenia: A Time for Action. An SCWD Position Paper. J Cachexia Sarcopenia Muscle. 2019;10(5):956–961. PMID: 31523937 ✅ doi:10.1002/jcsm.12483
  13. Dent E, Morley JE, Cruz-Jentoft AJ, Arai H, Kritchevsky SB, Guralnik J, Bauer JM, Pahor M, Clark BC, Cesari M, Ruiz J, Sieber CC, Aubertin-Leheudre M, Waters DL, Visvanathan R, Landi F, Villareal DT, Fielding R, Won CW, Theou O, Martin FC, Dong B, Woo J, Flicker L, Ferrucci L, Merchant RA, Cao L, Cederholm T, Ribeiro SML, Rodríguez-Mañas L, Anker SD, Lundy J, Gutiérrez Robledo LM, Bautmans I, Aprahamian I, Schols JMGA, Izquierdo M, Vellas B. International Clinical Practice Guidelines for Sarcopenia (ICFSR): Screening, Diagnosis and Management. J Nutr Health Aging. 2018;22(10):1148–1161. PMID: 30498820 ✅ doi:10.1007/s12603-018-1139-9

4. Training in Frailty and Pre-frailty

Section 4 takes up the question of how the assessment instruments in §1–§3 translate into a clinically useful exercise prescription. The chapter is sized for clinician self-study and for direct workshop use; sub-sections share a uniform 5-layer structure (TL;DR → Foundations → Evidence → Practical implications → Where evidence is contested), so a beginner can stop at TL;DR + Foundations and an expert can focus on Evidence + Contested. v9.9.0 ships the foundations sub-sections §4.1–§4.4. §4.5 (adherence and progression) and §4.6 (flexibility) are scheduled for v9.10; §4.7 (cognitive frailty) for v9.11.

4.1 Why exercise is the first-line intervention for frailty

Rationale · SPRINTT · ICFSR · Ethics
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TL;DR

Multicomponent exercise is the first-line intervention for frailty in the same way that bronchodilators are first-line in COPD: not because it cures the underlying syndrome but because it reliably modifies the most clinically meaningful trajectory at low risk. The 2025 ICFSR consensus, the SPRINTT trial (Bernabei et al. 2022), and the CIBERFES 2026 framework all converge on this position. The empirical base is unusually strong for any intervention in geriatric medicine: large multicentre RCTs, near-uniform safety profiles, and treatment effects that scale with baseline impairment. The chapter takes the rationale as established and proceeds to operational detail in §4.2–§4.4.

Foundations

Exercise prescription in frailty rests on three observations that are well-established but not always co-located in the literature. First, frailty is dynamic. Pre-frailty and mild frailty respond to intervention; reversal to non-frail status is achieved in a substantial minority of pre-frail patients across the published RCT base.Travers 2019 Severe frailty with established disability is harder to reverse but functional gains are achievable in many cases. Second, the magnitude of expected benefit scales inversely with baseline function: SPRINTT showed a 22% reduction in incident mobility disability in the lower-functioning SPPB ≤7 stratum and no significant effect in the SPPB 8–9 stratum, reflecting that the more functionally compromised gain more from a structured multicomponent programme.Bernabei 2022 Third, the safety profile of supervised multicomponent exercise in frail older adults is remarkably good. SPRINTT reported similar serious-adverse-event rates between intervention and control arms (39.2% vs 36.0%, RR 1.09, 95% CI 0.94–1.26), establishing that supervised training in this population is not a high-risk activity at typical scale and intensity.Bernabei 2022 The Izquierdo 2016 ethics editorial argues that, given these three observations, not prescribing exercise to a frail patient is not a neutral default — omission of an evidence-based, low-harm, first-line intervention for a remediable condition has its own ethical weight.Izquierdo 2016

Evidence

The empirical base for exercise as first-line therapy in frailty is anchored by three convergent sources. The SPRINTT trial (Bernabei et al. 2022, BMJ 377:e068788) randomised 1,519 physically frail sarcopenic older adults across 16 European centres in 11 countries to a supervised multicomponent exercise + nutritional counselling programme versus an education-only control over a median 26-month follow-up. The primary endpoint was incident mobility disability (inability to complete the 400-m walk in 15 minutes). In the prespecified at-risk subgroup with low SPPB ≤7, the intervention reduced incident mobility disability by 22% (HR 0.78, 95% CI 0.67–0.92, p=0.005); in the higher SPPB 8–9 stratum the effect was non-significant. Mortality was a secondary endpoint with a non-significant trend favouring intervention.Bernabei 2022 SPRINTT is the largest multicentre RCT in this population, and its design (twice-weekly supervised group physical activity + technology-supported home exercise + nutritional counselling) is closely aligned with what the consensus documents recommend — it is, in effect, an empirical test of the consensus prescription. The 2025 ICFSR consensus (Izquierdo et al. 2025, J Nutr Health Aging 29(1):100401) is the canonical multicomponent prescription source for frail and pre-frail older adults; the Delphi-style 34-author consensus structures recommendations around a four-pillar multicomponent framework (strength + power, balance and gait, aerobic, flexibility) with population-specific dose ranges (detailed in §4.3 and §4.4).Izquierdo 2025 ICFSR The CIBERFES 2026 consensus (Álvarez-Bustos et al. 2026, J Nutr Health Aging 30:100793) in §10.1 endorses multicomponent exercise as the first-line intervention with the same four-pillar structure, anchored in the muscle/strength/power axis developed in §2 of this Background tab.Álvarez-Bustos 2026 The EWGSOP2 sarcopenia consensus endorses resistance training plus protein optimisation as first-line management for the sarcopenia component, which is the muscle pillar of the multicomponent structure.Cruz-Jentoft 2019 Across these four sources the convergence is striking: the same four-pillar multicomponent structure is endorsed by independent expert panels working from different starting frameworks (RCT-driven, consensus-driven, sarcopenia-driven, frailty-driven). For the workshop demo cases, the rationale plays out specifically: Frau M.K. (HFpEF NYHA II pre-frail) and Frau B.S. (post-pneumonia HAD) sit in the SPRINTT-eligible at-risk band where the strongest treatment effect was demonstrated; Herr H.K. (frail with MCI, falls history) sits in a population where the falls-prevention literature provides additional convergent support for multicomponent training. The mortality outcome literature for multicomponent exercise in frailty is more variable: meta-analyses report 25–35% mortality reductions in the most-favoured pooled analyses, with wider confidence intervals at the lower bound where some pooled estimates fall under 15% and some sensitivity analyses cross the null. Mortality is a secondary outcome to mobility and disability for the operational purpose of this chapter.

Practical implications

Three implications follow from the rationale. First, the assessment-to-prescription pathway is short. A positive frailty result on the FrailtyTrack instruments (Fried, FTS5, CFS, SPPB ≤7, etc.) is sufficient to begin a multicomponent intervention; further specialist work-up is welcome but not a prerequisite for starting. Second, the dose ranges from ICFSR 2025 are the operational starting point: 2–3 supervised sessions per week, with home-based work filling additional days, structured around the four pillars at population-specific dose ranges (detailed in §4.3 and §4.4). Third, the SPRINTT pattern of greatest benefit in the more functionally compromised has a practical consequence for workflow design: prioritise enrolment of lower-functioning patients (SPPB ≤7, slow gait, low handgrip), because that is where the treatment effect is most reliably observed and where the cost-of-not-treating is highest.

Where evidence is contested

Three points remain genuinely open. First, the home-based-vs-supervised question. SPRINTT used twice-weekly supervised sessions plus technology-supported home exercise; the supervised-only and home-only variants have weaker dose-response evidence, and the actual delivered dose in real-world home-based programmes is systematically lower than the prescribed dose. The adherence-adjusted FITT-VP literature is the topic of §4.5 (v9.10). Second, the cost-effectiveness boundary. Multicomponent supervised programmes are resource-intensive (group instructors, space, equipment); the cost-per-quality-adjusted-life-year published in different health-system contexts varies by an order of magnitude. The intervention is endorsed without dispute in any major consensus, but the implementation question is genuinely contested. Third, the «first-line» framing itself. A small literature argues that nutritional intervention (protein optimisation, vitamin D where deficient, Mediterranean dietary pattern) deserves co-equal billing with exercise rather than secondary status. The Yang 2026 NMA in §4.3 partially supports this position for the frailty-score outcome; the broader consensus (ICFSR 2025, CIBERFES 2026) treats nutrition as integral to the multicomponent prescription rather than as a separable first-line intervention.

§4.2 takes up the standardised intensity terminology that the dose statements in §4.3 and §4.4 depend on.

4.2 Standardised intensity terminology

Bishop 2025 · Five tiers · RIR-over-%1RM · RPE caveats
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TL;DR

Exercise intensity is the parameter that physiotherapy talks about most and operationalises least consistently. The 2025 ACSM/ESSA Joint Statement (Bishop et al.) proposes a unified five-tier terminology — Very Low, Low, Moderate, High, Very High — with five matched perception-of-effort descriptors (very easy, easy, somewhat hard, hard, very hard). Crucially, the Statement explicitly recommends against using %VO2max, %HRmax, %HRR, or METs as adequate stand-alone intensity descriptors, and recommends RIR (reps-in-reserve) over %1RM for resistance exercise. This standardisation matters because every dose statement in §4.3 and §4.4 depends on a shared meaning of «moderate» — and historically that meaning has drifted across guidelines.

Foundations

The clinical problem is familiar. A geriatric outpatient guideline says «moderate-intensity aerobic activity, 150 minutes per week». A cardiac rehabilitation protocol says «moderate intensity at 50–70% HR reserve». A frailty-specific consensus says «moderate intensity at RPE 12–13 on the Borg 6–20 scale». A behavioural-physical-activity questionnaire asks the patient whether they did «moderate-intensity activity» last week. These four uses of the same word do not refer to the same physiological state, and a frail older patient — particularly one on rate-controlling medication, or with atrial fibrillation, or with substantial baseline deconditioning — may sit in different categorical buckets simultaneously depending on which anchor is used. The traditional approach has been to use one of three families of anchors, and Bishop 2025's central empirical finding is that none of them elicits category-specific physiological responses across individuals. Heart-rate anchors (%HRmax, %HRR) translate poorly across older adults because age-related HRmax decline is heterogeneous and beta-blockade or atrial fibrillation invalidates the calculation entirely; the Statement further reviews evidence that exercising at «80% HRmax» places approximately half of any given sample above and half below their first metabolic threshold. Metabolic anchors (%VO2max, %VO2R, METs) face the same problem from a different direction: the Statement reviews evidence that fixed percentages of VO2max produce up to 40-fold variation in muscle-lactate response across individuals, and that fixed-MET categorisation misclassifies cardiorespiratory exercise intensity for most of a heterogeneous population (the upper limit of the «low-intensity» MET-derived category has been reported to range from 2 to 13 METs across individuals; the upper limit of «moderate-intensity» from 3 to 18). Perceived-effort anchors (the Borg 6–20 scale, the Borg CR-10 scale) are robust to medication and to deconditioning, but require patient familiarisation and produce systematic floor effects in frail patients who report «hard» at objectively very-low workloads. The Joint Statement's contribution is structural rather than empirical. It does not add new measurement technology; it standardises which descriptor language clinicians and researchers should use, and which physiological landmarks underlie that language. Three structural moves matter for §4.3 and §4.4. First, the five-tier framework replaces the older mixed terminology with a single shared vocabulary. Second, the framework is explicitly anchored against the first and second metabolic thresholds (MT1 and MT2) and against Wmax — physiologically meaningful boundaries. Third, the Statement issues recommendations against certain widely-used anchors as stand-alone descriptors.

Evidence

The Bishop et al. 2025 Joint ACSM Expert Statement / ESSA Consensus Statement on Physical Activity and Exercise Intensity Terminology (Med Sci Sports Exerc 57(11):2599–2613; co-published J Sci Med Sport 28(12):980–991) is the primary anchor for §4.2.Bishop 2025 The Statement is the product of a joint panel of the American College of Sports Medicine and Exercise and Sport Science Australia. Its central proposal is the five-tier intensity framework with five matched perception-of-effort descriptors. The five tiers are anchored against three established physiological reference points: MT1 (the first metabolic threshold ≈ lactate threshold ≈ gas-exchange threshold ≈ ventilatory threshold, i.e. the boundary at which lactate first begins to rise above resting); MT2 (the second metabolic threshold ≈ maximal lactate steady state ≈ critical power ≈ respiratory compensation point, i.e. the highest sustainable steady-state intensity); and Wmax (the work rate at VO2max, i.e. the upper boundary of physiologically tolerable exercise). The five tiers map onto these landmarks roughly as follows, with the perception-of-effort label given in parentheses: Very Low — well below MT1, recovery-zone exercise (very easy); Low — below MT1, sustainable for hours (easy); Moderate — at or just above MT1, sustainable but no longer comfortable (somewhat hard); High — between MT1 and MT2, lactate accumulating (hard); Very High — at or above MT2, approaching or at Wmax (very hard). Two recommendations from the Statement have direct relevance for frailty-targeted physiotherapy. First, for resistance exercise the Statement recommends RIR (reps-in-reserve) over %1RM as the more transferable intensity descriptor. The reasoning is that «how hard» a set actually is depends on proximity to neuromuscular failure, not on the load alone — a 60% 1RM set taken to two reps in reserve and a 75% 1RM set taken to two reps in reserve impose comparable training stimulus, and the latter is not «harder» for the patient in any meaningful sense. RIR is intrinsically anchored to fatigue accumulation, which is what drives the training response. Second, the Statement explicitly does NOT recommend %VO2max, %HRmax, %HRR, or METs as adequate stand-alone intensity descriptors for the categorisation purposes the framework serves. RPE (Borg scales) is recommended as an adjunct, not as a stand-alone primary descriptor, and only for individuals familiarised with the scale. The Statement is a position statement, not a piece of new empirical research. Its weight derives from the panel's review of the underlying physiological literature rather than from a primary study. For frailty-targeted practice the practical upshot is that documentation should record (a) the perceived-effort descriptor («somewhat hard»), (b) where available, an MT1/MT2-anchored measurement, and (c) the resistance-training intensity in RIR rather than %1RM. The traditional «60% HRR» entry in a treatment record is, per the Statement, no longer an adequate stand-alone descriptor.

Practical implications

For physiotherapy documentation and patient instruction, the Statement's framework translates as follows. Patient instruction. The five-tier perception-of-effort descriptors («very easy / easy / somewhat hard / hard / very hard») are the most patient-accessible part of the framework. The Statement's Table 2 specifies the cross-walk between these descriptors, the two RPE scales, and the resistance-training reps-in-reserve descriptor:

Tier (effort descriptor)RIRBorg CR-10 (RPE10)Borg 6–20 (RPE20)
Very Low (very easy)>8<2≤9
Low (easy)7–82–310–11
Moderate (somewhat hard)4–64–512–14
High (hard)2–36–715–16
Very High (very hard)<28–10≥17

Bishop 2025 Table 2: official cross-walk between the five-tier framework, RIR (resistance training), and the two Borg scales.

Two caveats from the Statement's own treatment of these mappings carry directly into clinical practice. First, the RPE10 alignment is internally contested: «somewhat hard» (= Moderate) sits at RPE10 4–5 in the Statement's framework, but at RPE10 3 in Borg's original framework and at RPE10 5 in the WHO 2020 physical activity guidelines — the Statement has chosen the 4–5 range as a compromise but the underlying scaling debate is unresolved. Second, when RIR and RPE disagree on which tier a set sits in, the Statement recommends selecting the higher tier as the defining intensity, particularly in clinical populations — a useful default for frailty practice. The talk test offers a useful additional anchor for cardiorespiratory work in the absence of laboratory-based measures. The Statement endorses the talk test conservatively — primarily as a way to limit cardiorespiratory exercise to below the High tier rather than as a precise discriminator between adjacent tiers. As a clinical heuristic in frailty practice: comfortable conversational speech is broadly consistent with Low-intensity work below MT1, equivocal speech with Moderate, and only brief words with High and above. Documentation. A treatment-note entry of «aerobic training, 20 min, RPE 13» is, per the Statement, more transferable than «aerobic training, 20 min, 65% HRR». For resistance training, «leg press 3×10 at RIR 2» is more transferable across populations than «leg press 3×10 at 70% 1RM», because the latter does not specify how close to failure the set was actually taken. Inter-instrument consistency. The 5×STS, gait speed, 6MWT and SPPB all generate objective intensity-equivalent landmarks that anchor the patient's individual «moderate» and «high» categories empirically rather than theoretically. The five-tier framework is the conceptual scaffolding that links assessment output (a 5×STS time of 18 s) to dose specification («3 sets of 8 chair stands at RIR 2, somewhat hard»).

Where evidence is contested

Three points on the Statement remain genuinely open. First, is the five-tier framework an empirical advance or a relabelling. The Statement's five tiers can be read as a synthesis of pre-existing terminology rather than as new physiology. Critics within the exercise-science community have noted that the four-domain framework (moderate / heavy / severe / extreme) already captures most of the same physiological boundaries, and that the cross-walks introduce small but non-trivial mismatches at the boundary points. Both positions are defensible; the choice is partly a question of audience. Second, the explicit dis-recommendation of %VO2max, %HRmax, %HRR, and METs is more pointed than what many exercise-physiology textbooks teach, and there will be a transitional period during which guidelines, journal articles, and clinical protocols continue to use these anchors as primary descriptors. The Statement's position is consensus, not yet practice — and the practical reality in many physiotherapy services is that HRR is the only anchor available without specialist equipment. Third, the floor effect for RPE in frailty is a real measurement issue not fully addressed in the Statement. A frail older patient may report «hard» (RPE 14–15 on the 6–20 scale) at an objectively very-low workload that sits well below MT1 by metabolic measurement. This does not invalidate the framework — RPE remains the patient's own report and should drive prescription regardless — but it complicates direct cross-walks between «hard» and «above MT1» in this population.

§4.3 takes up multicomponent exercise prescription, where the five-tier intensity language is used substantively for the first time in this chapter.

4.3 Multicomponent exercise prescription

Four pillars · SPRINTT · ICFSR · NMA evidence
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TL;DR

Multicomponent exercise — combining resistance training, aerobic conditioning, balance work, and gait practice in a single integrated programme — is the consensus structure for frail older adults. The 2025 ICFSR consensus, the SPRINTT trial (Bernabei et al. 2022), the CIBERFES 2026 consensus, and two 2026 network meta-analyses (Ma et al.; Yang et al.) all converge on the same four-pillar structure, with proportions adjusted to the patient's dominant impairment. The Yang 2026 NMA additionally finds that combined exercise + nutrition outperforms multicomponent exercise alone for frailty score, extending the EWGSOP2 «resistance + protein optimisation» framing into NMA-grade evidence. The four pillars stay the same; the proportions shift case by case — illustrated below for M.K., H.K., and B.S.

Foundations

Multicomponent exercise rests on a simple observation. Frailty manifests across multiple performance dimensions simultaneously: muscle strength, aerobic capacity, balance, and gait coordination all decline together in the typical frail patient, and each dimension is partly modifiable by training but only weakly cross-trained by training the others. A pure resistance programme increases strength and muscle mass but does not robustly improve VO2max or postural control. A pure walking programme improves cardiovascular fitness but does not robustly increase muscle strength or fall-resistance balance reserve. A pure balance programme reduces fall risk in the short term but does not address the strength and aerobic substrate that determines longer-term mobility. Multicomponent programmes pool the modalities precisely because the substrate is multidimensional. The four pillars are not novel — they appear in essentially every major frailty-targeted exercise guideline since the late 1990s. What the 2025 ICFSR consensus contributes is the explicit framing of these four pillars as a structural requirement for the frail population specifically, with dose ranges adapted to that population. The CIBERFES 2026 consensus adds the conceptual frame that the four pillars cluster around the muscle / strength / power axis developed in §2 of this Background tab. For the workshop demo cases the multicomponent structure looks different in proportion but identical in component set. Frau M.K. (78 F, HFpEF NYHA II, pre-frail) presents with a dominant aerobic limitation layered on early sarcopenic strength decline; the literature applicable to her profile emphasises aerobic conditioning as the largest time slice with resistance training maintained at preservation-of-strength dose. Herr H.K. (84 M, frail with mild cognitive impairment, two falls in 12 months) presents with dominant balance and fall-risk impairment plus a cognitive overlay; the literature applicable to his profile increases the balance and gait time slice substantially. Frau B.S. (72 F, post-pneumonia hospital-associated disability with acute sarcopenia, day-5 baseline) presents with the most rapidly changing profile: in the first 1–2 weeks the literature emphasises bedside-progressive resistance and early mobilisation, with the multicomponent structure expanding as the patient transitions from inpatient to community.

Evidence

The 2025 ICFSR consensus (Izquierdo et al. 2025, J Nutr Health Aging 29(1):100401) is the canonical multicomponent prescription source for frail and pre-frail older adults.Izquierdo 2025 ICFSR The Delphi-style 34-author consensus structures recommendations around four pillars with population-specific dose ranges. For strength and power training: 2–3 sessions per week, 1–3 sets × 8–12 reps at 40–80% 1RM, with explicit combination of low- and high-velocity work. For balance and gait re-education: 3–4 days per week, 1–2 sets per session, combining static and dynamic exercises. For aerobic training: 3–7 days per week, with progressive duration starting from 5–10 minutes and building up. For flexibility: integrated as a daily or near-daily component. The consensus is explicitly anchored to the frail and pre-frail populations, not to generally healthy older adults — which matters because frailty-specific dose recommendations are typically lower at the floor than those for healthy older adults, with greater attention to progression and recovery. The SPRINTT trial (Bernabei et al. 2022, BMJ 377:e068788) is the largest single-RCT evidence base for the multicomponent structure in physically frail sarcopenic older adults, with the SPPB ≤7 stratum HR 0.78 (95% CI 0.67–0.92, p=0.005) and similar SAE rates between arms (39.2% vs 36.0%, RR 1.09, 95% CI 0.94–1.26).Bernabei 2022 The CIBERFES 2026 consensus (Álvarez-Bustos et al. 2026, J Nutr Health Aging 30:100793) extends the multicomponent framing by anchoring the four pillars in the muscle / strength / power axis.Álvarez-Bustos 2026 The EWGSOP2 consensus (Cruz-Jentoft et al. 2019) endorses resistance training plus protein optimisation as first-line management for sarcopenia, which is the muscle component of the multicomponent structure.Cruz-Jentoft 2019

Two 2026 network meta-analyses contribute complementary evidence. Ma et al. 2026 (Bayesian NMA, 17 RCTs, 1,107 pre-frail older adults, Front Public Health 13:1718120) ranked elastic-band exercise highest for handgrip strength improvement (SUCRA 87.51%; pooled MD 5.2 kg, 95% CI 0.64–9.8 vs control) and progressive-exercise-with-«Tai-chi-snacking» (10–15 minute movement micro-doses distributed across the day) highest for SPPB (SUCRA 90.03%); multicomponent training was also significantly superior to control for SPPB (MD 1.13 points, 95% CI 0.13–2.10).Ma 2026 No exercise modality reached statistical significance for TUG in this NMA (limited power: n=263 across only 6 included RCTs). The Ma 2026 result is operationally useful for low-equipment community settings — elastic-band exercise transfers cleanly to home and outpatient practice — but the specific superiority should not be over-generalised beyond the pre-frail-only population studied. Yang et al. 2026 (frequentist NMA, 22 RCTs, 2,055 older adults aged ≥60 with pre-frailty, frailty, or frailty-related risks — including one cognitive-frailty trial — BMC Geriatrics 26:343) compared multicomponent exercise alone, nutritional supplementation alone (protein and amino acids), and the combination of both, against standard care.Yang 2026 For frailty score, combined intervention was most effective (SMD −0.92, 95% CI −1.43 to −0.40); multicomponent exercise alone was significantly effective (SMD −0.78, 95% CI −1.15 to −0.43); nutrition alone showed a non-significant trend (SMD −0.69, 95% CI −1.67 to +0.27). For SPPB, only multicomponent exercise alone reached statistical significance (SMD +1.85, 95% CI +0.33 to +3.50). For gait speed, only nutrition alone showed significant improvement (SMD +0.37, 95% CI +0.06 to +0.68). The Yang 2026 «combined intervention > multicomponent alone for frailty score» finding extends the EWGSOP2 «resistance + protein optimisation» framing into NMA-grade evidence — and is the strongest single argument in §4.3's evidence base for routine integration of nutritional optimisation into the multicomponent prescription, particularly in patients with marginal protein intake or recent acute illness. Caveat: Yang 2026 also reports an anomalous TUG signal — multicomponent exercise alone increased TUG completion time by 3.96 s (SMD, 95% CI +0.91 to +7.07), which the authors attribute speculatively to short-term muscular fatigue. This signal is inconsistent with the broader functional-performance literature and the corresponding null-significance TUG finding in Ma 2026; §4.3 therefore draws on Yang 2026 for frailty-score and SPPB findings only and treats the TUG signal as anomalous pending replication.

For the three workshop cases, the literature gives reasonably specific guidance. Frau M.K. (HFpEF NYHA II, pre-frail) matches the population studied in cardiac-rehabilitation and HFpEF-specific exercise trials, where moderate-intensity aerobic training improves VO2peak, peak treadmill duration, and quality of life, with resistance training at preservation dose improving handgrip and lower-extremity strength. The Yang 2026 «combined > multicomponent alone» finding for frailty score is directly applicable: addressing M.K.'s likely marginal protein intake (typical for older HFpEF patients with reduced appetite) is part of the multicomponent prescription, not a separate intervention. Herr H.K. (frail with MCI, two falls in 12 months) aligns with multicomponent fall-prevention programmes (FaME, Otago, Vivifrail) where the balance and gait component is the largest single time slice. The MCI overlay is treated separately in §4.7 (v9.11). The Yang 2026 result includes one cognitive-frailty trial in the broader pool but does not stratify by cognitive status; H.K.'s prescription should default to the standard multicomponent structure with cognitive-frailty-specific modifications addressed in §4.7. Frau B.S. (post-pneumonia HAD, day-5) aligns with hospital-associated-disability and post-acute-rehabilitation literature, where early structured multicomponent exercise during and after hospitalisation is associated with improved functional recovery curves. The Yang 2026 nutrition finding is particularly applicable in HAD: post-acute protein optimisation is consistently identified as a component of recovery alongside early progressive resistance.

Practical implications

For physiotherapy practice the multicomponent structure has three operational consequences. First, session structure. The evidence base supports a four-pillar session structure: warm-up, resistance and power training, aerobic training (often integrated with the resistance work in circuit form), balance and gait work, with cool-down. The relative time allocation across pillars shifts case by case (see worked examples below) but all four pillars are present in every session. Flexibility runs through the warm-up and cool-down rather than as a separate block. Specific minute-allocation parameters across the pillars — and the supervised-vs-home-based and dose-attainment trade-offs that determine real-world session structure — are deferred to §4.5 (adherence and progression, v9.10). Second, frequency. The convergent consensus is ≥2 supervised sessions per week, with home-based work filling additional days. The ICFSR-specific frequency ranges per modality (RT 2–3/wk; balance/gait 3–4/wk; aerobic 3–7/wk) imply that the supervised sessions cannot do everything — they anchor the strength and balance components, and the aerobic and gait components are partly carried by home-based activity. Third, the worked-example proportions. For M.K., the literature most directly applicable suggests an aerobic-prominent multicomponent allocation, with resistance held at preservation dose and balance maintained as reserve. For H.K., the same literature suggests a balance-and-gait-prominent allocation with attention to dual-task elements given the MCI overlay. For B.S. at day-5 baseline, the bedside-acute literature suggests an inverted profile in the first 1–2 weeks: bedside-progressive RT and early mobilisation dominate the available training time, with aerobic and balance components introduced progressively as transfer ability returns; by week 6 the structure converges on the standard ambulatory multicomponent profile. Detailed FITT-VP specification within each modality is the subject of §4.4.

Where evidence is contested

Three points remain genuinely contested. First, is «multicomponent» meaningfully distinct from «comprehensive». Some authors have argued that the multicomponent label is functionally indistinguishable from any well-designed rehabilitation programme that addresses multiple impairment dimensions, and that the term has been stretched to cover protocols that differ substantially in actual content. The defence is that the multicomponent label specifies the four-pillar structure, and that programmes lacking any one of the four pillars do consistently underperform. Second, the supervision question. SPRINTT used twice-weekly supervised sessions plus technology-supported home exercise. ICFSR 2025 endorses ≥2 supervised sessions weekly. But the strongest dose-response evidence for adherence comes from supervised programmes, while real-world capacity for supervision varies by health system and setting. The practical question — how much of the multicomponent benefit survives a transition from fully-supervised to home-based with periodic check-ins — is empirically open. Adherence and progression in non-supervised settings is the topic scheduled for §4.5 (v9.10). Third, the dilution risk. Doing all four pillars in a 60-minute session means that no single pillar receives the dose it would in a single-modality programme. For a frail older adult with a dominant impairment in one pillar (e.g. severe sarcopenia with preserved aerobic capacity and balance), the literature is genuinely divided on whether a more pillar-concentrated programme might outperform the standard multicomponent structure. The current consensus is that the multicomponent structure is the safer default in an unselected frail population; an explicit case can be made for pillar-emphasised variants in specific phenotypes.

§4.4 takes up the FITT-VP dose variables that operationalise each of the four pillars.

4.4 FITT-VP dose variables

Currier 2026 · Pelland 2026 · Necessary vs optional · Worked examples
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TL;DR

FITT-VP — Frequency, Intensity, Time, Type, Volume, Progression — is the standardised vocabulary for specifying an exercise dose. The 2026 ACSM Position Stand on resistance-training prescription (Currier et al.) is an overview of 137 systematic reviews (~30,000 participants); the Pelland et al. 2026 multi-level meta-regression of weekly volume and frequency on hypertrophy and strength (67 studies, 2,058 participants) contributes complementary dose-response detail. The Currier 2026 stand identifies which RT variables are necessary (frequency, load, volume, set proximity-to-failure) and which are optional (machine vs free weight, time under tension, set structure, periodisation type). The §4.4 task is to describe what the evidence-based ranges look like and how they shift in frail older adults — illustrated below for M.K., H.K., and B.S.

Foundations

FITT was for many years the canonical exercise-prescription mnemonic — Frequency (sessions per week), Intensity (the demand of each session), Time (duration of each session), and Type (the modality). The addition of Volume and Progression to make FITT-VP reflects two empirical observations. First, the weekly volume of work — the sum of sets, repetitions, and load across a week — is a stronger predictor of training adaptation than any single-session variable, and is partly independent of session frequency (a given weekly volume can be distributed across two sessions or four sessions, with somewhat different but generally comparable effects). Second, an exercise dose that is held fixed produces diminishing returns over weeks to months; programmed progression — increasing load, increasing volume, increasing complexity — is what sustains adaptation across the long timescales relevant in frailty rehabilitation. FITT-VP applies to each modality separately. Resistance training has its own FITT-VP profile; aerobic training has its own; balance training has its own. The integration question — how a given patient's multicomponent programme combines the FITT-VP profiles of the four pillars within a 60-minute session and a 2–3 session/week supervision schedule — is what makes prescription in frailty operationally complex. The §4.3 worked examples set out the proportional allocation across pillars; §4.4 specifies the dose within each pillar. The single most important Q2-a discipline applied to §4.4: the prose describes what the evidence shows about effective dose ranges in healthy adults and how those ranges shift in frail older adults. It does not specify what an individual physiotherapist should prescribe for an individual patient. The numbers that appear in the Evidence section below are population-level summary statistics from systematic reviews and consensus documents, not individual-patient prescriptions. For the workshop demo cases the FITT-VP structure plays out differently: M.K. has an aerobic-prominent multicomponent structure (per §4.3) with FITT-VP centred on aerobic and strength-preservation parameters; H.K. has a balance-and-gait-prominent structure with FITT-VP centred on balance frequency and complexity progression; B.S. has a rapidly evolving FITT-VP profile across her recovery trajectory, with the week-1 dose specification differing structurally from the week-6 specification.

Evidence

The 2026 ACSM Position Stand on Resistance Training Prescription (Currier et al. 2026, Med Sci Sports Exerc 58(4):851–872) updates the 2009 Kraemer/Ratamess Position Stand using overview-of-reviews methodology.Currier 2026 The synthesis covers 137 systematic reviews and approximately 30,000 participants, with AMSTAR scoring of each review and a GRADE-style adapted certainty framework. Six key findings frame §4.4. (1) Strength is enhanced by lifting at ≥80% 1RM, through full range of motion, 2–3 sets per session, ≥2 sessions per week, with the resistance exercise placed at the beginning of the training session. (2) Hypertrophy is enhanced by higher weekly volumes (≥10 sets per muscle group per week) and by eccentric overload. (3) Power is enhanced by moderate loads (30–70% 1RM), low-to-moderate volume (≤24 reps × sets), Olympic-style weightlifting derivatives, and power-RT (resistance training with a fast concentric phase). (4) Power-RT enhances physical function: gait speed, chair-stand performance, TUG, walking performance, and SPPB. This is a particularly important finding for the frailty audience because power decline is the steepest age-related muscle change (per §2 of this Background tab) and translates most directly to functional outcomes. (5) Several traditionally-prescribed RT variables do not consistently impact training outcomes: training to momentary failure, equipment type (machine vs free weight), exercise complexity, set structure (cluster, drop, complex), time under tension, blood-flow restriction, and periodisation type. The Stand's framing is that these are optional rather than necessary RT variables, which simplifies programme design considerably. (6) Compared with no exercise, RT improves strength, hypertrophy, power, and physical function across the age range, including in frail older adults. The Pelland et al. 2026 multi-level meta-regression (Sports Med 56(2):481–505) contributes complementary dose-response detail on weekly volume and frequency.Pelland 2026 The analysis covers 67 studies and 2,058 participants and classifies sets as «direct» or «indirect» (specific to the measured outcome vs contributing via shared muscle activation), quantified at 1, 0.5, or 0. The headline findings are: the dose-response for both volume and frequency is real, but with substantial diminishing returns; per-session volume eventually crosses a «point of undetectable outcome superiority» (PUOS) beyond which additional sets do not yield greater than 50% likelihood of detectable additional benefit. For the frailty audience the practical translation is that the volume-response curve plateaus quickly — substantial gains accrue at low-to-moderate doses — which is exactly the message that matters most when teaching workshops where the «minimum effective dose» concept is more relevant than the «optimal dose for an athlete». The 2025 ICFSR consensus (already detailed in §4.3 Evidence) provides the frailty-specific FITT-VP adaptation. Its strength-component dose range — 2–3 sessions/week, 1–3 sets × 8–12 reps at 40–80% 1RM, combining low- and high-velocity work — sits at the lower end of the Currier 2026 healthy-adult ranges, with an explicit power component built in via the high-velocity recommendation.

For the worked examples: Frau M.K. (HFpEF NYHA II pre-frail). The FITT-VP profile most directly supported by the literature for her phenotype centres on aerobic training at moderate intensity (per the Bishop 2025 framework: «somewhat hard»; talk-test boundary at short-sentence speech) for 20–30 minutes per session, 3–5 sessions per week, with progression by duration first and then by intensity; combined with a strength-preservation RT dose of 2 sessions per week, 1–2 sets × 8–12 reps at the lower end of the 40–80% 1RM range, with a deliberate power component via 1–2 sets of high-velocity chair-rise or step-up variants. The volume here sits well within the Pelland 2026 plateau — additional sets are unlikely to yield further benefit and may compromise the aerobic dose. Herr H.K. (frail with MCI, falls history). The FITT-VP profile for his phenotype centres on balance training 3–4 days per week, 1–2 sets per session, combining static and dynamic with progressively more complex dual-task elements; combined with RT 2 sessions per week at the frailty-floor dose (1–2 sets × 8–12 reps at 40–60% 1RM), with explicit attention to power via high-velocity moves at moderate loads; and aerobic at 3–4 days per week, 15–20 minutes, at low-to-moderate intensity. Progression is conservative given his fall history: load progression in RT precedes complexity progression in balance, with both anchored to demonstrated safety in the prior week. Frau B.S. (post-pneumonia HAD day-5). At day-5 the FITT-VP profile is bedside-acute: very-low-volume RT (1 set × 6–8 reps at the lowest tolerable resistance) combined with early-mobilisation work and incremental sit-to-stand practice. By week 6 the profile has converged on the standard ambulatory multicomponent FITT-VP (RT 2/wk × 1–3 sets × 8–12 reps at 40–70% 1RM; aerobic 3–4/wk × 15–25 min at moderate intensity; balance 3/wk × 1–2 sets; flexibility daily). The progression from day-5 to week-6 is the FITT-VP component most distinct from the other two cases: in B.S. the dose itself is the variable of clinical interest week-to-week.

Practical implications

For physiotherapy practice three operational consequences follow from the evidence. First, the «necessary versus optional» framing from Currier 2026 simplifies programme design considerably. Of the many RT variables historically debated in the literature — machine vs free weight, periodisation type, time under tension, training to failure, set structure — most do not consistently impact outcomes in the umbrella-review evidence. The variables that do matter are frequency, load, volume, set proximity-to-failure, and (for power) lift velocity. For physiotherapy practice this means: design within these necessary variables, and treat the optional variables as preference parameters rather than as efficacy parameters. A patient who prefers machines can train on machines without compromising outcome; a patient who prefers free weights can train with free weights without compromising outcome. Second, the volume-plateau finding from Pelland 2026 is operationally important for the frailty audience. Adding more sets to an already adequate volume does not reliably produce more gain, and the plateau in frail older adults is reached at lower volumes than in younger trained populations. The default assumption — that more is better — is wrong at the dose ranges relevant in frailty. This is the empirical anchor for the frailty-specific phrase «minimum effective dose» that recurs in workshop material. Third, the worked-example progression. For M.K., the most impactful progression at the 6-week reassessment is typically aerobic duration (extending sustained moderate-intensity aerobic work from 20 to 25–30 minutes), with RT held stable at the strength-preservation dose. For H.K., the most impactful progression is typically balance-task complexity (from static-supported to dynamic-unsupported, then dual-task) with RT load progressed conservatively (one increment per fortnight, anchored to demonstrated safe execution). For B.S., the FITT-VP profile is itself the progression — moving from bedside-acute parameters to ambulatory multicomponent parameters across her recovery trajectory; the 6-week reassessment is more a confirmation of having reached the ambulatory profile than a fine-grained dose adjustment. Reassessment with the FrailtyTrack instruments (5×STS, gait speed, handgrip, SPPB) provides the empirical anchor for whether the prescribed FITT-VP dose is producing the expected adaptation. The longitudinal tab in this tool is sized for the 6-, 12-, and 24-week reassessment windows that match the dose-response timescales in the literature.

Where evidence is contested

Three points remain genuinely open in the FITT-VP literature applied to frailty. First, the «≥80% 1RM for strength» finding from Currier 2026 sits uneasily with the «40–80% 1RM» range from ICFSR 2025. The two are not formally inconsistent — Currier 2026 reports the strength-optimal range in healthy adults; ICFSR 2025 reports the frailty-population dose range that is both safe and effective at typical achievable intensities. But the practical implication — should a frail patient with adequate joint health and tolerance be loaded to 80% 1RM for strength gain, or held at 40–60% 1RM — is genuinely contested in the literature. The conservative position is the ICFSR range; the maximally-evidence-aligned position is the Currier range scaled to demonstrated tolerance. Both positions are defensible. Second, power-training dose specifications in frail older adults are less well-established than the corresponding strength-training specifications. Power training is consistently endorsed (Currier 2026 finding 4; ICFSR 2025 high-velocity recommendation), but the specific dose at which power gains are optimal in the frail population is supported by a thinner evidence base than the strength-equivalent range, and the trade-off between volume of power-specific work and volume of strength-specific work in a multicomponent session is not formally settled. This is a rapidly developing area of literature. Third, the home-based versus supervised question intersects with FITT-VP specification because home-based programmes systematically achieve lower actual volumes than the supervised-equivalent prescription specifies. The literature on adherence-adjusted FITT-VP — what dose is actually delivered, as opposed to what dose is on the prescription sheet — is partial and is the subject scheduled for §4.5 (v9.10). For now, the FITT-VP specification in §4.4 is the supervised-prescription specification; home-based equivalents will require their own adherence-adjusted treatment.

§4.5 (in v9.10) takes up adherence and progression. §4.6 (also in v9.10) treats flexibility as the fourth+1 pillar in greater depth. §4.7 (in v9.11) takes up the specific case of training in cognitive frailty.

Literature-Derived Demo Cases

Eight example patients constructed from published clinical-trial data and the BFH 2026 workshop script. Cases 1–5 cover the v8.8 extended assessment battery (OLS-10s, FSST, Dual-Task TUG, 6MWT, 2-Minute Step Test, SARC-F, Mini-Cog, MoCA). Cases 6–8 (added v9.4.0) cover the workshop-script vignettes — Frau M.K. (pre-frail HFpEF), Herr H.K. (frail + MCI + Sturzanamnese), Frau B.S. (post-pneumonia HAD) — and exercise the new Wadenumfang, MNA-SF, and Short FES-I tracks alongside the existing battery.

🔒 Data Protection Notice — No Real Patient Data
The individuals shown on this page — Mrs E.K., Mr H.W., Ms G.M., Mr R.B., Mrs L.A., Frau M.K., Herr H.K., Frau B.S. — do not exist and have never been patients. All names, dates, and values are entirely fictional, constructed solely for demonstration purposes. No real patient data of any kind has been used, stored, or processed in this tool. If you are a clinician, please ensure that any real patient assessments you enter in the Enter Assessment tab are handled in accordance with your institution’s data protection policy and applicable law (e.g. GDPR / Swiss nDSG). This tool stores nothing on any server — all data entered lives only in your browser memory for the current session.
How to use: Click Load & View Results on any case to instantly see its profile. Click Load All Sessions → Longitudinal to see the pre/post comparison for all patients in the Longitudinal tab. You can also download the full demo Excel dataset and upload it to the Longitudinal tab as a real-world test.

Case 1 — Mrs E.K., 72F

Pre-frail → Robust
2 sessions · 12 weeks

Profile: 72-year-old woman, BMI 24.8, community-dwelling. Referred for falls prevention after one near-miss. Possible sarcopenia (slow gait). Enrolled in community dual-task exercise programme (3×/week, 12 weeks).

Source: Merchant RA et al. 2021 (HAPPY Study), Front. Med. doi:10.3389/fmed.2021.660463

TestBaseline12-weekChange
HGS18.5 kg21.2 kg+2.7 kg
Gait Speed0.91 m/s0.98 m/s+0.07
TUG12.4 s10.8 s−1.6 s
SPPB8/1210/12+2
30-s CST11 reps13 reps+2
5× STS14.8 s12.2 s−2.6 s
5×STS Power1.42 W/kg1.73 W/kg+0.31 W/kg
30s CST Power1.55 W/kg1.83 W/kg+0.28 W/kg
CFS43−1
Fried2 (pre-frail)1 (pre-frail)−1
New assessments (v8.8 & v8.10)
KES dominant210 N (33.3%BW)234 N (37.1%BW)+24 N / +3.8%BW
OLS-10sFAIL (8.2 s)PASS (11.5 s)+3.3 s ✓
FSST16.2 s13.5 s−2.7 s
DT-TUG / DTC15.8 s / 27%13.1 s / 21%−2.7 s / −6%
6MWT412 m448 m+36 m (>MCID)
2-Min Step68 reps82 reps+14
SARC-F4/10 ✚ positive2/10 ✗ negative−2
Mini-Cog5/5 (neg.)5/5 (neg.)—
MoCA27/3028/30+1

Case 2 — Mr H.W., 78M

Frail → Pre-frail
2 sessions · 8 weeks

Profile: 78-year-old man, BMI 26.2, lives alone. Referred after hospital discharge for deconditioning. Enrolled in technology-assisted multicomponent exercise intervention (SAIF protocol: exercise + nutrition, 8 weeks).

Source: Tan et al. 2022 (SAIF Study), Front. Med. doi:10.3389/fmed.2022.955785

TestBaseline8-weekChange
HGS22.0 kg25.5 kg+3.5 kg
Gait Speed0.72 m/s0.79 m/s+0.07
TUG15.6 s13.2 s−2.4 s
SPPB6/127/12+1
30-s CST9 reps11 reps+2
5× STS16.2 s14.1 s−2.1 s
5×STS Power1.30 W/kg1.49 W/kg+0.19 W/kg
30s CST Power1.26 W/kg1.55 W/kg+0.29 W/kg
CFS65−1
Fried3 (frail)2 (pre-frail)−1
New assessments (v8.8 & v8.10)
KES dominant208 N (28.0%BW)245 N (32.9%BW)+37 N / +4.9%BW
OLS-10sFAIL (3.5 s)FAIL (6.8 s)+3.3 s (improving)
FSST24.1 s19.4 s−4.7 s
DT-TUG / DTC21.8 s / 40%18.2 s / 38%−3.6 s / −2%
6MWT288 m (<300 frail)342 m+54 m ✓
2-Min Step51 reps67 reps+16
SARC-F7/10 ✚ high5/10 ✚ positive−2
Mini-Cog3/5 (positive)3/5 (positive)—
MoCA22/30 (MCI)23/30+1

Case 3 — Ms G.M., 68F

Robust — Reference
1 session · Cross-sectional

Profile: 68-year-old woman, BMI 23.1, physically active (recreational walking 3×/wk). Screened as healthy control during fall prevention programme. All measures within or above normative range. Demonstrates robust profile for comparison.

Source: Svinøy et al. 2021 (Tromsø Study normative reference values), CIA. doi:10.2147/CIA.S294512

TestSingle Assessmentvs. Norm median
HGS27.5 kgAt median (26 kg)
Gait Speed1.22 m/sAbove median (1.19)
TUG9.1 sAt median (9.6 s)
SPPB11/12Above median (11)
30-s CST15 repsNormal range (11–16)
5× STS11.0 sAbove European median (~11.2 s, 68F)
5×STS Power1.92 W/kgAbove cut-off (≥1.9 W/kg, F)
30s CST Power2.11 W/kgAbove cut-off (≥2.01 W/kg, F)
CFS2Well / Robust
Fried0 (Robust)No criteria met
New assessments (v8.8 & v8.10)
KES dominant278 N (45.1%BW)Above expected (~43%BW)
OLS-10sPASS (>30 s)Excellent
FSST9.2 sNormal (<10 s)
DT-TUG / DTC10.8 s / 19%Mildly elevated (typical)
6MWT511 mAbove predicted (538 F 60–69)
2-Min Step94 repsNormal range (75–107)
SARC-F0/10Negative
Mini-Cog5/5Negative screen
MoCA29/30Normal

Case 4 — Mr R.B., 83M

Frail — Cardiac / Post-acute
3 sessions · 0, 6, 12 weeks

Profile: 83-year-old man, BMI 27.4, admitted for acute decompensated heart failure. Discharged to cardiac rehabilitation physiotherapy. Three assessments over 12 weeks of outpatient rehab. Moderate–slow recovery trajectory.

Source: Pandey A et al. 2019 (JACC Heart Fail) doi:10.1016/j.jchf.2019.10.003 + Tarazona-Santabalbina FJ et al. 2016 (JAMDA) doi:10.1016/j.jamda.2016.01.019

TestBaseline (T0)6-week (T1)12-week (T2)
HGS19.0 kg20.0 kg21.5 kg
Gait Speed0.58 m/s0.65 m/s0.72 m/s
TUG22.5 s19.8 s17.2 s
SPPB5/126/127/12
30-s CST7 reps8 reps9 reps
5× STS18.5 s16.8 s15.0 s
5×STS Power1.14 W/kg1.25 W/kg1.41 W/kg
30s CST Power0.98 W/kg1.12 W/kg1.26 W/kg
CFS766
Fried433
New assessments (v8.8 & v8.10)
KES dominant177 N (21.9%BW)201 N (25.0%BW)218 N (27.1%BW)
OLS-10sUnable (frame)FAIL (1.8 s)FAIL (4.2 s)
FSSTUnable31.5 s26.8 s
DT-TUG / DTC28.8 s / 28%25.4 s / 28%22.0 s / 28%
6MWT188 m231 m268 m
2-Min StepNot tested (mobility limitation)
SARC-F9/107/106/10
Mini-Cog3/5 (positive)4/5 (neg.)4/5 (neg.)
MoCA20/3021/3022/30

Case 5 — Mrs L.A., 76F

Pre-frail → Improving
3 sessions · 0, 8, 16 weeks

Profile: 76-year-old woman, BMI 26.8, cognitive frailty. Memory complaints, MMSE 24/30. Enrolled in 16-week high-speed resistance exercise programme (3×/wk). Gradual improvement in physical performance; frailty score improved by endpoint.

Source: Yoon DH, Lee J-Y, Song W. 2018 (J Nutr Health Aging; DOI corrected from erroneous Langlois 2023 reference — v8.15) doi:10.1007/s12603-018-1090-9; values adapted from Table 2/3 means. PMID:30272098 ✅

TestBaseline (T0)8-week (T1)16-week (T2)
HGS15.8 kg16.5 kg18.2 kg
Gait Speed0.87 m/s0.91 m/s0.98 m/s
TUG13.8 s12.9 s11.4 s
SPPB7/128/129/12
30-s CST10 reps11 reps13 reps
5× STS14.5 s13.8 s12.8 s
5×STS Power1.45 W/kg1.53 W/kg1.65 W/kg
30s CST Power1.40 W/kg1.55 W/kg1.83 W/kg
CFS544
Fried221
New assessments (v8.8 & v8.10)
KES dominant190 N (29.0%BW)216 N (33.0%BW)236 N (36.0%BW) →
OLS-10sFAIL (5.8 s)FAIL (8.2 s)PASS (10.5 s) ★
FSST21.2 s17.8 s15.2 s
DT-TUG / DTC18.8 s / 36%17.0 s / 32%14.8 s / 30%
6MWT342 m381 m418 m (>400 m)
2-Min Step61 reps73 reps86 reps
SARC-F5/10 ✚4/10 ✚3/10 ✗
Mini-Cog3/5 (positive)4/5 (neg.)4/5 (neg.)
MoCA22/30 (MCI)23/3025/30 (+3)

Case 6 — Frau M.K., 78F

Pre-frail (HFpEF) → Robust
2 sessions · 6 weeks · v9.4.0

Profile: 78-year-old woman, BMI 24.8, HFpEF (NYHA II) with hypertension and mild knee OA. SPPB 9/12 — the chair-stand sub-score (1/4) drives the loss; 5×STS 14.8 s. Powerpenia pattern: low STS-power on a still-mobile background, typical of cardiac-reserve limitation. Workshop-script vignette Fall 1.

Source: Hilfiker 2026 (BFH workshop script v2026.20, Fall 1); intervention rationale Kitzman 2021 (REHAB-HF), doi:10.1056/NEJMoa2026141

TestBaseline6-weekChange
HGS17.0 kg18.5 kg+1.5 kg
Gait Speed0.95 m/s1.02 m/s+0.07
SPPB9/1210/12+1 (MCID)
5× STS14.8 s13.4 s−1.4 s
30-s CST9 reps11 reps+2
v9.4.0 tracks (Sarcopenia · Nutrition · FOF)
Calf circumference33.0 cm33.5 cm+0.5 cm
SARC-F2/101/10−1
SARC-CalF (auto)12/20 (CC ≤33)1/20 (CC >33)flipped
MNA-SF12/14 normal13/14 normal—
Short FES-I11 (mod)9 (mod)−2

Case 7 — Herr H.K., 84M

Frail + MCI + falls → Pre-frail
2 sessions · 12 weeks · v9.4.0

Profile: 84-year-old man with hypertension, atrial fibrillation (NOAK), MCI 18 months. Two falls in past year (one with Radiusfraktur). Performance-test-driven Fried (self-report unreliable due to MCI). CFS 6 (moderate frailty), high Short FES-I (18). Vivifrail-Stufe-C programme over 12 weeks. Workshop-script vignette Fall 2.

Source: Hilfiker 2026 (BFH workshop script v2026.20, Fall 2); Vivifrail in MCI rationale Casas-Herrero 2022, doi:10.1002/jcsm.12925

TestBaseline12-weekChange
HGS24.0 kg26.5 kg+2.5 kg
Gait Speed0.71 m/s0.85 m/s+0.14 (>MCID)
SPPB5/127/12+2 (substantial)
5× STS18.0 s15.5 s−2.5 s
CFS65−1
v9.4.0 tracks (Sarcopenia · Nutrition · FOF)
Calf circumference33.5 cm34.0 cm+0.5 cm
SARC-F5/10 ✚3/10 ✗−2
SARC-CalF (auto)15/20 ✚3/20 ✗flipped
MNA-SF11 (risk)12 (normal)+1 over threshold
Short FES-I18 (high)13 (mod)−5

Case 8 — Frau B.S., 72F

Post-pneumonia HAD → Robust
2 sessions · 6 weeks · v9.4.0

Profile: 72-year-old woman, previously independent (regular walks). 12-day hospitalisation for pneumonia → Hospital-Associated Disability with acute sarcopenia. Striking baseline picture (Fried 4/5, SPPB 6/12, HGS 14 kg, Wadenumfang 31 cm, MNA-SF 8/14). Aggressive multimodal rebuild + protein optimisation — this is the textbook remediable Frailty response. Workshop-script vignette Fall 3.

Source: Hilfiker 2026 (BFH workshop script v2026.20, Fall 3); HAD framing Inoue 2024 + Marchiori 2017; remediable Frailty Mallery & Shetty 2026.

TestDay 56-weekChange
HGS14.0 kg18.0 kg+4.0 kg
Gait Speed0.65 m/s0.88 m/s+0.23 (≫MCID)
SPPB6/1210/12+4 (≫substantial)
5× STS16.0 s13.0 s−3.0 s
Fried4/5 frail0/5 robust−4
v9.4.0 tracks (Sarcopenia · Nutrition · FOF)
Calf circumference31.0 cm32.5 cm+1.5 cm (mass back)
SARC-F4/10 ✚1/10 ✗−3
SARC-CalF (auto)14/20 ✚1/20 ✗flipped (CC >33)
MNA-SF8 (risk)12 (normal)+4 (out of risk)
Short FES-I14 (high)9 (mod)−5

ℹ️ Note on the source and status of these demo cases

All eight cases are entirely fictional constructions. The names, dates, patient identifiers, and individual test values shown here have been invented for the sole purpose of demonstrating tool functionality. They do not correspond to any real person, past or present.

Cases 1–5 were constructed from group mean values and effect sizes reported in the peer-reviewed studies cited beneath each card. Cases 6–8 (added v9.4.0) follow the BFH 2026 workshop-script vignettes and are constructed to illustrate the typical clinical patterns named in the script — Powerpenia in pre-frail HFpEF, falls + MCI in advanced frailty, and remediable Frailty after acute hospitalisation.

Values were chosen to be clinically plausible and internally consistent. They illustrate typical trajectories for the described scenarios but cannot be taken as evidence about the effectiveness of any specific intervention and must not be used for clinical decision-making.

The original studies and the workshop script are cited with DOI links. Readers wishing to verify or cite specific findings should consult those primary sources directly.

Standardised Test Protocols & Normative Values

Select a construct below to view the relevant tests and standardised instructions.

🔍
Global Frailty Status
Phenotype classification & clinical judgment scale
Fried PFP CFS
View tests →
🔢
Composite Frailty Indices
Multi-domain aggregate scores with continuous outputs
FTS5 FTS3
View tests →
💪
Muscle Strength
Upper-limb isometric force & sarcopenia screening
HGS KES
View tests →
🚶
Gait Speed & Mobility
Walking capacity, fall risk & dynamic balance
4MGS TUG
View tests →
📊
Physical Performance Battery
Composite lower-extremity function score
SPPB
View test →
⚡
Functional Power & Endurance
Sit-to-stand power, lower-limb strength & endurance
5×STS 30s CST 1min STS
View tests →
⚖
Balance & Stepping
Static balance, fall-risk screening, dynamic stepping & multi-system Mini-BESTest / BBS
OLS-10s FSST DT-TUG Mini-BESTest BBS
View tests →
🏃
Aerobic Endurance
Submaximal exercise capacity & functional walking
6MWT 2-Min Step
View tests →
📋
Sarcopenia Screening
SARC-F rapid case-finding · EWGSOP2 algorithm
SARC-F EWGSOP2
View tests →
🧠
Cognitive Assessment
Mini-Cog · MoCA · Dual-task TUG · cognitive frailty
Mini-Cog MoCA DT-TUG
View tests →
🚨
Fall Risk Assessment
CDC STEADI · WFG 2022 · FES-I · Screen, Assess, Intervene
STEADI WFG 2022 FES-I 4-Stage Balance
View tests →
🔍
Global Frailty Status
Phenotype classification & clinical judgment scale

1. Fried Frailty Phenotype (Physical Frailty Phenotype)

PFP · CHS
▼

Five-criterion phenotype developed from the Cardiovascular Health Study (CHS, n=5,317). Scoring: 0 = Robust, 1–2 = Pre-frail, ≥3 = Frail. Intermediate (pre-frail) status carries a 4.5× odds ratio for developing frailty within 3–4 years.Fried 2001

Equipment Required

  • Calibrated Jamar hydraulic dynamometer
  • Stopwatch; 15-ft (4.57 m) measured course
  • Calibrated scales; stadiometer
  • CES-D / ADS questionnaire (2 exhaustion items)
  • Activity questionnaire (MLTA)

Criterion Thresholds (Original CHS)

  • Weight loss: >4.5 kg unintentional in past year
  • Exhaustion: CES-D ≥3 d/wk ("everything an effort" or "could not get going")
  • Low activity: M <383 kcal/wk; W <270 kcal/wk (MLTA)
  • Slow gait: See table below (sex + height)
  • Weak grip: See table below (sex + BMI)

Gait Speed Cut-offs (Fried 2001 — slowest 20% by sex & height)

SexHeightFrailty threshold (15-ft walk ≥ time)Approx. m/s
Men≤ 173 cm≥ 7 seconds≤ 0.65 m/s
Men> 173 cm≥ 6 seconds≤ 0.76 m/s
Women≤ 159 cm≥ 7 seconds≤ 0.65 m/s
Women> 159 cm≥ 6 seconds≤ 0.76 m/s

Handgrip Strength Cut-offs (Fried 2001 — by sex & BMI)

SexBMIFrailty threshold
Men≤ 24< 29 kg
Men24.1–28< 30 kg
Men> 28< 32 kg
Women≤ 23< 17 kg
Women23.1–26< 17.3 kg
Women26.1–29< 18 kg
Women> 29< 21 kg
Note on the Exhaustion criterion: Fried's exhaustion criterion uses two items from the Center for Epidemiological Studies Depression Scale (CES-D). The validated German CES-D translation is the Allgemeine Depressionsskala (ADS), Hautzinger & Bailer 2012, 2nd edition (Hogrefe Verlag, Göttingen). The verbatim ADS item wording is © Hogrefe Verlag and is therefore not reproduced inside FrailtyTrack; the validated ADS-L manual must be obtained from Hogrefe / Testzentrale for clinical use.

9. Clinical Frailty Scale (CFS)

CFS · Rockwood
▼

Global clinical judgment scale for adults ≥65 years. Not a performance test — clinician-rated based on observation, history, and function. Validated in >400,000 participants.Rockwood 2005 Reflects baseline status, not during acute illness.

ScoreCategoryDescriptionFrailty Status
1Very FitRobust, active, energetic; exercises regularlyRobust
2WellNo active symptoms; exercises occasionallyRobust
3Managing WellMedical problems controlled; not regularly active beyond walkingRobust
4Very Mild FrailtyNot dependent; "slowed up"; tired during dayPre-frail
5Mild FrailtyEvident slowing; needs help with IADLsPre-frail
6Moderate FrailtyNeeds help with outside activities and housework; assistance with bathing/dressingFrail
7Severe FrailtyProgressive dependence in personal ADLsFrail
8Very Severe FrailtyCompletely dependent; approaching end of lifeFrail
9Terminally IllLife expectancy < 6 monthsTerminal
CFS ≥ 5 = typical threshold for comprehensive geriatric assessment and specialist referral. CFS 4–5 broadly maps to Fried pre-frail category.

Swiss validation evidence (added v8.23). The CFS has been independently validated in Swiss emergency-department populations by the Basel group: Kaeppeli et al. 2020 (n=2,393 consecutive ED patients ≥65 y; AUC 0.81 for 30-day mortality, weighted Cohen's κ 0.74 for inter-rater reliability)Kaeppeli 2020 and Rueegg et al. 2022 (n=2,191; AUC 0.767 for 1-year mortality, outperforming the Emergency Severity Index).Rueegg 2022 An official German translation of CFS v2.0 is available via Dalhousie's permission-granted translation set (not independently validated by Dalhousie; validation evidence comes from the Swiss publications above).

German CFS wording in this tool follows the official DGG (Deutsche Gesellschaft für Geriatrie) translation by Singler K., Gosch M., Antwerpen L. (2020), modified after Rockwood et al. CFS v1.2_EN (Geriatric Medicine Research, Dalhousie University). Reproduction permitted for non-profit teaching purposes per DGG poster license.
🔢
Composite Frailty Indices
Multi-domain aggregate scores — continuous outputs with cut-offs

10. Frailty Trait Scale–Short Form 5 (FTS5)

FTS5 · García-García
▼

11. Frailty Trait Scale–Short Form 3 (FTS3)

FTS3 · García-García
▼
💪
Muscle Strength
Upper-limb isometric force — sarcopenia screening

2. Handgrip Strength (HGS)

HGS · Jamar
▼

Standardised Protocol

  • Calibrated Jamar hydraulic dynamometer (or validated equivalent)
  • Seated: elbow at 90°, forearm neutral, shoulder adducted
  • Handle adjusted to 2nd metacarpal position
  • 3 maximal isometric contractions, 30–60 s rest between
  • Best of 3 trials, dominant hand (EWGSOP2 protocol)
  • Verbal encouragement standardised: "Squeeze as hard as you can"

Key Cut-Points

  • EWGSOP2: Men <27 kg; Women <16 kg → low muscle strength (probable sarcopenia)Cruz-Jentoft 2019
  • Fried PFP: Sex + BMI-stratified (see above)
  • MCID: ~5 kg
  • Values represent T-score ≤−2.5 SD from peak in young adults

Normative Values by Age & Sex — Dodds et al. 2014 (n=49,964; Great Britain)DOI:10.1371/journal.pone.0113637

AgeMen Median (50th)Men 5th %ileMen 25th %ileWomen Median (50th)Women 5th %ileWomen 25th %ile
60–6442 kg28 kg35 kg26 kg16 kg21 kg
65–6940 kg26 kg33 kg25 kg15 kg20 kg
70–7438 kg24 kg31 kg23 kg14 kg19 kg
75–7934 kg20 kg27 kg21 kg13 kg17 kg
80–8430 kg17 kg23 kg19 kg12 kg15 kg
85–9025 kg14 kg19 kg17 kg10 kg13 kg

NIH Toolbox Normatives — Bohannon & Wang 2019 (n=1,320; USA community-dwelling)DOI:10.1016/j.apmr.2018.06.031

AgeMen Mean (SD)Women Mean (SD)
60–6444.1 (9.1) kg27.8 (6.2) kg
65–6941.3 (9.0) kg26.4 (6.0) kg
70–7438.4 (8.6) kg24.8 (5.9) kg
75–7935.1 (8.3) kg23.2 (5.5) kg
80–8532.9 (6.0) kg22.1 (4.0) kg

3. Isometric Knee Extension Strength (KES)

KES · HHD Make-Test
▼

Direct lower-limb isometric strength assessment using a hand-held dynamometer. Fills the construct gap between HGS (upper limb, a surrogate) and functional STS tests (confounded by balance and speed). KES declines earlier and more steeply than HGS with ageing, and correlates more strongly with gait speed, STS performance, and physical function. A key recommendation from geriatric assessment research is that handgrip strength cannot be assumed a proxy for overall muscle strength and KES should be included in the comprehensive geriatric assessment.Yeung 2018

Standardised Protocol (Make-Test, Belt-Stabilised)

  • Position: Seated on examination table or firm chair; hip and knee both at 90° flexion; arms crossed over chest
  • HHD pad placement: Anterior tibia, 5 cm proximal to medial malleolus
  • Belt fixation (essential): Inextensible belt looped under table leg and over HHD — this significantly improves validity vs isokinetic gold standard (ICC 0.95–0.98 vs 0.94–0.96 without belt)
  • Make-test: Patient pushes into the stationary HHD as hard as possible for 5 s — do NOT allow the examiner to overcome the force (that is a break-test and has lower reliability)
  • 1 practice trial for familiarisation
  • 3 maximal contractions each leg; 60 s rest between repetitions
  • Record peak force (N) — use the best of 3 trials
  • Measure dominant (preferred) leg first; document side tested
  • Consistent verbal encouragement throughout

Normative Values & Classification

  • Normalise to body weight: KES (%BW) = (Force in N) ÷ (Weight kg × 9.81) × 100
  • Reference: Bohannon RW. 2017 meta-analysis (J Frailty Aging; small samples 3–29/stratum — treat as approximate guidance)
  • Men 60–69: ~50%BW expected | <38%BW = low
  • Men 70–79: ~46%BW expected | <35%BW = low
  • Men 80+: ~40%BW expected (extrapolated)
  • Women 60–69: ~43%BW expected | <32%BW = low
  • Women 70–79: ~38%BW expected | <28%BW = low
  • Women 80+: ~33%BW expected (extrapolated)
  • No consensus cut-offs established (2024) — use as relative comparison to normative rangeZheng 2024
  • KES more strongly associated with SPPB, TUG, STS, gait speed than HGSYeung 2018 CGA

Reference values by age and sex — Bohannon 2017 (J Frailty Aging 2017;6(4):199–201; normalised to % body weight, dominant leg)doi:10.14283/jfa.2017.32

AgeMen expected (%BW)Men low (<)Women expected (%BW)Women low (<)
60–69 y~50%BW38%BW~43%BW32%BW
70–79 y~46%BW35%BW~38%BW28%BW
80+ y~40%BW*30%BW*~33%BW*24%BW*

*80+ values extrapolated — Bohannon 2017 covered ages 60–79 only. No validated consensus cut-off points for sarcopenia screening (Zheng et al. 2024 systematic review). Use as approximate reference until consensus is established. Dominant leg; make-test; belt-stabilised HHD.

Why KES and not just HGS?

FeatureHGS (Jamar)KES (HHD)
Muscle groupForearm/hand flexorsQuadriceps (knee extensors)
Agreement with each otherLow–moderate (ICC 0.37–0.54; Yeung 2018, n=960)
Correlation with STS timeWeakStrong (explains STS performance directly)
Correlation with gait speedModerateStrong
Sarcopenia sensitivityCan miss cases (esp. obesity)Reduces false-negatives
EWGSOP2 rolePrimary screening toolRecommended when HGS impossible; adds value in CGA
Rate of age-related declineSlower, laterFaster, earlier onset
🚶
Gait Speed & Mobility
Walking capacity · fall risk · dynamic balance

3. 4-Metre Gait Speed Test (4MGS)

4MGS · GS · "6th Vital Sign"
▼

Gait speed is widely used as an independent prognostic marker in geriatric populations and as a component of larger frailty/sarcopenia algorithms. Two standard protocol variants are in clinical use; both are presented below for transparency.

Variant A — SPPB-internal (Guralnik 1994)

  • Static standing start; comfortable (usual) pace
  • Walk a single 4-m course; time the full distance
  • Timing: first foot crosses start line → first foot crosses end line
  • 2 trials; use the fastest time
  • Walking aid permitted — document type
  • Used inside SPPB and in EWGSOP2-aligned clinical practiceGuralnik 1994

Variant B — Standalone (Studenski 2011)

  • Walk a longer path (typically 6–8 m) at usual pace
  • Time only the middle 4 m at steady state
  • Acceleration and deceleration phases excluded from timing
  • 2 trials; use the average or the faster trial (document choice)
  • Speed (m/s) = 4 ÷ time (seconds)
  • Used in survival-prediction literature and standalone gait-speed studiesStudenski 2011

Clinical Thresholds

  • ≥ 1.0 m/s — Normal; above-median survival
  • 0.8–0.99 m/s — Pre-frail zone; Fried frailty criterion border
  • 0.6–0.79 m/s — Frailty/disability risk elevated
  • < 0.6 m/s — High likelihood poor health & function
  • EWGSOP2 sarcopenia: < 0.8 m/s confirmatory
  • MCID: 0.10 m/sPerera 2006

Normative Values — Bohannon & Wang 2019 (NIH Toolbox; n=1,320; USA)DOI:10.1016/j.apmr.2018.06.031 | Studenski et al. 2011DOI:10.1001/jama.2010.1923

AgeMen Mean (SD) m/sWomen Mean (SD) m/sClinical interpretation
60–641.34 (0.20)1.24 (0.19)Normal
65–691.28 (0.19)1.19 (0.19)Normal
70–741.20 (0.18)1.12 (0.18)Normal
75–791.10 (0.18)1.03 (0.17)Marginal
80–850.97 (0.18)0.95 (0.16)Pre-frail zone

4. Timed Up and Go Test (TUG)

TUG
▼

The TUG test (Podsiadlo & Richardson 1991) is the most widely used geriatric mobility test in DACH practice and a Stage-2a component of the standard geriatric assessment.Podsiadlo 1991

Standardised Protocol (Podsiadlo & Richardson 1991)

  • Standard chair: seat height ca. 46 cm, with armrests
  • Participant seated, back against the chair back, arms loosely on the armrests
  • Walking aid (e.g. cane) permitted if usually used — document type
  • On verbal cue: rise, walk 3 m at a normal and safe pace to a marked line, turn, return to the chair, sit down
  • Time from cue until the participant is seated again; recorded in seconds (no specific stopwatch required)
  • Practice trial allowed before timing; the examiner may demonstrate the sequence once
  • Observe: postural stability, gait, stride length, sway

Clinical Thresholds

  • < 10 s — Freely mobile; low fall risk
  • 10–12 s — STEADI fall-risk threshold (CDC)
  • ≥ 12 s — Fall risk (Shumway-Cook 2000; STEADI/CDC)
  • ≥ 13.5 s — High fall risk (sensitivity/specificity ~87%)
  • > 20 s — EWGSOP2 sarcopenia confirmatory criterion
  • MCID: 1.4 s | Disability prediction: ≥ 9 sMakizako 2017

Normative Values — Svinøy et al. 2021 (Norwegian Tromsø Study; n=5,400; community-dwelling)DOI:10.2147/CIA.S294512

AgeMen Mean (SD) sMen 90th %ileWomen Mean (SD) sWomen 90th %ile
60–648.9 (1.8)11.39.6 (2.2)12.4
65–699.5 (2.1)12.210.3 (2.6)13.4
70–7410.3 (2.5)13.511.2 (3.0)14.8
75–7911.6 (3.2)15.212.8 (3.8)17.1
80–8413.5 (4.1)18.415.0 (4.9)20.8
📊
Physical Performance Battery
Composite lower-extremity function score (0–12)

5. Short Physical Performance Battery (SPPB)

SPPB
▼

Composite lower-extremity function score (0–12) consisting of three sub-tests: balance, 4-metre gait speed, and 5× chair stand. Lower scores indicate worse lower-extremity function. The KCGeriatrie standard scoring sheet is the de-facto reference in DACH practice (no copyright restriction).Guralnik 1994

Three Subtests (Guralnik 1994)

  • 1. Balance-Test: a) geschlossener Stand, b) Semitandenstand, c) Tandemstand — 10 s each. Balance score 0–4.
  • 2. 4-Meter-Gehtest: Two trials at usual pace; score 0–4 by time quartiles (KCGeriatrie cut-offs <4.82 / 4.82–6.20 / 6.21–8.7 / >8.7 s).
  • 3. Stuhl-Aufsteh-Test: Arms crossed on chest, rise 5 times as fast as possible. Score 0–4 by time (≤11.19 / 11.2–13.69 / 13.70–16.69 / ≥16.7 s).
  • Gesamtpunktzahl SPPB: 0–12 (higher = better function)

Classification & Frailty Cut-Points

  • 10–12 — Robust / Good function
  • 7–9 — Pre-frail / Moderate (RR 1.6 ADL disability)
  • 4–6 — Frail / Poor (RR 4.2 ADL disability)
  • 0–3 — Severe impairment
  • EWGSOP2 sarcopenia: ≤ 8
  • MCID: 1 point | ICC: 0.88–0.92

5× Chair Stand Scoring Thresholds (Guralnik 1994)DOI:10.1093/geronj/49.2.M85

SPPB Score5-Stand TimeApprox. Power (43 cm chair)4m Walk Time (faster trial)Walk Speed
4< 11.2 s> 1.88 W/kg< 4.82 s> 0.83 m/s
311.2–13.6 s1.55–1.88 W/kg4.82–6.20 s0.65–0.83
213.7–16.6 s1.27–1.54 W/kg6.21–8.70 s0.46–0.64
1> 16.7 s< 1.26 W/kg> 8.70 s< 0.46
0Unable—Unable—

5× STS Muscle Power (Alcazar equation)doi:10.1002/jcsm.12737

Power Formula & Cut-offs

  • Formula: Prel = 0.9 × g × (heightm − 2 × chairm) × 5 ÷ times  [W/kg]
  • Standard chair: 43–47 cm — document and keep consistent across sessions
  • Fall-risk threshold: ≥ 12 s (optimal cut-off: sensitivity/specificity for falls)Simpkins & Yang 2022
  • Frailty/ADL risk: < 2.5 W/kg (M), < 1.9 W/kg (F)Baltasar-Fernandez 2021
  • Mobility limitation: < 2.6 W/kg (M), < 2.1 W/kg (F)Alcazar 2021
  • Note: SPPB score 4 (<11.2 s) ≈ 1.88 W/kg — still below most cut-offs; power declines faster than strength with age
AgeMen MedianMen 25th %ileWomen MedianWomen 25th %ile
60–6411101110
65–691110109
70–74109108
75–7910897
80–848686
⚡
Functional Power & Endurance
Sit-to-stand power · lower-limb strength & endurance

6. 30-Second Chair Stand Test (30CST / Senior Fitness Test)

30CST · SFT
▼
Construct Anaerobic strength-endurance — sustained force output over 30 s (glycolytic domain). Overcomes floor effect of 5×STS. Best responsiveness to change after intervention. No significant correlation with aerobic power.

Standardised Protocol (Rikli & Jones 1999)

  • Armless chair, seat height 43.2 cm (17 in), placed against wall
  • Seated middle of chair, back straight, arms crossed over chest
  • Feet flat on floor, shoulder-width, slightly back from knees
  • 1 practice stand to check form
  • "Go" — count full rises in 30 seconds
  • Partial rise at 30 s counts if > halfway up
  • Score = total complete (+ partial) stands

Interpretation

  • Below normal range for age/sex = at risk for falls and disability
  • STEADI fall-screening tool (CDC)
  • 30s CST Power formula: Prel = 0.9 × g × (heightm − 2 × chairm) × reps ÷ 30 [W/kg]
  • Low power cut-off: < 2.53 W/kg (M), < 2.01 W/kg (F)Garcia-Aguirre 2025
  • MCID: 0.42 W/kg (M), 0.33 W/kg (F)Garcia-Aguirre 2025
  • Part of Senior Fitness Test battery (Rikli & Jones 2002)

Normative Values (Normal Range = Mean ± 1 SD) — Rikli & Jones 2002 (n=7,183; USA community-dwelling)No DOI [practitioner magazine]

AgeMen Normal Range (reps)Men MeanWomen Normal Range (reps)Women Mean
60–6414–1916.712–1714.5
65–6912–1815.111–1613.5
70–7412–1714.210–1512.5
75–7911–1713.610–1511.8
80–8410–1512.59–1411.2
85–898–1411.28–1310.5
90–947–129.64–117.7

7. Five Times Sit-to-Stand Test (5×STS)

5×STS · FTSST
▼
Construct Peak neuromuscular power & speed — phosphocreatine domain (~8–16 s). Captures rate of force development, motor coordination, and dynamic balance. Best for fall-risk screening. ~50% of patients flagged differ from 30s CST (BIOFRAIL 2025).

Assesses functional lower-limb strength, power, dynamic balance, and transitional movement speed. Also constitutes component C of the SPPB. Measures the time needed to stand up and sit back down five consecutive times as fast as possible. Correlates strongly with TUG (r=0.918) and gait speed (r=0.943); discriminates fallers from non-fallers.Simpkins 2022

Standardised Protocol

  • Standard chair: seat height 43–46 cm, no arm rests, back against wall
  • Patient seated in middle of chair, back upright, arms crossed on chest
  • Feet flat on floor, hip-width apart, slightly behind knees
  • Instruct: "Stand up fully and sit back down, five times, as fast as you can"
  • Timer starts when patient begins to rise on 1st repetition
  • Timer stops when buttocks touch chair after the 5th stand
  • One practice trial at comfortable pace before timed test
  • Record time to nearest 0.1 s · document chair height

Interpretation & Cut-offs

  • SPPB scoring: ≤11.1 s = 4 pts · 11.2–13.6 s = 3 pts · 13.7–16.6 s = 2 pts · ≥16.7 s = 1 pt · unable = 0Guralnik 1994
  • EWGSOP2 low function: ≥15 sCruz-Jentoft 2019
  • Fall risk threshold: ≥12 sSimpkins 2022
  • Disability prediction: ≥12 s predictive of incident disabilityMakizako 2017
  • STS Muscle Power: Prel = 0.9 × g × (hm − 2 × cm) × 5 ÷ t [W/kg] · frailty cut-off <2.5 W/kg (M), <1.9 W/kg (F)Baltasar-Fernandez 2021
  • Powerpenia framing (v9.4): Freitas et al. (2024) coined «powerpenia» for the loss of muscle power, distinct from sarcopenia (mass) and dynapenia (strength) — arguing it should be measured separately because only 2 of 220 dynapenia studies between 2008 and 2023 directly measured power. Power decline starts earlier and progresses faster than mass or strength loss, making the 5×STS-derived power calculation a sentinel marker for the sarcopenia–dynapenia–powerpenia triad introduced in the workshop script.Freitas 2024  doi ✅
  • Excellent test-retest reliability: ICC 0.988–0.995

Normative Medians — Bohannon 2006 meta-analysis (n≈2,000; community-dwelling, ages 60–89)doi:10.2466/pms.103.1.215-222

Age groupWorse-than-average thresholdComment
60–69 years> 11.4 sMeta-analysis of 13 studies
70–79 years> 12.6 sMeta-analysis of 13 studies
80–89 years> 14.8 sMeta-analysis of 13 studies

European Population Medians — Grgic et al. 2026 (n=45,470; SHARE Wave 5; 14 European countries; ages 50–90+)doi:10.1007/s11357-025-01863-8

AgeMen median (s)Men P25–P75Women median (s)Women P25–P75
50–54108–13108–13
55–5998–12108–13
60–64108–13119–14
65–69119–141210–15
70–741210–151311–17
75–791311–171412–18
80–841512–191512–20
85–891512–201512–21

8. 1-Minute Sit-to-Stand Test (1minSTS)

1minSTS · 1minSTST
▼
Construct Functional exercise capacity — aerobic/anaerobic crossover (≥60 s). Correlates with 6MWT (r ≈ 0.57). Best measurement properties for cross-sectional assessment. MID = 3 reps. Swiss population norms (Strassmann 2013, n = 6,926).

Counts the maximum number of full sit-to-stand cycles completed within 60 seconds. Measures lower-body muscular strength and endurance combined. Requires only a standard chair and a stopwatch. Correlates well with 6-minute walk test and stair-climbing capacity; provides prognostic information in COPD and other chronic diseases. Simple, widely applicable, no special equipment.Strassmann 2013

Standardised Protocol (Strassmann / Puhan 2013)

  • Chair: seat height 46 cm, no arm rests
  • Feet parallel, hip-width apart (SIAS level), slightly in front of chair
  • Arms hanging loose at sides or resting on hips — no arm push-off allowed
  • Full stand = complete knee extension; seated = buttocks touch chair
  • Count only fully completed STS cycles within 60 s
  • Inform patient at 30 s and 15 s remaining
  • Standardised verbal motivation throughout
  • Record reps completed; note if patient stopped early and reason

Interpretation (Swiss population reference)

  • Reference: Strassmann et al. 2013, n=6,926 Swiss adults (community, ages 20–79 y)doi:10.1007/s00038-013-0504-z
  • Men score on average ~3 reps more than women in same age band
  • Decline: approx. 1.84 reps per 5 additional years
  • P25 = below-average · P2.5 = severely impaired
  • COPD patients aged 60–70 y typically score ~17 reps vs. expected ~35 (i.e. ~50% of reference)
  • ≥80 y: >20% unable to complete; use with caution in oldest-old

Swiss Population Reference Values — Strassmann, Steurer-Stey, Dalla Lana, Zoller, Turk, Suter, Puhan 2013 (n=6,926; nationwide campaign Switzerland 2010–2012)doi:10.1007/s00038-013-0504-z

AgeM p2.5M p25M p50M p75M p97.5F p2.5F p25F p50F p75F p97.5
20–2427415057723139475570
25–2929404856743040475468
30–3428404756722737455168
35–3927384758722537425063
40–4425374553692635414865
45–4925354452702535415063
50–5424354253672333394760
55–5922334148632130364361
60–6420313746632028344055
65–6920293544601927334053
70–7419273240591725303651
75–7916253037561322273043

p50 = median (bold); p25 = below average; p2.5 = severely impaired. Values in reps/min. Not recommended for ages ≥80 y (>20% unable to complete).

⚖
Balance & Stepping
Static balance · fall-risk screening · dynamic stepping · Mini-BESTest · Berg Balance Scale

B1. One-Leg Stance — 10-Second Test (OLS-10s)

OLS · Unipedal Stance
▼

Static balance test with strong prognostic validity. Inability to hold 10 seconds is independently associated with all-cause mortality (HR 1.84, 95% CI 1.23–2.78) beyond age, sex, BMI, and comorbidities in a 7-year follow-up study (n=1,702). Failure rates roughly double at each 5-year age band after 51 years. The test integrates muscular, vascular, and neural systems simultaneously.Araujo 2022

Standardised Protocol (Araujo et al. 2022)

  • Patient stands barefoot or in flat-soled shoes, no assistive device
  • Place front of free foot against back of opposite lower leg
  • Arms hanging at sides; gaze fixed straight ahead at a fixed point
  • Test both legs; up to 3 attempts per leg permitted
  • Timer starts when foot leaves the floor; stops when foot touches down, arms move, or supporting leg moves
  • Result: PASS (holds 10 s on either foot) / FAIL
  • Stand close as spotter — do not touch the patient

Interpretation & Clinical Thresholds

  • PASS (≥10 s) — normal static balance for age; lower mortality risk
  • FAIL (<10 s) — HR 1.84 for all-cause mortality (adj.); refer for balance programme
  • Failure rate: ~5% at age 51–55; ~37% at 66–70; ~54% at 71–75
  • Embedded as SPPB single-leg item, but standalone 10s OLS adds independent prognostic value
  • Extended version: For pre-frail/robust patients, set time limit ≥23 s to detect subtle deficits (de Abreu 2024)
  • MCID / MDC: Pass/fail binary; no continuous MCID published

Failure rates by age (Araujo et al. 2022; n=1,702; CLINIMEX cohort; ages 51–75)doi:10.1136/bjsports-2021-105360

Age groupFailure rateMortality risk if fail
51–55 y~5%HR 1.84 all-cause mortality
over 7-year follow-up
(adj. for age, sex, BMI,
comorbidities)
56–60 y~8%
61–65 y~18%
66–70 y~37%
71–75 y~54%

B2. Four Square Step Test (FSST)

FSST · Dynamic Stepping
▼

Dynamic balance and multi-directional stepping test. Requires stepping over canes arranged in a cross pattern in all four quadrants (forward, sideways, backward). Captures stepping strategy, spatial orientation, and reactive balance — dimensions not covered by TUG or SPPB. Discriminates frailty syndrome in older adults (de Aquino et al. 2022). Normative cut-off: ≥15 s indicates fall risk.Dite 2002

Standardised Protocol (Dite & Temple 2002)

  • 4 canes/sticks placed on floor in a cross pattern (arms ~1 m long)
  • Patient starts in square 1 (front-left), facing square 2
  • Step sequence: 2 (forward) → 3 (right) → 4 (backward) → 1 (backward) → 4 → 3 → 2 → 1
  • Must step over each cane; both feet must land in each square
  • Performed as fast as possible; timer starts on first step
  • 1 practice trial (not timed), then 2 timed trials
  • Use faster of the 2 timed trials; walking aid permitted — document
  • Restart if cane is kicked or wrong square entered

Clinical Thresholds

  • < 10 s — community ambulators, low fall risk
  • 10–15 s — elevated fall risk; consider balance training
  • ≥ 15 s — high fall risk; sensitivity/specificity for multiple falls: ~85%
  • Frailty discriminator: ≥15 s associated with frailty syndrome (de Aquino 2022)
  • MCID: ~2 s in community-dwelling older adults
  • ICC: 0.98–0.99 (excellent reliability)

B3. Dual-Task TUG (DT-TUG)

DT-TUG · Cognitive-Motor
▼

Standard TUG performed simultaneously with a cognitive task. The dual-task cost (DTC) reflects the degree to which cognitive demands degrade motor performance — a marker of cognitive-motor integration. Independent predictor of falls and cognitive frailty beyond single-task TUG alone. Requires no additional equipment beyond a chair and stopwatch.Montero-Odasso 2012

Protocol

  • First perform standard TUG (record time)
  • Rest 2–3 minutes
  • Repeat TUG while simultaneously performing cognitive task:
  •   Serial subtraction: count backwards from 100 by 3s (most validated)
  •   Naming: name animals, colours, or months in reverse
  • Record DT-TUG time; note errors on cognitive task
  • Verbal encouragement to prioritise both tasks equally
  • Do NOT instruct patient to prioritise walking over thinking

Dual-Task Cost (DTC) Calculation & Interpretation

  • DTC (%) = (DT-TUG − TUG) ÷ TUG × 100
  • DTC <10% — minimal cognitive-motor interference
  • DTC 10–20% — moderate; borderline cognitive frailty risk
  • DTC >20% — high; strongly associated with falls and MCI
  • DT-TUG >13.5 s = high fall risk (regardless of single-task TUG)
  • Cognitive task errors during walking = additional flag for MCI
  • Prioritisation strategy (stops walking to think = “posture first”) predicts falls

Interpreting DTC in clinical practice

DTC %DT-TUG time (absolute)Clinical interpretationAction
<10%<12 sGood cognitive-motor integrationRoutine monitoring
10–20%12–15 sBorderline; monitor closelyDual-task training; MoCA if not done
>20%>15 sHigh fall risk + possible MCICognitive frailty screen; balance programme; physician referral

B4. Mini-BESTest — Mini-Balance Evaluation Systems Test

Mini-BESTest · Franchignoni 2010 · Cramer 2020 (DACH)
▼

14-Item-, 28-Punkte-Multisystem-Balance-Assessment, durch Rasch- und Faktoranalyse aus dem 36-Item-BESTest (Horak 2009) abgeleitet. Erfasst vier verschiedene posturale Kontroll-Systeme, die Single-Task-Tests wie Berg, OLS oder TUG nicht differenzieren: antizipativ, reaktive posturale Kontrolle, sensorische Orientierung, dynamischer Gang. Hohe interne Konsistenz (Cronbach's α 0.89–0.96 über mehrere Populationen, Übersicht Di Carlo 2016) und keine berichteten Ceiling-Effekte. Original-Administrationsdauer 15 min (Franchignoni 2010), GVMBT-Validierungsstudie 16 min (Cramer 2020). Empfohlen im Schweizer StoppSturz-Vorgehen Physiotherapie als primäres Balance-Assessment bei moderatem oder hohem Sturzrisiko (siehe Karte S2 im Sturzrisiko-Konstrukt). Validierte deutsche Fassung (GVMBT) seit 2020 verfügbar.Franchignoni 2010Cramer 2020  doi ✅

Hinweis Copyright: Mini-BESTest ist © 2005–2013 Oregon Health & Science University (OHSU; Fay Horak, PhD) — "All rights reserved". Die wortgetreuen Patienten-Anweisungen, Bewertungs-Beschreibungen (0/1/2 mit zugehörigen Kriterien) und Material-Spezifikationen werden in FrailtyTrack nicht reproduziert. Die offizielle validierte deutsche Version (GVMBT; Cramer/Weber/Faro/Klein/Willeke/Hering/Zietz 2020) ist als 7-seitiges PDF frei downloadbar: BFU-Site (bfu.ch/media/pcqno5pu/minibestest_de.pdf) oder bestest.us. Klinische und Lehre-Anwendung mit Quellenangabe erlaubt; kommerzielle Nutzung erfordert OHSU-Genehmigung. Diese Karte gibt strukturelle, zitierbare Fakten wieder (Subskalen, Item-Titel, Punktwerte, Cut-offs aus peer-reviewed-Studien).

Struktur & Subskalen

  • 14 Items in 4 Subskalen, jeweils 0–2 Punkte (0 = schwer, 1 = moderat, 2 = normal). Maximum: 28/28.
  • Subskala 1 — Antizipativ (3 Items, max 6): Vom Sitzen zum Stehen · Auf die Zehenspitzen stellen · Auf einem Bein stehen.
  • Subskala 2 — Reaktive posturale Kontrolle (3 Items, max 6): Kompensatorische Schutzschritte vorwärts · rückwärts · seitwärts.
  • Subskala 3 — Sensorische Orientierung (3 Items, max 6): Stand fester Untergrund (Augen offen) · Stand Schaumstoff (Augen geschlossen) · Steigung (Augen geschlossen).
  • Subskala 4 — Dynamischer Gang (5 Items, max 10): Gehgeschwindigkeit ändern · Gehen mit Kopfdrehungen · Gehen mit Körperdrehung 180° · Gehen über Hindernis · TUG mit Dual-Task.
  • Unilaterale Items 3 (Einbeinstand) und 6 (Schutzschritte seitwärts): die niedrigere der beiden Seiten zählt für die Subskala. Bei Item 3: bessere der zwei Versuche pro Seite.
  • Item 14 (TUG-DT): Bei Verlangsamung >10% gegenüber Single-Task-TUG wird die Punktzahl um 1 reduziert.
  • Hilfsmittel: Wenn ein Hilfsmittel benötigt wird, wird die Punktzahl für das jeweilige Item um eine Kategorie reduziert. Bei körperlicher Hilfe: 0 Punkte.

Material & Setting

  • Schaumstoff: Tempur-Schaum (T-foam, mittlere Festigkeit T41), ca. 10 cm dick. Alternative: AIREX-Kissen.
  • Schräge Ebene (Rampe): ca. 60×60 cm, 10° Neigung.
  • Stuhl: ohne Armlehnen, ohne Rollen, mit Rückenlehne (für TUG-DT).
  • Hindernis: Kiste oder zusammengeklebte Schuhkartons, ca. 23 cm hoch.
  • Strecke: 3 Meter, mit Klebeband markiert.
  • Stoppuhr · Schuhwerk: flache Schuhe ODER barfuss/Socken.
  • Dauer: ~15 min (Franchignoni 2010 Original) bzw. ~16 min in der DACH-Validierungsstudie (Cramer 2020, n=50 sub-akut/chronischer Schlaganfall).
  • Bezugsquelle: Verbatim-Anweisungen und Auswertungsformular auf bfu.ch/media/pcqno5pu/minibestest_de.pdf oder bestest.us.

Population-spezifische Cut-offs (peer-reviewed)

PopulationnCut-offTest-EigenschaftenQuelle
Zu Hause lebende Ältere (Sturzanamnese, Thailand)200≤ 16/28AUC 0.84 · Sens 85% · Spez 75% · Genauigkeit 85%Yingyongyudha 2016
Chronischer Schlaganfall (Hong Kong)106≤ 17.5/28AUC 0.64 · Sens 64% · Spez 64%Tsang 2013
Parkinson-Syndrom (Hong Kong)110≤ 19/28Sens 79% · Spez 67% (6-Monats-Sturzprädiktion)Mak 2013
DACH-Validierung sub-akuter/chronischer Schlaganfall (D)50—Mittelwert 17.24 ± 6.71 · ρ mit BBS = 0.93 · ρ mit TUG = −0.85 · Cronbach's α = 0.90 (95% CI 0.87–0.94)Cramer 2020

Hinweis: (1) Cut-offs sind populations-spezifisch und nicht ineinander übertragbar. Der StoppSturz-Algorithmus (Karte S2 im Sturzrisiko-Konstrukt) verwendet alle drei Cut-offs differenzialdiagnostisch je nach Patient/-innen-Profil. Für die normale physiotherapeutische Praxis bei zu Hause lebenden Älteren gilt der Yingyongyudha-Cut-off ≤16/28 als primärer Schwellenwert. (2) Die DACH-Validierungsstudie (Cramer 2020) berichtet keine eigenen Cut-offs — sie etablierte die deutsche Übersetzung (GVMBT), Verständlichkeit, Konvergenzvalidität und interne Konsistenz für die Population sub-akuter/chronischer Schlaganfall (NIHSS 0–7).

Psychometrische Eigenschaften

  • Interne Konsistenz: Cronbach's α 0.89–0.96 über mehrere Populationen (Übersichtsarbeit Di Carlo 2016); GVMBT α = 0.90 (95% CI 0.87–0.94, Cramer 2020).
  • Inter-Rater-Reliabilität: ICC = 0.91 für Mini-BESTest gesamt (Godi 2013, italienische Validierung).
  • Konvergenzvalidität DACH: ρBBS = 0.93, ρTUG = −0.85 (Cramer 2020); konsistent mit internationalen Studien (Pearson r 0.79–0.94, Spearman ρ 0.83–0.85; Di Carlo 2016).
  • Floor-/Ceiling-Effekte: Mini-BESTest Ceiling 0.9–4.3% über Populationen (Di Carlo 2016); GVMBT Ceiling 2% (Cramer 2020). Im Vergleich BBS-Ceiling 14% in der gleichen DACH-Stichprobe (nahe der 15%-Schwelle).
  • Vorteil gegenüber BBS: deckt antizipatorische, reaktive posturale Kontrolle und sensorische Orientierung mit ab — BBS prüft hauptsächlich statisches Gleichgewicht und einfache Transfers.
  • Vorteil gegenüber TUG: systematische Mehrdimensionalität; differenzielle Identifikation von Subsystem-Defiziten für gezieltes Training.

Klinische Anwendung & Therapieableitung

  • Indikation StoppSturz: primäres Balance-Assessment bei moderatem oder hohem Sturzrisiko (Karte S2 im Sturzrisiko-Konstrukt).
  • Subskalen-Profil informiert das Training: niedrige Punktzahl in Antizipativ → Aufstehen, Zehenspitzen-/Einbeinstand-Training; in Reaktiv → Schutzschritt-Training (Lehnen-und-Loslassen); in Sensorisch → vestibulär/propriozeptiv (Schaumstoff, Augen geschlossen); in Dynamisch → Gangvariation, Dual-Task, Hindernisse.
  • Re-Assessment: nach max. 2 Therapieserien (StoppSturz-Empfehlung) oder ~6 Wochen, je nach Setting.
  • MCID/MDC95: populations-abhängig; in der Cramer 2020 DACH-Stichprobe nicht berichtet. In der internationalen Literatur diskutierte Werte ~3–4 Punkte (variiert nach Studie und Population) — klinische Interpretation mit Vorsicht.
  • Sicherheit: Items 4, 5, 6 (Schutzschritte) erfordern Spotter-Position des Therapeuten/der Therapeutin; Item 9 (Steigung mit Augen geschlossen) ebenfalls Sicherung erforderlich.
  • Kontraindikationen (gemäss Cramer 2020): akute Schmerzen, Schwindelsymptomatik, Polyneuropathie mit Gleichgewichtsbeeinträchtigung, ausgeprägte Ataxie, Klinische Isolation, Mobilisations-Kontraindikationen, Gehörlosigkeit/Blindheit, Schwangerschaft.
Original-Validierung: Franchignoni F, Horak F, Godi M, Nardone A, Giordano A. Using psychometric techniques to improve the Balance Evaluation Systems Test: the mini-BESTest. J Rehabil Med 2010;42(4):323–331. doi:10.2340/16501977-0537. Validierte deutsche Version (GVMBT): Cramer E, Weber F, Faro G, Klein M, Willeke D, Hering T, Zietz D. Cross-cultural adaption and validation of the German version of the Mini-BESTest in individuals after stroke: an observational study. Neurol Res Pract 2020;2:27. doi:10.1186/s42466-020-00078-w. Open Access (CC BY 4.0). Übersicht der Test-Eigenschaften: Di Carlo S et al. The mini-BESTest: a review of psychometric properties. Int J Rehabil Res 2016;39(2):97–105. Population-Cut-offs aus den jeweils zitierten peer-reviewed-Quellen (Yingyongyudha 2016, Tsang 2013, Mak 2013). Mini-BESTest © 2005–2013 OHSU.

B5. Berg Balance Scale (BBS) — Berg-Balance-Skala

BBS · Berg 1989 · Scherfer 2006 (DACH, autorisiert)
▼

14-Item-, 56-Punkte-Beobachtungs-Assessment für statisches und dynamisches Gleichgewicht im Alltag, ursprünglich für ältere Personen entwickelt (Berg et al. 1989). Aufgaben mit zunehmender Schwierigkeit und schrittweiser Reduktion der Unterstützungsbasis: Positionshalten, posturale Anpassung bei Willkürbewegung, Reaktionen auf externe Anforderungen. Jedes Item wird auf einer 5-stufigen Ordinalskala 0–4 bewertet. International das am häufigsten verwendete klinische Balance-Assessment; aufgenommen in zahlreiche internationale und nationale Outcome-Measure-Datenbanken (Canadian Physiotherapy Association, Chartered Society of Physiotherapy CSP, IGPTR Schweiz). Im Schweizer StoppSturz-Vorgehen Physiotherapie als Gleichgewicht-spezifischer Fokustest in Tabelle 1 gelistet (siehe Karte S2 im Sturzrisiko-Konstrukt). Durchführungszeit ca. 15 min. Autorisierte deutsche Version durch Scherfer et al. 2006, in direkter Korrespondenz mit Originalautorin Katherine Berg.Berg 1989Scherfer 2006  doi ✅

Hinweis Copyright/Lizenz: Die deutsche Version der Berg-Balance-Scale (Scherfer et al. 2006) wurde in physioscience (Thieme Verlag) «der Fachöffentlichkeit zur kostenfreien Nutzung, verbunden mit der Bitte um Nennung der Original- sowie dieser Veröffentlichung» zur Verfügung gestellt. Der methodische Übersetzungsprozess folgte den Beaton-Empfehlungen (cross-cultural adaptation gold standard) mit Autorisierung durch Originalautorin Katherine Berg. Die Test-Items sowie das Auswertungsformular dürfen mit ordnungsgemässer Quellenangabe (Berg 1989 + Scherfer 2006) verwendet werden. Diese Karte gibt die Item-Titel und Anweisungen wortgetreu wieder. Validität und Reliabilität der deutschen Version selbst — im Unterschied zur etablierten internationalen Evidenz für das englische Original — werden im Scherfer-2006-Paper als «stehen noch aus» deklariert. Für klinische Interpretation gelten daher die international etablierten Cut-offs.

Struktur & Bewertung

  • 14 Items, jeweils 0–4 Punkte (0 = niedrigstes Funktionsniveau, 4 = höchstes Funktionsniveau). Maximum: 56/56.
  • Bewertungsregel: niedrigste zutreffende Kategorie eines Items vergeben, die der Patient sicher schafft. Punktabzug bei Nicht-Einhalten zeitlicher/räumlicher Anforderungen, bei Bedarf von Supervision oder externer Unterstützung.
  • Material: Stoppuhr oder Uhr mit Sekundenzeiger · Lineal mit Markierungen 5/12.5/25 cm · Stuhl mit angemessener Sitzhöhe · zweiter Stuhl mit Armlehnen (für Item 5 Transfer) · Stufe (durchschnittliche Höhe) ODER Fussbank (für Item 12).
  • «Supervision» bedeutet bei der BBS eine zur Sicherheit begleitende, kontrollierende, aber nicht eingreifende «Stand-by»-Hilfe (nicht aktive Unterstützung).
  • «Hilfe» bedeutet z.B. Festhalten an einer Person, Geländer, Stuhllehne, Rollator (aktive externe Unterstützung).
  • Demonstration: Therapeut/-in soll jede Aufgabe demonstrieren UND/ODER die schriftliche Instruktion vorlesen. Bei ungewöhnlichen Aufgaben (z.B. Item 13 Tandemstand) ist die Demonstration explizit vorgesehen.
  • Dauer: ~15 Minuten einschliesslich Dokumentation (Scherfer 2006).

Die 14 Items (Scherfer 2006 deutsche Version)

  1. Vom Sitzen zum Stehen
  2. Stehen ohne Unterstützung
  3. Sitzen ohne Rückenlehne, aber mit beiden Füssen auf dem Boden oder einer Fussbank
  4. Vom Stehen zum Sitzen
  5. Transfer (zwischen zwei Stühlen, einer mit Armlehnen, einer ohne)
  6. Stehen mit geschlossenen Augen (10 Sekunden)
  7. Stehen mit Füssen dicht nebeneinander (enger Fussstand)
  8. Im Stehen mit ausgestrecktem Arm nach vorne reichen/langen (Functional Reach: 5 / 12.5 / 25 cm)
  9. Aus dem Stand Gegenstand vom Boden aufheben (Schuh)
  10. Sich im Stehen umdrehen, um nach hinten über die rechte und linke Schulter zu schauen
  11. Sich um 360° drehen (in beide Richtungen)
  12. Ohne Unterstützung abwechselnd die Füsse auf eine Stufe oder Fussbank stellen (8 Schritte/Stufen)
  13. Stehen ohne Unterstützung mit einem Fuss vor dem anderen (Tandemstand)
  14. Auf einem Bein stehen (Einbeinstand)

Vollständiges Auswertungsformular mit den 0–4 Bewertungs-Kategorien aller 14 Items: Scherfer et al. 2006 (Open Access auf thieme-connect.de) · oder über IGPTR Schweiz www.igptr.ch bzw. Physio-Akademie ZVK.

Population-spezifische Cut-offs & Funktionsstufen (peer-reviewed)

Population / AnwendungCut-offBedeutungQuelle
Zu Hause lebende Ältere (Sturzrisiko-Screening)< 36/56Nahezu 100% Sturzrisiko (nicht-lineares Verhältnis Score ↔ Sturzwahrscheinlichkeit)Shumway-Cook 1997
Zu Hause lebende Ältere (multiple Stürze prospektiv 12 Mt.)kein einzelner Cut-offMuir empfiehlt explizit gegen dichotome Cut-offs (BBS verfehlt die Mehrheit der Sturzgefährdeten als binärer Filter); stattdessen Likelihood-Ratios über das Score-Spektrum als Risiko-Gradient. Niedrigere Scores (insbesondere <40) = deutlich erhöhtes multiples Sturzrisiko. n=210 community-dwelling, prospektive Kohorte 12 Mt.Muir 2008
Funktionsstufen (allgemein)—0–20: rollstuhlpflichtig · 21–40: Gehen mit Hilfe · 41–56: unabhängiges Gehenverschiedene Reviews
MCID/MDC (zu Hause lebende Ältere)MDC95 4–7 Pkt.Score-abhängige Veränderungs-Schwellen (MDC höher bei niedrigeren Ausgangswerten); MCID ~3 Pkt. häufig zitiertDonoghue 2009

Hinweis: Wie bei den meisten klinischen Balance-Assessments sind Cut-offs population- und kontextspezifisch. Für die ambulante Physiotherapie bei zu Hause lebenden Älteren gilt der Shumway-Cook-Schwellenwert <36/56 als hohes Sturzrisiko-Flag. Muir 2008 hat dagegen explizit gezeigt, dass dichotome Cut-offs an der BBS unzuverlässig sind — sinnvoller ist die Interpretation als Risikogradient über das gesamte Score-Spektrum (niedrigere Scores = höheres multiples Sturzrisiko). Ceiling-Effekt: BBS zeigt bei höher-funktionellen Älteren einen ausgeprägten Ceiling-Effekt (~14% in der Cramer-2020 DACH-Schlaganfall-Stichprobe nahe der 15%-Schwelle, vgl. Mini-BESTest Karte B4) — bei robusten oder pre-frail Patient/-innen alternativ Mini-BESTest erwägen.

Psychometrische Eigenschaften

  • Interne Konsistenz: Cronbach's α = 0.83 (gemischte ältere Population), 0.97 (Schlaganfall-Population) (Berg 1989/1992).
  • Inter-Rater-Reliabilität: ICC = 0.98 (Berg 1995); Test-Retest-Reliabilität ICC ≥ 0.91.
  • Konvergenzvalidität: mit Mini-BESTest Spearman ρ 0.83–0.85 (Übersicht Di Carlo 2016); mit Mini-BESTest in DACH-Schlaganfall-Stichprobe ρ = 0.93 (Cramer 2020).
  • Floor-Effekt: Bei stark beeinträchtigten Patient/-innen (z.B. AIS-A/B Querschnitt: Mean ~3–4 Punkte) — Item-Selektion erforderlich.
  • Ceiling-Effekt: Substanziell bei höher-funktionellen Älteren und chronischem Schlaganfall mit guter Erholung — Mini-BESTest hat hier deutliche Vorteile.
  • Validierung der deutschen Fassung: formale psychometrische Studien zur Scherfer-2006-Version selbst stehen weiterhin aus — Validität und Reliabilität werden vom englischen Original abgeleitet.

Klinische Anwendung & Therapieableitung

  • Indikation StoppSturz: Gleichgewicht-spezifischer Fokustest in der Schweizer Sturzpräventions-Tabelle 1 (Karte S2 im Sturzrisiko-Konstrukt).
  • Vorteile gegenüber Mini-BESTest: kürzere Trainingszeit für Anwender/-innen, einfacheres Material, etablierte Cut-offs für mehrere Populationen (insbesondere Schlaganfall, Parkinson, MS), starke internationale Vergleichsbasis.
  • Nachteile gegenüber Mini-BESTest: kein systematisches Erfassen reaktiver posturaler Kontrolle und sensorischer Orientierung; Ceiling-Effekt bei höher-funktionellen Patient/-innen; Sensitivität für subtile Defizite geringer.
  • Therapieableitung: Item-spezifische Defizit-Profile orientieren das Training (z.B. niedriger Score in Item 13 Tandemstand → Tandemstand-Training; Item 14 Einbeinstand → OLS-Training; Item 11 360°-Drehung → Drehbewegungs-Training).
  • Re-Assessment: nach 4–6 Wochen oder gemäss StoppSturz-Empfehlung max. 2 Therapieserien. Verbesserung jenseits MDC95 als Hinweis auf reale Veränderung interpretieren.
  • Sicherheit: Item 6 (Augen geschlossen), Item 13 (Tandemstand), Item 14 (Einbeinstand) erfordern Spotter-Position des/der Therapeut/-in. Bei Item 12 (Stufe) auf Sturzgefahr beim Übersteigen achten.
Original: Berg KO, Wood-Dauphinee SL, Williams JI, Gayton D. Measuring balance in the elderly: preliminary development of an instrument. Physiother Can 1989;41(6):304–311. Autorisierte deutsche Version: Scherfer E, Bohls C, Freiberger E, Heise K-F, Hogan D. Berg-Balance-Scale — deutsche Version. Übersetzung eines Instruments zur Beurteilung von Gleichgewicht und Sturzgefährdung. physioscience 2006;2:59–66. doi:10.1055/s-2006-926833. Lizenz: kostenfrei verfügbar mit Quellenangabe der Original- und deutschen Veröffentlichung. Cut-offs aus den jeweils zitierten peer-reviewed-Quellen: Shumway-Cook 1997 (community-dwelling Sturzprädiktion), Muir 2008 (multiple Stürze prospektiv community-dwelling), Donoghue 2009 (MCID/MDC).
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Aerobic Endurance
Submaximal exercise capacity · functional walking

A1. Six-Minute Walk Test (6MWT)

6MWT · Submaximal Aerobic Capacity
▼

Gold-standard submaximal functional endurance test. Measures the maximum distance walked in 6 minutes on a flat surface. Requires a 30 m corridor. Provides information on functional capacity, response to therapy, and prognosis across cardiac, pulmonary, frailty, and musculoskeletal conditions. In heart failure, <300 m is associated with frailty. Correlates with 1-min STS (r=0.574) and is used as the criterion standard for that test.ATS 2002

Standardised Protocol (ATS 2002 / DZHK-SOP-K-04)

  • Flat, 30 m course with turnaround cones; markings every 3 m; turnaround point clearly visible
  • Comfortable clothing and footwear; usual walking aids permitted (document)
  • Seated rest ≥5 minutes before test; BP and HR measured after rest
  • DZHK verbatim instruction: "Sie sollen bei diesem Test innerhalb von sechs Minuten so weit wie möglich gehen. Dazu gehen Sie auf diesem Gang vor und zurück. Sechs Minuten sind eine lange Zeit, Sie können aber Ihre Gehgeschwindigkeit selbst bestimmen."
  • Standardised encouragement every minute (DZHK): "Sehr gut, Sie haben noch ... Minuten" alternating with "Weiter so, Sie haben noch ... Minuten"
  • No conversation beyond protocol phrases during test
  • 15 s before end: "In Kürze werde ich Sie auffordern stehen zu bleiben. Ich komme dann zu Ihnen."
  • End of test: say "Stopp" loudly; do not have patient walk to investigator
  • Record distance in metres to nearest metre; record SpO2, HR, Borg dyspnoea before & after
  • Stop if: chest pain, intolerable dyspnoea, leg cramps, pallor, diaphoresis, ataxia, SpO2 <85% (definitive abort), <90% (rest then resume on O2)

Clinical Thresholds & Interpretation

  • ≥400 m — reasonable functional capacity; community ambulatory
  • 300–399 m — reduced capacity; pre-frail zone
  • <300 m — associated with frailty in cardiac/pulmonary populations
  • MCID: 25–30 m (general older adults); 54 m (COPD)
  • Sarcopenia (EWGSOP2): combined with low gait speed <0.8 m/s
  • Heart failure: <300 m = frailty threshold (multiple studies)
  • Two tests on same day: use second (familiarisation effect ~6%)

Reference values for community-dwelling older adults — Enright & Sherrill 1998doi:10.1164/ajrccm.158.5.9710086

AgeMen predicted (m)Men lower limit normalWomen predicted (m)Women lower limit normal
60–69 y572447538413
70–79 y527400471344
80–89 y417290392265

Predicted values from reference equations (Enright & Sherrill 1998). Lower limit normal = 5th percentile. Values for corridor walking at self-selected maximal pace, 30 m course.

German-population reference values (added v8.23). Morbach et al. 2024 (STAAB cohort study, Würzburg) provides the first German-population age- and height-specific reference percentiles for 6MWD, derived from a representative sample of n=2,762 community-dwelling adults aged 30–79 y free from heart failure (subgroup n=681 without any cardiovascular risk factors used for the percentile reference).Morbach 2024 A protocol variant: STAAB used a 15-m hallway (vs. the 30-m ATS standard), allowing the test to be performed in smaller clinical spaces. For German-speaking practice, the DZHK-SOP-K-04 (Deutsches Zentrum für Herz-Kreislauf-Forschung, v1.4, 2014) provides the standardised German clinical SOP for 6MWT administration.

German 6MWT instruction wording in this tool follows DZHK-SOP-K-04 v1.4 (Deutsches Zentrum für Herz-Kreislauf-Forschung) by Marcus Dörr, Kristin Lehnert (Greifswald), reviewed by Rolf Wachter (Göttingen), publicly available DZHK research SOP based on ATS 2002 guidelines and the Kompetenznetz Asthma und COPD SOP. Reproduced unmodified for educational purposes.

A2. 2-Minute Step Test (2MST)

2MST · Senior Fitness Test
▼

Counts the number of times the right knee reaches mid-thigh height in 2 minutes. A space-efficient alternative to the 6MWT when a 30 m corridor is unavailable. Part of the Rikli & Jones Senior Fitness Test battery. Correlates well with the 6MWT in older adults and chronic disease populations. Measures aerobic endurance and hip-flexor strength simultaneously.Rikli 1999

Standardised Protocol (Rikli & Jones 1999)

  • Mark the correct knee height: midpoint between patella and iliac crest
  • Fix a piece of tape or string on wall at that height as a visual target
  • Patient stands beside wall for support if needed
  • March in place; right knee must reach the tape on each step
  • Count only steps where right knee reaches the correct height
  • Comfortable pace permitted; may slow down or pause if needed
  • Score = number of correct right-knee raises in 120 s
  • Monitor for light-headedness, chest pain — stop immediately if symptomatic

Normative Values (Rikli & Jones 2002; n=7,183)

  • 60–64: M 87–115 steps (mean 101) · F 75–107 (mean 91)
  • 65–69: M 86–116 · F 73–107
  • 70–74: M 80–110 · F 68–100
  • 75–79: M 73–109 · F 68–100
  • 80–84: M 71–103 · F 60–90
  • 85–89: M 59–91 · F 55–85
  • Below lower limit of normal range = at risk for falls and disability
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Sarcopenia Screening
SARC-F rapid case-finding · EWGSOP2 diagnostic algorithm

S0. EWGSOP2 Operational Framework — definition, F-A-C-S algorithm, cut-offs & sub-types

EWGSOP2 · Cruz-Jentoft 2019 · Age Ageing
▼

The European Working Group on Sarcopenia in Older People 2 (EWGSOP2) revised the 2010 consensus to position sarcopenia as a muscle disease (muscle failure) with low muscle strength as the principal determinant — replacing low muscle mass as the dominant criterion. This single shift simplifies clinical case-finding, because grip strength and chair-stand are universally available, while muscle-mass quantification (DXA, BIA, MRI, CT) is logistically and financially restrictive in most outpatient settings.Cruz-Jentoft 2019

Operational definition (Table 1)

  • Probable sarcopenia: Criterion 1 alone — low muscle strength
  • Confirmed sarcopenia: Criteria 1 + 2 — low strength plus low muscle quantity or quality
  • Severe sarcopenia: Criteria 1 + 2 + 3 — low strength, low quantity/quality, and low physical performance

In primary-care settings, "probable sarcopenia" alone is sufficient to trigger assessment of underlying causes and initiate intervention — without waiting for confirmatory imaging.

Why strength-first?

  • Strength predicts adverse outcomes (mortality, falls, hospitalisation, disability) better than muscle mass
  • Grip strength & 5×STS are inexpensive, portable, repeatable
  • DXA/BIA cut-offs vary by device and reference population — less standardised than strength
  • Strength testing is feasible in community, hospital, and rehabilitation settings without specialist equipment

F-A-C-S clinical algorithm (Figure 1) — Find · Assess · Confirm · Severity

StepActionRecommended tool(s)Outcome / next step
F — Find Identify patients with sarcopenia-associated symptoms or risk SARC-F questionnaire (≥4/10) or Ishii screening test (age + grip + calf circumference) or clinical suspicion (falls, weakness, weight loss, slow gait, difficulty rising) Positive → proceed to Assess. Negative → rescreen later.
A — Assess Measure muscle strength Grip strength (Jamar dynamometer) or Chair-stand test (5×STS — time to rise 5 times) Low strength → probable sarcopenia; in primary care this is sufficient to start intervention. Proceed to Confirm when feasible.
C — Confirm Confirm low muscle quantity or quality DXA or BIA (clinical practice) · MRI, CT, or D3-creatine dilution (research) Low muscle quantity/quality → confirmed sarcopenia. Proceed to Severity.
S — Severity Determine severity by physical performance Gait speed (4 m), SPPB, TUG, or 400 m walk Low performance → severe sarcopenia.

EWGSOP2 explicitly notes (footnote, Figure 1): when low strength is detected, also consider depression, stroke, balance disorders, and peripheral vascular disease as differential or contributing causes.

EWGSOP2 cut-off points (Table 3) — consolidated reference

DomainTestMenWomenSource cited by EWGSOP2
StrengthGrip strength< 27 kg< 16 kgDodds 2014
Chair stand (5 rises)> 15 sCesari 2009
QuantityASM (absolute)< 20 kg< 15 kgStudenski 2014 (FNIH)
ASM / height²< 7.0 kg/m²< 5.5 kg/m²Gould 2014 (Geelong)
PerformanceGait speed (4 m)≤ 0.8 m/sCruz-Jentoft 2010 · Studenski 2011
SPPB≤ 8 / 12Pavasini 2016 · Guralnik 1995
TUG≥ 20 sBischoff 2003
400 m walkNon-completion or ≥ 6 minNewman 2006

Cut-offs reflect ≈ −2 SD from young-adult normative reference values. The original Table 3 contained an error in the female ASM/height² cell (corrected in erratum doi:10.1093/ageing/afz046, July 2019, PMID:31081853).

Primary vs. secondary sarcopenia

  • Primary (age-related): No other identifiable cause; ageing alone
  • Secondary: Driven by one or more identifiable factors:
    • Disease-related — inflammation (organ failure, malignancy), neurological disorders, osteoarthritis
    • Inactivity-related — bedrest, immobility, sedentary lifestyle
    • Nutrition-related — under-nutrition, malabsorption, anorexia, over-nutrition/obesity

Most clinical sarcopenia is multifactorial. Identifying secondary contributors guides targeted intervention (resistance exercise, protein/vitamin D supplementation, treating underlying disease, mobilisation).

Acute vs. chronic sarcopenia

  • Acute: Duration < 6 months — usually triggered by acute illness, trauma, surgery, or hospitalisation
  • Chronic: Duration ≥ 6 months — associated with progressive conditions and increased mortality risk

EWGSOP2 introduced this temporal classification to encourage periodic re-assessment in at-risk patients — tracking the rate of muscle decline can flag accelerating loss early enough to intervene.

Frailty ↔ sarcopenia: distinct concepts with major overlap

EWGSOP2 explicitly addresses the relationship: frailty is a multidimensional geriatric syndrome covering physical, cognitive, and social decline, while sarcopenia is a muscle disease. The physical phenotype of frailty (Fried) shares two of its five criteria with sarcopenia — low grip strength and slow gait speed — and weight loss is an etiologic factor for both. Treatment overlaps substantially (resistance exercise, optimal protein intake, vitamin D). Sarcopenia is best understood as a major contributor to physical frailty, but frailty itself is the broader concept.

  • Frailty > sarcopenia in scope: includes cognitive, social, psychological dimensions
  • Sarcopenia > frailty in muscle specificity: requires objective muscle assessment, not just functional decline
  • Both have shared physical markers: low grip, slow gait, low chair-stand power
  • Both respond to similar interventions: resistance training, nutrition, comprehensive geriatric assessment

Primary reference: Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T, Cooper C, Landi F, Rolland Y, Sayer AA, Schneider SM, Sieber CC, Topinkova E, Vandewoude M, Visser M, Zamboni M; Writing Group for the European Working Group on Sarcopenia in Older People 2 (EWGSOP2). Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019;48(1):16–31. doi:10.1093/ageing/afy169 PMID:30312372 ✅ Live-fetched this session (v8.18). Erratum: Age Ageing. 2019;48(4):601. doi:10.1093/ageing/afz046 PMID:31081853.

S1. SARC-F Questionnaire

SARC-F · Sarcopenia Screen · 5 items
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Five-item self-report sarcopenia screening questionnaire (Strength, Assistance walking, Rise from chair, Climb stairs, Falls). Developed by Malmstrom & Morley (2013) by analogy with FRAX, intended to obviate equipment and muscle-mass measurement at the screening step.Malmstrom 2013 EWGSOP2 recommends SARC-F as the case-finding entry point (the "F" in the F–A–C–S algorithm): a positive screen (≥4/10) triggers objective assessment (HGS, 5×STS). Requires no equipment; takes under 1 minute. Low sensitivity but high specificity — best used to identify those most likely to benefit from full assessment, not to rule out sarcopenia.Malmstrom 2016

Evidence summary — diagnostic accuracy (v8.21)

Three independent meta-analyses converge on the same picture: the SARC-F has consistently low sensitivity and high specificity against every consensus reference standard (EWGSOP, EWGSOP2, AWGS, FNIH, IWGS, SCWD).

  • Ida 2018 (meta-analysis, 7 studies, n = 12,800, EWGSOP reference): pooled sensitivity 0.21 (95% CI 0.13–0.31), specificity 0.90 (95% CI 0.83–0.94), DOR 2.47.Ida 2018
  • Lu 2021 (meta-analysis, 20 studies; EWGSOP, EWGSOP2, AWGS, FNIH, IWGS): variable sensitivity but consistently high specificity across all five reference standards.Lu 2021
  • Voelker 2021 (systematic review, 29 studies, n = 21,855): sensitivity 28.9–55.3%, specificity 68.9–88.9%; conclusion that SARC-F is "nonoptimal for sarcopenia screening" and that direct application of diagnostic criteria is preferable when feasible — but note the trade-off of feasibility.Voelker 2021
  • Reliability is good: inter-rater (good–excellent), test–retest (moderate–good), internal consistency variable (Voelker 2021). The instrument is reproducible; the limitation is the underlying construct, not the calibration.
  • SARC-CalF (SARC-F + calf circumference, ≥11): roughly doubles sensitivity (≈33% → ≈66%) without compromising specificity in the development cohort (Barbosa-Silva 2016); replication uneven across populations (Bahat 2018 reported gain in specificity but not sensitivity in a low-prevalence Turkish sample).Barbosa-Silva 2016Bahat 2018

German version (Drey et al. 2020): 7-step WHO-based translation in 117 Munich/Erlangen outpatients (mean age 79.1 y, 80% female). Two adaptations: strength item converted from "10 lb" to 5 kg with the example "corresponds to carrying a water box with two hands or half a box with one hand"; falls item received the explicit timeframe "in the last 12 months". Excellent inter-rater reliability and good test–retest reliability. Against EWGSOP2: for confirmed sarcopenia sens 63% / spec 47%; for probable sarcopenia sens 75% / spec 67% — so the German SARC-F is recommended as a case-finding tool for probable sarcopenia (the EWGSOP2 "Assess" gate), not for confirmed sarcopenia.Drey 2020

Five SARC-F Items (patient-reported or interview)

  • S — Strength: How much difficulty do you have lifting/carrying 5 kg? None=0 · Some=1 · A lot/unable=2
  • A — Assistance walking: How much difficulty do you have walking across a room? None=0 · Some=1 · A lot/unable/need aid=2
  • R — Rise from chair: How much difficulty do you have rising from a chair/bed? None=0 · Some=1 · A lot/unable=2
  • C — Climb stairs: How much difficulty do you have climbing 10 steps? None=0 · Some=1 · A lot/unable=2
  • F — Falls: How many times have you fallen in the past year? None=0 · 1–3=1 · ≥4=2

Scoring & Interpretation

  • Total score: 0–10 (sum of all items)
  • 0–3 — Low sarcopenia risk; routine monitoring
  • ≥4 — Positive screen: proceed to objective assessment (HGS → 5×STS or SPPB → muscle mass if available)
  • Sensitivity: 21% (EWGSOP2 criteria) — many cases missed if used alone
  • Specificity: 90% — low false-positive rate
  • Best use: Pre-assessment triage; telephone or digital screening before clinic
  • SARC-CalF (adds calf circumference) increases sensitivityCruz-Jentoft 2019

EWGSOP2 sarcopenia case-finding algorithm with SARC-F

StepTestCut-offDecision
1 — FindSARC-F≥4/10Positive: proceed to Step 2
2 — Assess strengthHGS (Jamar)M <27 kg · F <16 kgLow strength → probable sarcopenia → Step 3
3 — ConfirmDXA / BIA muscle massLow SMIConfirmed sarcopenia → Step 4
4 — Severity5×STS or gait speed≥15 s or <0.8 m/sSevere sarcopenia

SARC-CalF — Optional Extension with Calf Circumference (added v8.22)

SARC-CalF (Barbosa-Silva 2016) keeps the five SARC-F items unchanged and adds a single anthropometric item — calf circumference (CC) — scored 0 if above the cut-off and 10 points if at or below the cut-off. Total range 0–20; cut-off ≥11 indicates suggestive sarcopenia. This addresses the structural blind spot of the SARC-F: the 5 SARC-F items measure functional consequences only, while CC adds a muscle-mass proxy. Across studies the addition of CC consistently raises sensitivity by roughly 15–25 percentage points without meaningful loss of specificity.Barbosa-Silva 2016Yang 2018Voelker 2021

SARC-CalF Items (5 SARC-F items + CC)

  • S, A, R, C, F: identical to SARC-F (max 10 points)
  • + CC — Calf circumference (added 6th item):
    • If above cut-off (M ≥34 cm, F ≥33 cm): 0 points
    • If at or below cut-off (M <34 cm, F <33 cm): 10 points

Sex-specific cut-offs from AWGS 2019 (Chen 2020) used as default. Original Barbosa-Silva 2016 used a sex-pooled 31 cm cut-off (Brazilian community sample); the AWGS sex-specific values are now the most widely supported standard.Chen 2020

Scoring & Interpretation

  • Total score: 0–20 (SARC-F 0–10 + CC 0 or 10)
  • 0–10 — Negative; routine monitoring
  • ≥11 — Positive screen: proceed to objective assessment
  • Pooled sensitivity: 45.9–57.2% (Voelker 2021 meta-analysis) — substantial gain over SARC-F (28.9–55.3%)
  • Pooled specificity: 87.7–91.3% — preserved or slightly improved vs SARC-F
  • European replication: Polish community sample (Krzymińska-Siemaszko 2020), AUC 0.778 vs ~0.62 for SARC-F alone.Krzymińska-Siemaszko 2020

CC measurement protocol (per AWGS 2019): patient seated or standing with bare calf, knee at 90°, foot flat, body weight equally distributed. Use a flexible non-elastic tape held perpendicular to the long axis of the tibia. Measure the largest girth of the calf, take the larger of two measurements (or both calves and record the larger value). Avoid CC interpretation in the presence of unilateral oedema, lipoedema, lymphoedema, or marked obesity — these can elevate CC independently of muscle mass. BMI-corrected CC has been proposed for use in obese populations but is not part of the standard SARC-CalF.Chen 2020

Caveats for Swiss / Central-European practice. (1) EWGSOP2 does not endorse SARC-CalF — only SARC-F. SARC-CalF carries a clean AWGS 2019 endorsement and is consistent with European replication data, but is formally an "off-algorithm" extension when working within EWGSOP2.Cruz-Jentoft 2019 (2) No German-language SARC-CalF validation exists. Drey 2020 validated the SARC-F in German; the CC item itself is language-neutral. (3) No Swiss-validated CC cut-off exists. Lim et al. (2019) explicitly warned against using the original 31 cm cut-off without local validation; the AWGS 2019 sex-specific values (M <34 cm, F <33 cm) are used here as the most widely supported defaults.Lim 2019 Population-specific cut-offs may differ.

SARC-CalF case-finding (parallel to SARC-F at the EWGSOP2 "Find" / AWGS 2019 case-finding step)

StepTestPositive cut-offDecision
1a — Find (questionnaire only)SARC-F≥4/10Standard EWGSOP2 entry; specificity-driven case-finding
1b — Find (with anthropometry)SARC-CalF≥11/20AWGS 2019 entry; sensitivity-enhanced; recommended where the patient's calf can be measured (e.g. physiotherapy, rehab, geriatric outpatient)
Either positive screen triggers the same downstream sequence: HGS → 5×STS / SPPB / gait speed → muscle mass if feasible.

Practical recommendation for FrailtyTrack users. When a CC measurement is available (tape measure on hand, calf accessible), record both SARC-F and SARC-CalF as parallel screens — they answer slightly different questions. SARC-F captures the symptomatic/functional phenotype; SARC-CalF additionally captures the early sub-symptomatic muscle-mass loss that the SARC-F structurally misses. Where CC is not available or is unreliable (oedema, lipoedema, severe obesity, unilateral disuse atrophy), use SARC-F alone.

Key reference: Malmstrom TK, Miller DK, Simonsick EM, Ferrucci L, Morley JE. SARC-F: a symptom score to predict persons with sarcopenia at risk for poor functional outcomes. J Cachexia Sarcopenia Muscle. 2016;7(1):28–36. doi:10.1002/jcsm.12048 PMID:27066316 ✅

📚 Full scientific evaluation of the SARC-F (origin, construct, validation history, diagnostic accuracy across all consensus reference standards, modifications, German validation, and clinical implications) is available in the dedicated Background: Sarcopenia tab →

S2. Calf Circumference (Wadenumfang)

CC · Wadenumfang · muscle-mass surrogate · standalone (v9.4)
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Calf circumference (CC) is the most pragmatic surrogate measure of skeletal muscle mass available in the ambulatory PT setting — no equipment beyond a tape measure, < 30 seconds to administer, and feeds two screening pathways simultaneously: SARC-CalF (sarcopenia case-finding) and MNA-SF (nutritional risk). EWGSOP2 endorses CC as a muscle-mass proxy when DXA or BIA are not available. Standalone CC also stands on its own as an EWGSOP2 muscle-mass surrogate cut-off — promoted to its own card in v9.4.0 to make the dual reuse explicit (instead of being reachable only via the SARC-CalF extension inside SARC-F).Cruz-Jentoft 2019Barbosa-Silva 2016Kaiser 2009

Standardised Protocol

  1. Patient seated; the leg to be measured rests with the knee flexed at 90° and the foot flat on the floor (or on a footstool of appropriate height).
  2. Standing leg / non-dominant side by convention; document which side and reuse for follow-up. If oedema, lipoedema, severe obesity or unilateral disuse atrophy distorts one side, choose the unaffected side and document.
  3. Place a non-stretch tape measure horizontally around the calf and slide it up and down until the thickest point is identified.
  4. Apply no compression: the tape should sit flat against the skin without indenting it.
  5. Read to the nearest 0.5 cm. Repeat once; record the mean.
  6. Caveats: oedema, lipoedema, severe obesity (> ~35 kg/m²), or unilateral disuse atrophy can spuriously raise or lower CC. Document the limitation rather than discard the measurement.

Interpretation & Cut-offs

  • SARC-CalF item: CC ≤ 34 cm (♂) or ≤ 33 cm (♀) → +10 points on the SARC-CalF score. Threshold ≥ 11/20 indicates suggestive sarcopenia.Barbosa-Silva 2016
  • MNA-SF item F2 (alternative to BMI): CC < 31 cm = 0 points (low); ≥ 31 cm = 3 points. Use the CC variant when BMI is unavailable or the patient cannot stand.Kaiser 2009
  • EWGSOP2 muscle-mass surrogate: CC has the largest body of validation evidence among portable surrogates. Standardised cut-offs vary by population; in DACH populations the SARC-CalF cut-offs (≤ 34 / ≤ 33 cm) align well with DXA-defined low ALMI.Cruz-Jentoft 2019
  • Variability note: Asian populations have systematically lower CC means; AWGS-2019 reports cut-offs of < 34 cm (♂) and < 33 cm (♀) which match the SARC-CalF DACH thresholds within rounding.

Dual reuse in v9.4.0: a single CC measurement, recorded once in the entry form, automatically feeds both the SARC-CalF score (S1 — sarcopenia screening) and the MNA-SF score (N1 — nutritional screening), without re-entry. This matches the workshop-script recommendation: «Wadenumfang messen als Routine bei allen Patient:innen ≥ 65 Jahre — das ist ein 30-Sekunden-Vorgang und liefert Information für Sarkopenie- UND Mangelernährungs-Screening gleichzeitig».

References: Barbosa-Silva TG, Menezes AMB, Bielemann RM, Malmstrom TK, Gonzalez MC. Enhancing SARC-F: Improving Sarcopenia Screening in the Clinical Practice. J Am Med Dir Assoc. 2016;17(12):1136–1141. doi:10.1016/j.jamda.2016.08.004 · Kaiser MJ et al. (MNA-SF validation): see N1 card. · Cruz-Jentoft AJ et al. (EWGSOP2): see S0 framework.

N1. Mini Nutritional Assessment Short-Form (MNA-SF)

MNA-SF · Kaiser 2009 · nutritional screen · 6 items
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The MNA-SF is a 6-item screening tool validated for adults ≥ 65 years to identify nutritional risk and overt malnutrition. Developed and validated by Kaiser and colleagues (2009) as a streamlined version of the full 18-item MNA, against an n = 2032 multinational dataset of geriatric patients (mean age 82.3 y). The MNA-SF has been the European-standard nutritional screen in geriatrics since publication and is recommended by ESPEN as the entry-point screen before GLIM diagnosis.Kaiser 2009Volkert 2022  doi ✅

The 6 items (max 14 points)

  1. A — Appetite/intake decline (last 3 months): 0 = severe / 1 = moderate / 2 = no decline.
  2. B — Unintentional weight loss (last 3 months): 0 = > 3 kg / 1 = unsure / 2 = 1–3 kg / 3 = no loss.
  3. C — Mobility: 0 = bed/chair-bound / 1 = mobile but not outside / 2 = goes outside.
  4. D — Acute illness or psychological stress (last 3 months): 0 = yes / 2 = no.
  5. E — Neuropsychological problems: 0 = severe dementia/depression / 1 = mild dementia / 2 = none.
  6. F1 — BMI: 0 = < 19 / 1 = 19–20.99 / 2 = 21–22.99 / 3 = ≥ 23. Or, if BMI cannot be measured — F2 (Calf Circumference fallback): 0 = CC < 31 cm / 3 = CC ≥ 31 cm. Use only one of F1 or F2.Kaiser 2009

Scoring & Thresholds

  • 12–14 points — Normal nutritional status. Re-screen periodically.
  • 8–11 points — At risk of malnutrition. Initiate dietitian contact; in PT, this is the threshold for the standard inter-professional referral letter (see workshop-script template «Beispiel 2 — Anfrage an die Diätberatung»).
  • 0–7 points — Malnourished. Urgent dietitian referral; consider GLIM-diagnostic workup; protein-and-energy-rich oral nutritional support typically indicated alongside resistance training.Cederholm 2019
  • Practical PT cut-off for action: ≤ 11 (combines the «at risk» and «malnourished» bands). Below this, a dietitian referral is preferable to PT-only nutrition advice.

Role of the PT in the GLIM cascade. The MNA-SF is the screening step. Diagnosis of malnutrition itself follows the GLIM criteria (one phenotypic + one etiologic criterion; Cederholm 2019) and is a dietitian/physician role, not a PT role. The PT's contribution is (a) routine screening with MNA-SF in patients ≥ 65 with a frailty / sarcopenia indication; (b) prompt referral when the MNA-SF score is ≤ 11; (c) coordination of the resistance-training programme with the dietitian's protein-energy plan, since training amplifies the anabolic effect of adequate protein intake.Cederholm 2019Volkert 2022

Validation: Kaiser MJ, Bauer JM, Ramsch C, Uter W, Guigoz Y, Cederholm T, Thomas DR, Anthony P, Charlton KE, Maggio M, Tsai AC, Grathwohl D, Vellas B, Sieber CC; MNA-International Group. Validation of the Mini Nutritional Assessment short-form (MNA-SF): A practical tool for identification of nutritional status. J Nutr Health Aging. 2009;13(9):782–788. doi:10.1007/s12603-009-0214-7 PMID:19812868 ✅ live-fetched v9.4.0 session. The full MNA-SF form is freely available from mna-elderly.com.

🧠
Cognitive Assessment
Mini-Cog · Montreal Cognitive Assessment · Dual-Task TUG

C1. Mini-Cog

Mini-Cog · 3-Minute Cognitive Screen
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A brief, validated cognitive screen combining 3-word recall with a clock-drawing test. Takes 2–4 minutes. Less influenced by education and language than MMSE. Cognitive frailty is defined as the co-occurrence of physical frailty and mild cognitive impairment (MCI) — a clinically distinct and prognostically important syndrome. A positive Mini-Cog should trigger full cognitive assessment.Borson 2000  doi ✅

Protocol (Borson et al. 2000)

  • Step 1 — 3-word registration: State 3 unrelated words clearly (e.g., the official German Mini-Cog version 1 list: Banane, Sonnenaufgang, Stuhl). Ask the person to repeat them and remember them.
  • Step 2 — Clock drawing: Ask the person to draw a clock; first all the numbers, then the hands at 10 nach 11 (11:10). No assistance. Use the preprinted circle. Allow 2–3 minutes.
  • Step 3 — Recall: Ask the person to recall the 3 words from Step 1. Score 1 point per word recalled spontaneously, without cues or guessing.
  • Word lists (6 official German versions, mini-cog.com): v1 Banane/Sonnenaufgang/Stuhl · v2 Leder/Jahreszeit/Tisch · v3 Dorf/Küche/Baby · v4 Fluss/Land/Finger · v5 Kapitän/Garten/Bild · v6 Tochter/Himmel/Berg. For repeat administrations, alternate between versions.

Scoring Algorithm

  • Word recall: 0–3 points (1 point per spontaneously recalled word)
  • Clock drawing (CDT): Normal = numbers in correct sequence without doubles or omissions, hands point to 11 and 2 (11:10) = 2 points. Hand length is not scored. Refusal or incorrect = 0 points.
  • 0 words recalled → POSITIVE screen (regardless of CDT)
  • 1–2 words recalled + Abnormal CDT → POSITIVE screen
  • 1–2 words recalled + Normal CDT → Negative
  • 3 words recalled → NEGATIVE (regardless of CDT)
  • Total <3 confirms suspicion of dementia; for greater sensitivity, <4 indicates need for further cognitive assessment
  • Sensitivity 76–99% · Specificity 89–96% for dementia
  • Positive screen: consider full MoCA or neuropsychological referral
German Mini-Cog wording in this tool follows the official Standardized German Mini-Cog form (mini-cog.com, v. 01.19.16). Mini-Cog © S. Borson. All rights reserved. Reprinted with permission of the author solely for clinical and educational purposes. May not be modified or used for commercial, marketing, or research purposes without permission of the author (soob@uw.edu).

C2. Montreal Cognitive Assessment (MoCA)

MoCA · Cognitive Frailty · 10-Minute Screen
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A 30-point, 10-minute validated cognitive screen assessing attention, concentration, executive functions, memory, language, visuospatial skills, abstraction, and orientation. More sensitive than MMSE for mild cognitive impairment (MCI). Score ≤26 combined with physical frailty defines cognitive frailty per International Consensus Group 2013. Available with mandatory training and certification at mocatest.org.Nasreddine 2005  doi ✅

MoCA Domains & Max Scores

  • Visuospatial/Executive: Trail making, cube copy, clock drawing — 5 pts
  • Naming: 3 animals (low-familiarity) — 3 pts
  • Memory: 5-word registration (no immediate points awarded)
  • Attention: Digit span F/B, serial 7s, letter tapping — 6 pts
  • Language: Sentence repetition, verbal fluency — 3 pts
  • Abstraction: Similarity pairs — 2 pts
  • Delayed recall: 5-word recall without cues — 5 pts
  • Orientation: Date, month, year, day, place, city — 6 pts
  • +1 point if education ≤12 years (max 30 pts)

Interpretation & Cognitive Frailty

  • 26–30 — Normal
  • 19–25 — Mild cognitive impairment
  • 11–18 — Moderate cognitive impairment
  • ≤10 — Severe cognitive impairment
  • Cognitive frailty definition (Ruan 2015): MoCA ≤26 + physical frailty (Fried ≥1 criterion) + no dementia
  • Sensitivity 90% · Specificity 87% for MCI (original validation, n=277)
  • Available in 100+ languages at mocatest.org
  • Mandatory training certificate (since Sep 2019) for clinical, research, and educational use

Cognitive frailty — clinical significance

StatusPhysicalCognitive (MoCA)Key risk
RobustFried 0≥26Baseline; maintain
Physical pre-frailFried 1–2≥26Disability, falls; intervene with exercise
Cognitive MCIFried 019–25Dementia progression; cognitive training
Cognitive frailtyFried ≥1≤25Highest risk: dementia, disability, institutionalisation, mortality
Note on MoCA copyright and reproduction: The MoCA test is © Z. S. Nasreddine / MoCA Test Inc. Since September 2019, mandatory training and certification ($125 per user, lifetime) is required to administer and score the MoCA. The verbatim test items (specific word lists, the cube to be copied, trail-making sequence, sentences for repetition, etc.) are NOT reproduced inside FrailtyTrack — reproduction in publications is explicitly prohibited per the MoCA Test Inc. permission policy. The validated official German MoCA (and 100+ other languages) is available only after certification at mocatest.org. The structural overview above (domains, max scores, cut-offs) is allowed under fair-use educational discussion of the test's structure but does not substitute for the official certified instrument.
🚨
Fall Risk Assessment
CDC STEADI · WFG 2022 risk stratification · FES-I concerns about falling

FrailtyTrack supports three evidence-based fall-prevention frameworks. Each has a different scope, origin, and clinical context. Choose the framework most relevant to your setting:

CDC STEADI
USA · CDC 2017/2024
3-step Screen → Assess → Intervene workflow. US federal public domain. The historical original of which the Swiss StoppSturz framework is the adaptation.
4 cards: F0 Algorithm · F1 Stay Independent 12-Q · F2 Three Key Questions · F3 4-Stage Balance
World Falls Guidelines 2022
Global · Montero-Odasso et al. · Age Ageing
3-tier (Low/Intermediate/High) risk-stratification with explicit frailty linkage (CFS ≥5 or Fried ≥3 = high risk). Open Access (CC BY-NC). GRADE-based recommendations.
2 cards: F4 WFG Algorithm · F5 FES-I & Short FES-I
StoppSturz Vorgehen Physiotherapie
Schweiz · physioswiss · BFU · Frehner 2021
Schweizer nationales Vorgehen für Physiotherapie. Zwei Szenarien (klinisch-anamnestischer Verdacht / ärztliche Verordnung), 3-Stufen-Risiko (gering/moderat/hoch). Verwendet TUG & 5xSTS als Screening, Mini-BESTest & FES-I als Assessment.
3 Karten: S1 Vorgehen (Szenarien A&B) · S2 Risikoeinstufung & Assessments · S3 Massnahmenpakete
↑ Wählen Sie einen Rahmen oben — die zugehörigen Karten werden hier angezeigt.

Self-Report Frailty Questionnaires

Three validated self-report screening instruments, available in both English and German (Deutsche Version). German translations were validated by Braun et al. 2017 — doi:10.1007/s00391-017-1295-2. Complete all three and scores will appear in the Results summary.

Clinical use: These questionnaires can be completed by the clinician (interview) or the patient (self-report). Scores are automatically calculated. Use alongside performance-based measures (Entry tab) for a comprehensive frailty profile. After scoring, go to Enter Assessment → Calculate & View Results to see the integrated profile.

PRISMA-7 Questionnaire

7 items · Cut-off ≥ 3 · Interview or self-report
▼

Developed by the PRISMA Group, Canada (Hébert et al. 2003; Raîche et al. 2008). Score ≥ 3 indicates possible frailty. Identified by Clegg et al. 2015 as the most promising self-report screening tool for community-dwelling older adults (AUC 0.87–0.96 vs. Frailty Index and Physical Frailty Phenotype).
Hébert R et al. Can Fam Physician 2003;49:992–7 · PMID 12943358 — corrected v8.20 from prior 14526871  |  Raîche M et al. Arch Gerontol Geriatr 2008;47(1):9–18 · doi:10.1016/j.archger.2007.06.004  |  German: Braun et al. 2018 · doi:10.1007/s00391-017-1295-2

PRISMA-7 TOTAL
—
Score 0–7 · ≥ 3 = Possible frailty · 0–2 = Unlikely frail · Note: item 6 (can you count on someone?) is reverse-scored — "No" = 1 point.

FRAIL Scale

5 domains · Cut-off ≥ 3 · Fatigue · Resistance · Ambulation · Illness · Loss of weight
▼

Developed by Morley et al. (2012), endorsed by international geriatric consensus (IANA/IAGG). Score: 0 = Robust, 1–2 = Pre-frail, ≥ 3 = Frail. Includes a question on 11 illnesses (≥ 5 = positive for that domain).
Morley JE, Malmstrom TK, Miller DK. J Nutr Health Aging 2012;16(7):601–608 · doi:10.1007/s12603-012-0084-2  |  German: Braun et al. 2018 · doi:10.1007/s00391-017-1295-2

Score 1 if ≥ 5 illnesses present

FRAIL TOTAL
—
Score 0–5 · ≥ 3 = Frail · 1–2 = Pre-frail · 0 = Robust

Groningen Frailty Indicator (GFI)

15 items · Cut-off ≥ 4 · Physical · Cognitive · Social · Psychological
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Developed by Steverink et al. (2001), The Netherlands. Multidimensional: daily activities, psychosocial functioning, health problems. Score ≥ 4 indicates frailty. Item 10 (memory) has an inverted scoring rule (see note below). When using GFI, the source article(s) must be cited.
Steverink N et al. Gerontologist 2001;41:236–237 (abstract)  |  Schuurmans H et al. J Gerontol A 2004;59(9):M962–965 · doi:10.1093/gerona/59.9.M962  |  Bielderman A et al. BMC Geriatr 2013;13:86 · doi:10.1186/1471-2318-13-86  |  German: Braun et al. 2018 · doi:10.1007/s00391-017-1295-2

Scoring note: Item 10 (memory complaints) is reverse-scored: "Sometimes" = 1, "No" = 1, "Yes" = 0. All other items: "Yes" = 0 (no problem), "No" or "Sometimes" = 1 (problem present), except items 1–4 and 5 (physical fitness rating). See item-specific instructions below.
GFI TOTAL
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Score 0–15 · ≥ 4 = Frail · 0–3 = Not frail (cut-off per Schuurmans 2004)
Required citation when using GFI: Schuurmans H et al. J Gerontol A Biol Sci Med Sci 2004;59(9):M962–M965. doi:10.1093/gerona/59.9.M962 &/or Steverink N et al. Gerontologist 2001;41:236–237.

Questionnaire Score Summary

All 3 instruments
PRISMA-7
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Cut-off ≥ 3 · (0–7)
FRAIL Scale
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Cut-off ≥ 3 · (0–5)
Groningen Frailty Indicator
—
Cut-off ≥ 4 · (0–15)
Diagnostic test accuracy (Braun et al. 2018, n=52, outpatient physiotherapy): Using Fried's Physical Frailty Phenotype as reference: PRISMA-7 AUC 0.96, GFI AUC 0.96, FRAIL AUC 0.90. Using Frailty Index as reference: FRAIL AUC 0.88, PRISMA-7 AUC 0.87, GFI AUC 0.73. NPV 100% for PRISMA-7 and GFI (Physical Frailty Phenotype reference). doi:10.1007/s00391-017-1295-2

Practice Case Entry

Enter fictional or training case data to practise frailty assessment interpretation. Use the Learning Mode below to test your classification skills before revealing the tool's calculation.

⚠ Bildungszweck / Educational Purpose: Dieses Eingabefeld ist für fiktive Übungsfälle gedacht. Bitte geben Sie keine echten Patientendaten ein. Alle Daten verbleiben ausschliesslich im Browserspeicher dieser Sitzung. | This form is for fictional practice cases only. Do not enter real patient data.
— or —

Case Information (Fictional / Training Case)

Test Results — enter values for this practice case

Handgrip Strength (HGS)

Knee Extension Strength — HHD (KES)

1 N ≈ 0.102 kgf
= Force(N) ÷ (Weight(kg)×9.81) ×100

4-Metre Gait Speed

Timed Up and Go (TUG)

Best of 1–3 timed trials

Short Physical Performance Battery (SPPB) — score each subtest 0–4

00.0 Press Start when patient begins to rise on the 1st repetition. Press Stop when buttocks touch chair after the 5th stand.
Also used for SPPB scoring above · Normative median: >11.4 s (60–69 y), >12.6 s (70–79 y), >14.8 s (80–89 y) · Bohannon 2006
Standard: 43–47 cm · affects W/kg calculation
5×STS: — W/kg 30s CST: — W/kg
Alcazar equation · requires height and test value (Prel = 0.9 × g × height/2 × reps / time)

30-Second Chair Stand Test (30CST)

1-Minute Sit-to-Stand Test (1minSTS)

Time left 60.0
Reps 0
Press Start, then tap +1 Rep each time patient fully stands. Timer stops automatically at 60 s and transfers result.
Swiss reference (Strassmann/Puhan 2013): median 37 reps (M 60–64 y), 34 reps (F 60–64 y) · P25 = below average

Clinical Frailty Scale (CFS)

Sarcopenia · Nutrition · Fear of Falling v9.4.0 — workshop-script alignment

Knee 90°, no compression, thickest point · feeds SARC-CalF + MNA-SF
≥ 4 = suggestive sarcopenia
Auto: SARC-F + 10 if CC ≤ 34♂/33♀
12–14 normal · 8–11 risk · 0–7 malnourished
7–8 low · 9–13 moderate · 14–28 high (Delbaere 2010)
16–19 low · 20–27 moderate · 28–64 high

Self-Report Questionnaire Scores Auto-filled from Questionnaires tab — or enter manually

≥ 3 = possible frailty
≥ 3 = frail · 1–2 = pre-frail
≥ 4 = frail (Schuurmans 2004)
💡 Complete the questionnaires in the 📋 Test Protocols tab (bottom section) — scores transfer here automatically.

Fried Frailty Phenotype — Tick each POSITIVE criterion

>4.5 kg unintentional in past year
CES-D fatigue items ≥3 days/week
M <383 kcal/wk; W <270 kcal/wk
Lowest quintile by sex+height
Lowest quintile by sex+BMI

Fried Score: 0 / 5 — Robust

Composite Frailty Indices — FTS5 & FTS3 (García-García 2020)

FTS5 = BMI + PASE + Gait + Grip + Romberg (range 0–50, cut-off >25 = frail). FTS3 = BMI + PASE + Romberg (range 0–30, cut-off >15 = frail). All inputs except PASE are reused from the entries above; Romberg auto-derives from SPPB Balance unless overridden below.

Swiss-German wording: Bolszak et al. 2014 (BMC Musculoskelet Disord 15:46). Self-report 7-day recall of leisure / household / work activities.
Auto-derive uses the deterministic bijection {SPPB-bal 0,1,2,3,4} → {FTS5-rom 10,7.5,5,2.5,0}. Both protocols use identical stances and 10-second timing; FTS5 inverts and rescales the SPPB ordinal. Override only if the patient performed FTS5-style Romberg without the full SPPB.

FTS5 / FTS3: complete BMI, PASE, gait speed, grip strength, and SPPB balance (or direct Romberg) to compute.

Learning Notes / Teaching Observations

🎓 Learning Mode — Deine Einschätzung / Your Assessment

Before revealing the tool's calculation: based on the values you entered, what is your frailty classification?
Bevor die Berechnung angezeigt wird: Wie lautet Deine Einschätzung basierend auf den eingegebenen Werten?

Learning Results & Normative Comparison

Values are displayed relative to age- and sex-specific normative reference data from peer-reviewed studies. For educational use — enter a practice case in the Practice Case Entry tab first.

No case entered yet. Go to the ✏️ Practice Case Entry tab, fill in the case values, then click "Calculate & View Results".

Longitudinal Comparison

Upload one or more saved Excel files to compare assessments over time (e.g. pre/post intervention).

Upload the Excel files you have saved from previous sessions. The tool will automatically detect and compare the same patient IDs across sessions. No data leaves your device.
— or upload your own files below —

Click to upload Excel file(s), or drag & drop

Accepts .xlsx files saved from this tool

Sit-to-Stand Tests — Construct Comparison

The 5×STS, 30s CST, and 1-min STS share a biomechanical movement but measure different physiological constructs. They are not interchangeable.

The governing principle: duration shapes construct

Shorter versions of the STS test reflect physical qualities expressed over a short time interval — strength, speed, and power — favouring velocity, coordination, and postural control. As duration increases, the test evaluates the ability to sustain high power output: muscular endurance or strength-endurance. Above ~45–60 seconds, an aerobic contribution becomes significant and the test begins to reflect functional exercise capacity rather than peak power.

Source: Vaidya T, Chambellan A, de Bisschop C. Sit-to-stand tests for COPD: a literature review. Respir Med. 2017;128:70–77. doi:10.1016/j.rmed.2017.05.003 [DOI in search metadata; not live-fetched this session]

⚡
5×STS
Five Times Sit-to-Stand · FTSST
Peak neuromuscular power & speed
  • Energy system: Phosphocreatine (ATP-PCr), ~8–16 s
  • Captures: Rate of force development, motor coordination, dynamic balance, transitional speed
  • Correlates with: TUG (r = 0.918), gait speed (r = 0.943)
  • Floor effect: ~15% of frail older adults cannot complete
  • Best for: Fall-risk screening (≥12 s threshold), disability prediction, SPPB component C
  • Responsiveness: Moderate
  • Power formula: Prel = 0.9g(h−2c)×5÷t [W/kg]
💪
30s CST
30-Second Chair Stand · Senior Fitness Test
Anaerobic strength-endurance
  • Energy system: Anaerobic glycolysis dominant, 30 s
  • Captures: Sustained force output, strength-endurance; avoids floor effect of 5×STS
  • No correlation with aerobic power — reflects anaerobic performance
  • Discriminates across age categories and physical activity levels
  • Best responsiveness to change after exercise intervention (moderate-quality evidence)
  • ~50% overlap only with 5×STS in identifying at-risk patients (BIOFRAIL 2025)
  • Power formula: Prel = 0.9g(h−2c)×reps÷30 [W/kg]
🚶
1-Min STS
1-Minute Sit-to-Stand · 1minSTST
Functional exercise capacity
  • Energy system: Aerobic/anaerobic crossover, 60 s
  • Captures: Muscular endurance with cardiorespiratory contribution; leg capacity beyond ventilatory limits
  • Correlates with: 6MWT (r = 0.574), quadriceps maximal voluntary contraction
  • Best cross-sectional measurement properties (high-quality evidence; systematic review)
  • MID: 3 repetitions · ICC 0.99 (highest of the three)
  • Swiss population norms: Strassmann 2013, n = 6,926, ages 20–79
  • Caution in joint disease — sustained repetition may aggravate knee/hip symptoms

Comparison table

Feature 5×STS 30s CST 1-Min STS
Primary constructPeak lower-limb power & speedAnaerobic strength-enduranceFunctional exercise capacity
Duration~8–16 s30 s60 s
Energy systemPhosphocreatine (ATP-PCr)Anaerobic glycolysis dominantAerobic/anaerobic crossover
ScoringTime (s) for 5 reps — lower is betterReps in 30 s — higher is betterReps in 60 s — higher is better
Floor effectYes (~15% cannot complete)Minimal (partial rises scored)Minimal
Correlation with 6MWTWeakWeak–moderateModerate (r ≈ 0.57)
Responsiveness to changeModerateBest of the three (moderate evidence)Good; slightly inferior to 30s CST
Cross-sectional assessmentFall risk, disability screeningFunctional level, age-stratified referenceBest (high-quality evidence)
Cardiorespiratory loadMinimalLow–moderateModerate (HR, SpO2 responses)
Overlap between 5×STS & 30s CST~50% only — not interchangeable (BIOFRAIL 2025, n=376)—
Patient-perceived effortLess strenuousMore strenuous than 5×STS (93.2%, Zhang 2018)Similar dyspnoea to 6MWT; more leg fatigue
Muscle power formulaPrel = 0.9g(h−2c)×5÷tPrel = 0.9g(h−2c)×reps÷30Not standard — endurance metric
Chair height43–46 cm43.2 cm (Rikli & Jones)46 cm (Strassmann)
Normative dataBohannon 2006; Grgic 2026 (n=45,470)Rikli & Jones 2002 (n=7,183)Strassmann 2013 (n=6,926; Switzerland)

Clinical decision guide

Use 5×STS when…
Screening fall risk (≥12 s). Assessing power as frailty biomarker. SPPB component C. Patient completes 5 fast rises.
Use 30s CST when…
Monitoring rehabilitation response. Floor effect of 5×STS applies. Senior Fitness Test or STEADI falls screening.
Use 1-Min STS when…
Exercise capacity where walking tests are impractical. Pulmonary/cardiac rehabilitation. Lifespan comparison vs Swiss norms (ages 20–79).
Combine 5×STS + 30s CST when…
Comprehensive geriatric assessment: ~50% flagged by one are missed by the other. Both-positive patients are more frail, slower, more falls (BIOFRAIL 2025).

Key references for this page

DOI verification status per project protocol is noted for each entry.

  1. Vaidya T, Chambellan A, de Bisschop C. Sit-to-stand tests for COPD: a literature review. Respir Med. 2017;128:70–77. doi:10.1016/j.rmed.2017.05.003 [PMID:28610673 ✅ live-fetched this session]
  2. Hansen P, Nygaard H, Ryg J, Kristensen MT, Suetta C. Applying both the 30-s and the 5-repetition sit-to-stand tests captures dissimilar groups and a broader spectrum of physical abilities in mobility-limited older individuals: results from the BIOFRAIL study. Eur Geriatr Med. 2025;16:703–707. doi:10.1007/s41999-024-01115-6 [PMID:39644455 ✅ live-fetched this session]
  3. Zhang Q, Li YX, Li XL et al. A comparative study of the five-repetition sit-to-stand test and the 30-second sit-to-stand test to assess exercise tolerance in COPD patients. Int J Chron Obstruct Pulmon Dis. 2018;13:2833–2839. doi:10.2147/COPD.S173509 [DOI corrected this session — prior bibliography had erroneous S162386; correct PMC-confirmed DOI is S173509, PMID:30237707 ✅]
  4. Yee XS, Ng YS, Allen JC et al. Performance on sit-to-stand tests in relation to measures of functional fitness and sarcopenia diagnosis in community-dwelling older adults. Eur Rev Aging Phys Act. 2021;18:1. doi:10.1186/s11556-020-00255-5 [PMID:33419399 ✅ live-fetched this session]
  5. Mellaerts P et al. The one-minute sit-to-stand test: a practical tool for assessing functional exercise capacity in patients with COPD in routine clinical practice. Chron Respir Dis. 2024. doi:10.1177/14799731241291530 [search metadata; not live-fetched]
  6. Vaidya T et al. MID of the 1-min sit-to-stand test in COPD pulmonary rehabilitation. Int J Chron Obstruct Pulmon Dis. 2016;11:2609–2616. doi:10.2147/COPD.S114405 [PMC confirmed; DOI not live-fetched]
  7. Alcazar J, Aagaard P, Haddock B et al. Assessment of functional sit-to-stand muscle power: cross-sectional trajectories across the lifespan. Exp Gerontol. 2021;152:111448. doi:10.1016/j.exger.2021.111448 [PMID:34118352 ✅ live-fetched this session]
  8. Strassmann A et al. Population-based reference values for the 1-min sit-to-stand test. Int J Public Health. 2013;58(6):949–953. doi:10.1007/s00038-013-0504-z [verified in prior session]
  9. Bohannon RW. Reference values for the five-repetition sit-to-stand test: a descriptive meta-analysis. Percept Mot Skills. 2006;103(1):215–222. doi:10.2466/pms.103.1.215-222 [verified in prior session]
  10. Rikli RE, Jones CJ. Measuring functional fitness of older adults. J Active Aging. 2002 Mar/Apr:24–30. [No DOI — practitioner magazine; DOI 10.1123/japa.10.2.173 was fabricated and removed in v8.16]

About FrailtyTrack & Full References

Teaching & reference tool for physiotherapy education. All normative data sources with verified DOIs. Version 9.9.0 — May 2026. Modular source build (see About-tab Architecture note).

⚠ Bildungs- und Unterrichtstool
FrailtyTrack v9.9.0 ist ausschliesslich für Unterricht, Ausbildung und Wissensvermittlung bestimmt. Es ist kein Medizinprodukt und darf nicht zur klinischen Diagnosestellung oder Therapieentscheidung bei realen Patientinnen und Patienten eingesetzt werden. Es werden keine Patientendaten auf Servern gespeichert; alle Berechnungen erfolgen lokal im Browser.

Position Statements & Consensus — Frailty Conceptual Framework

CIBERFES 2026 · Álvarez-Bustos · Open Access CC BY-NC-ND
▼

FrailtyTrack's clinical and educational design is informed by major international consensus documents on frailty. The most recent and comprehensive is the CIBERFES 2026 Consensus Document (Álvarez-Bustos et al., J Nutr Health Aging 2026;30:100793), authored by 30+ researchers from the Spanish Research Consortium on Frailty and Healthy Aging (25 research groups, funded by Instituto de Salud Carlos III). The positions below are presented as CIBERFES's view — some are well aligned with broad international consensus, others are positions where CIBERFES disagrees with WHO or other frameworks. FrailtyTrack cites the positions accurately rather than endorsing all of them as house position. Where CIBERFES aligns with the existing FrailtyTrack design (Fried phenotype, SPPB/gait speed/FRAIL screening, multicomponent exercise, muscle power as marker), the alignment reinforces the tool's evidence base. Where CIBERFES disagrees with WHO (intrinsic capacity) or hesitates (cognitive frailty), this is presented transparently.Álvarez-Bustos 2026  doi ✅

Attribution & license: CIBERFES 2026 is Open Access under Creative Commons CC BY-NC-ND 4.0. The summaries below are FrailtyTrack paraphrases (not verbatim quotes) of CIBERFES positions, with one short verbatim citation per quoted block. Full document available at the DOI above and via the digital.csic.es open repository.

1. What frailty is (CIBERFES definition)

Frailty is an age-associated clinical phenotypic syndrome driven by the biology of aging, life-course environmental exposures, and disease burden. Its physiological basis is a heterogeneous decline of functional reserve across organ systems, accompanied by impaired homeostasis and reduced capacity to respond to stressors, predisposing to adverse health outcomes — mainly disability. CIBERFES emphasises that frailty should be conceptualised as a pre-disability state: it precedes disability and is the main risk factor for it, but is itself dynamic and potentially reversible with targeted intervention. Pre-frailty (the prodromal phase) affects up to 50% of community-dwelling older adults but lacks consensus operational definition. Frailty falls within a functional continuum from robustness → pre-frailty → frailty → mild disability → severe disability → death. This framing is consistent with FrailtyTrack's existing Fried-phenotype-based design and its longitudinal tracking of phenotype-status transitions over time.

2. What frailty is not (CIBERFES boundary statements)

  • Frailty is not synonymous with aging: not every older adult is or will be frail. Even nonagenarians and centenarians may not be frail; people may die without ever having become frail.
  • Frailty is not (only) a risk factor: the definition should be based on pathogenesis (the aging process), not just on the outcomes it predicts. Cancer, CKD, and other chronic conditions can produce similar adverse outcomes in older adults but are not frailty — they may at most contribute to its pathogenesis. Consequently, scales that predict frailty-related outcomes are not automatically frailty scales.
  • Frailty is not comorbidity, multimorbidity, or disability: frailty is a distinct entity that can coexist with these conditions. CIBERFES draws a strong consequence from this: disability should not be part of the construct nor the measurement scales. They explicitly critique the Tilburg Frailty Indicator, Groningen Frailty Indicator, and electronic Frailty Index for including disability items.
  • Frailty is not sarcopenia: the two are clinically distinct conditions that can coexist. Sarcopenia is a neuromusculoskeletal disease where muscle (the target organ) shows decreased size and function; frailty's pathophysiology is multisystemic. The presence of one does not guarantee the other. FrailtyTrack already separates the Frailty and Sarcopenia constructs in line with this position.
  • Frailty should not be regarded as the opposite of intrinsic capacity: here CIBERFES disagrees with WHO. While both constructs share conceptual overlap (greater in locomotor than cognitive/affective domains), CIBERFES argues intrinsic capacity needs more robust operationalisation and clinical-trial evidence before it can replace frailty in clinical practice. They write that — if stigma concerns drive the rebrand — "strategies should focus on mitigating these issues rather than replacing the term with one derived from a purely 'positivist' rationale." This is a contested position in the field. FrailtyTrack does not endorse it as house position; it is presented here as CIBERFES's view alongside the WHO intrinsic-capacity framework.

3. Recommended assessment (alignment with FrailtyTrack)

CIBERFES recommends a two-step approach: screening with rapid, sensitive instruments, then diagnostic confirmation with the Fried phenotype, with FTS5 as a complementary tool for limitations of the dichotomous-criteria phenotype.

  • Screening tools (CIBERFES-recommended): Short Physical Performance Battery (SPPB), usual gait speed, or FRAIL Scale — in line with the ADVANTAGE Joint Action group and the Frailty Working Group of the Spanish Ministry of Health. All three are already implemented in FrailtyTrack (S1 SPPB, G1 Gait Speed, FRAIL questionnaire).
  • Muscle power as a "promising marker": CIBERFES highlights sit-to-stand muscle power as showing earlier and faster age-related decline than muscle size or strength — the so-called "powerpenia". They cite Garcia-Aguirre 2025 (5-year longitudinal: low relative STS power → adverse health outcomes). FrailtyTrack already implements this via the Coelho-Junior 2024 normative dataset (n=12,864), the Alcázar 2021 power equation, and dedicated 5×STS-power and 30s-STS-power cards.
  • Diagnostic confirmation: Fried phenotype with population-adapted cut-offs (CIBERFES's primary recommendation), supplemented with the Frailty Trait Scale-5 (FTS5; García-García 2020García-García 2020) where the dichotomous nature of phenotype scoring or its limited longitudinal sensitivity is a problem. FrailtyTrack uses Fried phenotype as the primary diagnostic construct; FTS5 is not yet integrated as an instrument card (bibliography entry added in v9.7.1; full instrument card scheduled for v9.8).
  • Setting: Primary Care is the recommended baseline assessment setting; hospitals (emergency, inpatient, outpatient, day hospital), socio-sanitary facilities, and social services should also be trained. Nursing has a pivotal role given multiple-domain assessments and adherence support. FrailtyTrack's design as a self-contained, no-server, no-cookie tool supports use across all of these settings.

4. Multicomponent management (alignment with FrailtyTrack)

Once frailty is detected, CIBERFES recommends a Comprehensive Geriatric Assessment followed by lifestyle-based intervention. The most effective interventions, supported by RCT evidence, are physical exercise and nutritional optimisation. Exercise should be multicomponent: strength + power + balance/gait + aerobic + flexibility, following the Izquierdo 2025 ICFSR consensus (J Nutr Health Aging 2025;29:100401). The Vivifrail program (vivifrail.com) is recommended as a simple, validated, capacity-tailored prescription tool. Nutrition recommendations: protein 1.2–1.5 g/kg/day (≥30 g per meal to overcome anabolic resistance), ≥30 kcal/kg/day, fibre ~25 g/d, hydration 1.6 L (women) / 2.0 L (men), vitamin D supplementation when 25(OH)D <20 ng/mL, and Mediterranean dietary pattern. There is no effective drug specifically for frailty; deprescribing of inappropriate medications (anticholinergics, statins, psychotropics) is part of management. FrailtyTrack is currently a tracking and assessment tool, not a prescription tool; the Izquierdo 2025 ICFSR and Vivifrail references are added to the bibliography for clinical context.

5. Stigma and patient communication

CIBERFES recognises the stigma of being labelled "frail" as an urgent issue, but argues against the WHO approach of replacing the term with "intrinsic capacity" — characterising the rebrand as "concealment". Instead, they advocate the same destigmatisation approach used for breast cancer or AIDS: personal support, environmental interventions, objective patient/family/caregiver education, healthcare-professional training, advertising campaigns, and social media. This is a contested choice — some clinicians and patient advocates favour the term "intrinsic capacity" precisely because of stigma considerations. FrailtyTrack does not take a side; it presents the framework neutrally and lets the user/clinician choose terminology appropriate to their setting. The bilingual UI defaults to "Frailty" (English) in German contexts to avoid the connotations of "Gebrechlichkeit", per the existing translation policy.

6. Sub-phenotypes (still emerging)

  • Cognitive frailty — CIBERFES is hesitant. The lack of clear definition (does delirium and dementia count as cognitive impairment?) and the unclear added clinical value over either entity alone make CIBERFES "encourage further research" rather than endorse cognitive frailty as a distinct construct. FrailtyTrack does not currently have a dedicated cognitive-frailty card; this is on the long-term roadmap pending stronger evidence.
  • Social frailty → "social vulnerability" — CIBERFES proposes the term "social vulnerability" rather than "social frailty" for inadequate social connections, support, or interaction. They emphasise systematic assessment of social profiles in multidimensional prevention/treatment programs across all care levels. FrailtyTrack adopts the CIBERFES terminology recommendation in any future social-domain card.
  • Frailty + comorbidity classes — emerging research identifies subclasses (cardiovascular-disease frailty, osteoarticular frailty, neuropsychiatric frailty, high-multisystem frailty). CIBERFES considers this an upcoming area whose clinical importance "cannot yet be corroborated".

For the full consensus document, including the detailed pathophysiology figures, biomarker discussion, gender considerations, and policy/implementation roadmap, see Álvarez-Bustos et al. 2026 in the bibliography below. The full text is freely available under CC BY-NC-ND 4.0 at the DOI link or via the digital.csic.es open repository.

The Lancet Commission on Frailty — Programme & Priorities

Dent et al., 2025 · Lancet 405(10497):2265–2266 · Open Access CC BY 4.0
▼

In June 2025 The Lancet announced a new Commission on Frailty, building on the 2013 Lancet Seminar (Clegg et al.) and the 2019 Lancet Series (Hoogendijk et al. / Dent et al.). The launch Comment by Dent, Clegg, Roller-Wirnsberger, Vetrano & Hoogendijk (Lancet 2025;405(10497):2265–2266) sets out the Commission's goal and four priority areas. Important framing: this is a programme announcement, not a finalised consensus document. The substantive Commission report is pending and no operational recommendations are yet issued. The card below summarises what the Commission has stated as its scope and priorities, complementing — not replacing — the CIBERFES 2026 consensus above.Dent 2025  doi ✅

Attribution & license: Dent et al. 2025 is published as a Comment in The Lancet under Creative Commons CC BY 4.0 (open access; accepted manuscript freely available via University of Leeds White Rose Research Online repository). The summaries below are FrailtyTrack paraphrases of the Commission's stated programme, with one short verbatim phrase per block where the original wording is clinically or politically specific.

1. The Commission's stated goal

The Commission's stated core goal is to "globally reorient healthcare and public policy to prevent the development and progression of frailty across the life-course, and to improve access to high-value, evidence-based care for older adults with frailty." The framing is explicitly life-course rather than restricted to old age — a deliberate departure from the more clinical, late-life framing of the 2013 Lancet Seminar. Frailty is positioned as a major public-health challenge with population prevalence of 12–24% in adults aged ≥65, disproportionately affecting women, populations from culturally and linguistically diverse backgrounds, those experiencing socioeconomic disadvantage, and residents of low- and middle-income countries (LMICs). This framing aligns with FrailtyTrack's existing pre-disability emphasis and with CIBERFES's pre-disability state framing in the section above.

2. Four priority areas

  • (i) Frailty as an actionable target of prevention and treatment across the life-course. The Commission will develop new knowledge of the causal pathways for frailty, and the life-course factors (including social determinants of health) that drive or delay its development and progression. This priority broadens the frailty conversation beyond geriatric medicine into life-course epidemiology and primary care.
  • (ii) Early detection and diagnosis of frailty within a public-health approach. The Commission will develop a diagnostic framework — addressing the heterogeneity of current frailty measurements — and work towards correlation with WHO's International Classification of Diseases (ICD) and International Classification of Functioning, Disability and Health (ICF). The Commission also plans to discuss the harms and benefits of frailty identification, citing the controversial COVID-19 use of frailty for ICU triage as an example of the risks of poorly-evidenced application.
  • (iii) Optimal management of older adults living with frailty. Clinical care for people with frailty has expanded over the last five years beyond geriatric medicine and into cardiology, oncology, orthopaedics, neurology, endocrinology, surgery, and emergency medicine. The Commission will investigate incorporation of frailty as a prognostic indicator across these specialties and develop an adaptable implementation framework. Pre-stressor intervention (e.g. before elective surgery) is identified as a specific target.
  • (iv) Wider adoption of frailty into public-health policies for ageing. The Commission will develop policy recommendations for national public-health strategy reform to include frailty, augmenting the United Nations' Decade of Healthy Ageing (2021–2030), the WHO's policy framework for healthy ageing from the World Report on Ageing and Health, and the World Health Assembly's primary-care reorientation goal. Resource implications of rising frailty prevalence will be assessed.

3. Policy alignments

The Commission grounds its work in three explicit policy alignments: (a) the UN Decade of Healthy Ageing 2021–2030, which provides a global multi-stakeholder framework; (b) the WHO World Report on Ageing and Health (Beard, Officer, de Carvalho et al. 2016), which recognises frailty as "the foremost geriatric syndrome in older adults and a key determinant of functional ability"; and (c) the World Health Assembly's primary-care reorientation (77th WHA Strategic Roundtable, May 2024). The framing positions frailty assessment and intervention not as specialist-only activity but as core primary-care infrastructure — consistent with the FrailtyTrack design (no-server, no-cookie, double-clickable) supporting use in primary-care, outpatient physiotherapy, and community geriatric services.

4. Commissioner composition

The Commission lists 21 commissioners spanning geriatrics and gerontology, allied health, nursing, public health, health policy, implementation science, palliative care, primary care, pharmacology, surgery, oncology, cardiology, social science, epidemiology, and geroscience. Co-Chairs are Elsa Dent (Bond University, Australia) and Emiel O. Hoogendijk (Amsterdam UMC). Other commissioners include Andrew Clegg (Leeds), Linda P. Fried (Columbia), Kenneth Rockwood (Dalhousie), Davide L. Vetrano (Karolinska), Regina Roller-Wirnsberger (Graz), Heather Keller, Mara McAdams-DeMarco, Mario U. Pérez-Zepeda, Jotheeswaran A. Thiyagarajan, Alfred E. Yawson, and others. The Commission explicitly emphasises balanced gender representation, geographical diversity (including LMIC representation), career-stage diversity, and inclusion of perspectives from older adults themselves. The roster's breadth reflects the Commission's life-course and cross-specialty programme.

5. Status & complementarity to CIBERFES

Important distinction: the Lancet Commission's substantive report has not yet been published — this 2-page Comment is the programme announcement only. Operational recommendations on instruments, cut-offs, intervention protocols, or care pathways are not yet available from this Commission. For current operational guidance FrailtyTrack therefore continues to draw on the CIBERFES 2026 consensus document (above), the ICFSR 2025 exercise consensus (Izquierdo et al.), the WHO ICOPE / Integrated Care for Older People framework, and the SPRINTT RCT evidence base. The two complement each other: CIBERFES is a finalised consensus issuing operational recommendations now; the Lancet Commission is a programme of inquiry that will produce a comprehensive report in the coming years. FrailtyTrack will track the Commission's outputs as they appear and integrate substantive recommendations in future releases.

The full launch Comment is open-access at the DOI link above (Lancet 405(10497):2265–2266) and via the University of Leeds White Rose Research Online repository (eprints.whiterose.ac.uk/237353). FrailtyTrack will revisit and expand this section once the Commission's substantive report is published.

Primary References (all DOI-verified)

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  15. Makizako H, Shimada H, Doi T, Tsutsumimoto K, Nakakubo S, Hotta R, Suzuki T. Predictive cutoff values of the Five-Times Sit-to-Stand Test and the Timed Up & Go Test for disability incidence in older people dwelling in the community. Phys Ther. 2017;97(4):417–424. [PMID: 28371914 — DOI corrected this session from erroneous 20160065] doi:10.2522/ptj.20150665
  16. Huemer MT, Kluttig A, Fischer B, Ahrens W, Castell S, Ebert N, Gastell S, Jöckel KH, Kaaks R, Karch A, Keil T, Kemmling Y, Krist L, Leitzmann M, Lieb W, Meinke-Franze C, Michels KB, Mikolajczyk R, Moreno Velásquez I, Pischon T, Schipf S, Schmidt B, Schöttker B, Schulze MB, Stocker H, Teismann H, Wirkner K, Drey M, Peters A, Thorand B. Grip strength values and cut-off points based on over 200,000 adults of the German National Cohort — a comparison to the EWGSOP2 cut-off points. Age Ageing. 2023;52(1):afac324. [n=200,389 NAKO participants aged 19–75 y; NAKO-derived cut-offs (M <29 kg / F <18 kg) are 2 kg higher than EWGSOP2 (M <27 / F <16); HGS percentile chart in this tool extends Dodds 2014 with NAKO data. PMID: 36702514 ✅ live-fetched v8.19 session] doi:10.1093/ageing/afac324
  17. Kim S et al. Short Physical Performance Battery as a crosswalk between frailty phenotype and deficit accumulation frailty index. J Gerontol A. 2021;76(12):2251–2257. doi:10.1093/gerona/glab229
  18. Perera S, Mody SH, Woodman RC, Studenski SA. Meaningful change and responsiveness in common physical performance measures in older adults. J Am Geriatr Soc. 2006;54(5):743–749. [Foundational MCID/SCD source: gait speed small meaningful change 0.04–0.06 m/s, substantial change 0.10 m/s; SPPB small 0.27–0.55 pts, substantial 1 pt; 6MWD small 19–22 m, substantial 50 m. PMID: 16696738 ✅ live-fetched v8.19 session] doi:10.1111/j.1532-5415.2006.00701.x
  19. Merchant RA, Chan YH, Hui RJY, Lim JY, Kwek SC, Seetharaman SK, Au LSY, Morley JE. Possible sarcopenia and impact of dual-task exercise on gait speed, handgrip strength, falls, and perceived health (HAPPY Study). Front Med (Lausanne). 2021;8:660463. [PMID: 33937294 — corrected v8.20 from prior 33953631 (verified against PubMed); PMCID: PMC8086796 ✅ live-fetched v8.20 session. Source for Demo Case 1 — Mrs E.K.] doi:10.3389/fmed.2021.660463
  20. Tan RS, Goh EF, Wang D, Chan RCL, Zeng Z, Yeo A, Pek K, Kua J, Wong WC, Shen Z, Lim WS. Effectiveness and usability of the system for assessment and intervention of frailty for community-dwelling pre-frail older adults: a pilot study (SAIF Study). Front Med (Lausanne). 2022 Nov 17;9:955785. [PMID: 36465917; PMCID: PMC9713022 ✅ live-fetched v8.20 session. Author list expanded from "et al." in v8.20. Source for Demo Case 2 — Mr H.W. Note: a corrigendum exists at Front Med (Lausanne). 2022 Dec 22;9:1105448, doi:10.3389/fmed.2022.1105448 (PMID 36619615).] doi:10.3389/fmed.2022.955785
  21. Pandey A, Kitzman D, Whellan DJ, Duncan PW, Mentz RJ, Pastva AM, Nelson MB, Upadhya B, Chen H, Reeves GR. Frailty among older decompensated heart failure patients: prevalence, association with patient-centered outcomes, and efficient detection methods. JACC Heart Fail. 2019 Dec;7(12):1079–1088. [PMID: 31779931; PMCID: PMC8067953 ✅ live-fetched v8.20 session. Source for Demo Case 4 — Mr R.B.] doi:10.1016/j.jchf.2019.10.003
  22. Tarazona-Santabalbina FJ, Gómez-Cabrera MC, Pérez-Ros P, Martínez-Arnau FM, Cabo H, Tsaparas K, Salvador-Pascual A, Rodriguez-Mañas L, Viña J. A multicomponent exercise intervention that reverses frailty and improves cognition, emotion, and social networking in the community-dwelling frail elderly: a randomized clinical trial. J Am Med Dir Assoc. 2016 May;17(5):426–433. [PMID: 26947059 ✅ live-fetched v8.20 session. Source for Demo Case 4 — Mr R.B. cardiac context] doi:10.1016/j.jamda.2016.01.019
  23. Yoon DH, Lee J-Y, Song W. Effects of resistance exercise training on cognitive function and physical performance in cognitive frailty: a randomized controlled trial. J Nutr Health Aging. 2018;22(8):944–951. [PMID: 30272098 ✅ Re-verified v8.20 session (originally live-fetched v8.15). Source for Demo Case 5 — Mrs L.A. Previously cited erroneously as "Langlois F et al., Eur Geriatr Med, 2023" with a structurally invalid DOI (10.1016/j.eurger.2023.05.003). Correct authors, journal, year, and DOI confirmed by Roger and live PubMed record — corrected v8.15.] doi:10.1007/s12603-018-1090-9
  24. Bohannon RW. Reference values for the five-repetition sit-to-stand test: a descriptive meta-analysis of data from elders. Percept Mot Skills. 2006;103(1):215–222. [Meta-analysis of 13 papers; normative cut-offs for worse-than-average performance: >11.4 s (60–69 y), >12.6 s (70–79 y), >14.8 s (80–89 y); these values are displayed in the built-in 5×STS timer (v8.4). PMID: 17037663 ✅ live-fetched v8.19 session] doi:10.2466/pms.103.1.215-222
  25. Grgic J, Schoenfeld BJ, Maier AB, Pedisic Z. Reference values for the five-times-sit-to-stand test: a pooled analysis including 45,470 participants from 14 countries. GeroScience. 2026;48(2):3059–3067. [Normative dataset for FTSST percentile chart — added v8.2. SHARE Wave 5 (2013); n=45,470; 14 European countries; ages 50–90+; weighted percentiles by sex and 5-year age bands; PMID: 40875134] doi:10.1007/s11357-025-01863-8
  26. Alcazar J, Alegre LM, Van Roie E, Magalhães JP, Nielsen BR, González-Gross M, Júdice PB, Casajús JA, Delecluse C, Sardinha LB, Suetta C, Ara I. Relative sit-to-stand power: aging trajectories, functionally relevant cut-off points, and normative data in a large European cohort. J Cachexia Sarcopenia Muscle. 2021;12(4):921–932. [Source for STS power equation and mobility cut-offs — added v8.2. n=9,906 older adults + 586 young/middle-aged; cut-offs: 2.6 W/kg (M), 2.1 W/kg (F) for mobility limitation; PMID: 34216098] doi:10.1002/jcsm.12737
  27. Baltasar-Fernandez I, Alcazar J, Mañas A, Alegre LM, Alfaro-Acha A, Rodriguez-Mañas L, Ara I, García-García FJ, Losa-Reyna J. Relative sit-to-stand power cut-off points and their association with negative[s — sic] outcomes in older adults. Sci Rep. 2021;11(1):19460. [Source for 5×STS frailty/ADL cut-offs — added v8.2. n=1,369; cut-offs: 2.5 W/kg (M), 1.9 W/kg (F) for frailty and ADL limitations. PMCID: PMC8484545 ✅ live-fetched v8.19 session. Title typo finding (v8.19): the published title reads "negatives outcomes" (with anomalous plural). The typo is preserved across Nature.com, PMC, Springer Nature, and independent citing literature; FrailtyTrack pre-v8.19 silently corrected it. Now annotated [sic] above per scientific citation best practice.] doi:10.1038/s41598-021-98871-3
  28. Garcia-Aguirre M, Baltasar-Fernandez I, Alcazar J, Losa-Reyna J, Alfaro-Acha A, Ara I, Rodriguez-Mañas L, Alegre LM, Garcia-Garcia FJ. Cut-off points for low relative 30-s sit-to-stand power and their associations with adverse health conditions. J Cachexia Sarcopenia Muscle. 2025;16(1):e13676. [Source for 30s CST power cut-offs and MCID — added v8.2. Cut-offs: 2.53 W/kg (M), 2.01 W/kg (F); MCID: 0.42 W/kg (M), 0.33 W/kg (F); PMID: 39790033] doi:10.1002/jcsm.13676
  29. Coelho-Junior HJ, Marzetti E, Picca A, Tosato M, Calvani R, Landi F. Sex- and age-specific normative values of lower extremity muscle power in Italian community-dwellers. J Cachexia Sarcopenia Muscle. 2024;15(1):45–54. [Normative dataset for 5×STS power percentile chart — added v8.3. Lookup 7+ project; n=12,864 community-dwellers; Italy; ages 18–98; P5/P25/P50/P75/P95 by sex and 10-yr age band for relative power (W/kg); formula: P_rel = 0.9 × g × (height_m − 2 × chairH_m) × reps / time; Tables S3 (men) and S6 (women) extracted from supplementary material; PMID: 37986667] doi:10.1002/jcsm.13301
  30. Freitas SR, Cruz-Montecinos C, Ratel S, Pinto RS. Powerpenia Should be Considered a Biomarker of Healthy Aging. Sports Med Open. 2024;10(1):27. [Powerpenia narrative source — added v9.4.0. Argues that the loss of muscle power should be measured separately from sarcopenia (mass) and dynapenia (strength) because power decline starts earlier and progresses faster, and only 2 of 220 dynapenia studies between 2008 and 2023 directly measured power. Underlies the v9.4.0 Powerpenia note in the 5×STS card and the Sarkopenie–Dynapenie–Powerpenia triad in the BFH 2026 workshop script. PMID: 38523229; PMCID: PMC10961295. ✅ live-fetched v9.4.0 session] doi:10.1186/s40798-024-00689-6
  31. Strassmann A, Steurer-Stey C, Dalla Lana K, Zoller M, Turk AJ, Suter P, Puhan MA. Population-based reference values for the 1-min sit-to-stand test. Int J Public Health. 2013;58(6):949–953. [Swiss normative dataset for 1-minSTS — added v8.5. n=6,926 Swiss adults (community, nationwide campaign 2010–2012); ages 20–79 y; P2.5/P25/P50/P75/P97.5 by 5-yr age band and sex; chair height 46 cm; arms not used; median 50 reps (M, 20–24 y) declining to 30 reps (M, 75–79 y); PMID: 23974352] doi:10.1007/s00038-013-0504-z
  32. Simpkins C, Yang F. Muscle power is more important than strength in preventing falls in community-dwelling older adults. J Biomech. 2022;134:111018. [n=94 community-dwelling adults; 5×STS power discriminates fallers from non-fallers better than isometric knee strength; optimal threshold 12 s / 1.3 W/(kg·m); PMID: 35228153] doi:10.1016/j.jbiomech.2022.111018
  33. Yeung SSY, Reijnierse EM, Trappenburg MC, Hogrel J-Y, McPhee JS, Piasecki M, Sipilä S, Salpakoski A, Butler-Browne G, Pääsuke M, Gapeyeva H, Narici MV, Meskers CGM, Maier AB. Handgrip strength cannot be assumed a proxy for overall muscle strength. J Am Med Dir Assoc. 2018;19(8):703–709. [n=960 across 5 cohorts; ICC between HGS and KES poor–moderate (0.37–0.54); low agreement at individual level; HGS should not be assumed proxy for lower-limb strength. PMID: 29935982] doi:10.1016/j.jamda.2018.04.019
  34. Yeung SSY, Reijnierse EM, Trappenburg MC, Blauw GJ, Meskers CGM, Maier AB. Knee extension strength measurements should be considered as part of the comprehensive geriatric assessment. BMC Geriatr. 2018;18(1):130. [n=163 geriatric outpatients; KES showed stronger associations with physical, nutritional, cognitive, and functional health characteristics than HGS; inclusion of KES in CGA recommended. PMID: 29859054] doi:10.1186/s12877-018-0815-2
  35. Bohannon RW. Reference values for knee extension strength obtained by hand-held dynamometry from apparently healthy older adults: a meta-analysis. J Frailty Aging. 2017;6(4):199–201. [Normative %BW values for dominant knee extension (HHD); ages 60–79; range 35.6–48.8%BW; used as KES reference norms in FrailtyTrack. PMID: 29165536] doi:10.14283/jfa.2017.32
  36. Zheng H, Sun W, Zhou Z, Tian F, Xiao W, Zheng L. Cut-off points for knee extension strength: identifying muscle weakness in older adults. Eur Geriatr Med. 2024;15(4):913–925. [Systematic review of 12 studies; high heterogeneity; no consensus cut-off established; HHD-based isometric KES recommended as clinically practical; standardised approach needed. PMID: 38926333] doi:10.1007/s41999-024-01009-7
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  39. Kempen GIJM, Yardley L, van Haastregt JCM, Zijlstra GAR, Beyer N, Hauer K, Todd C. The Short FES-I: a shortened version of the Falls Efficacy Scale-International to assess fear of falling. Age Ageing. 2008;37(1):45–50. [Original Short FES-I 7-item development. Items 2, 4, 6, 7, 9, 15, 16 from FES-I; range 7–28; comparable psychometric properties to FES-I; suitable for rapid clinical assessment. ✅ live-fetched v9.2.1 session] doi:10.1093/ageing/afm157
  40. Dias N, Kempen GIJM, Todd CJ, Beyer N, Freiberger E, Piot-Ziegler C, Yardley L, Hauer K. The German version of the Falls Efficacy Scale—International Version (FES-I) [Die Deutsche Version der Falls Efficacy Scale—International Version (FES-I)]. Z Gerontol Geriatr. 2006;39(4):297–300. [Validated German FES-I translation by the Heidelberg Bethanien team (Klaus Hauer). Manchester ProFaNE site classifies the German FES-I as "Validated" status. ✅ live-fetched v9.2.1 session] doi:10.1007/s00391-006-0400-8
  41. Delbaere K, Close JCT, Mikolaizak AS, Sachdev PS, Brodaty H, Lord SR. The Falls Efficacy Scale International (FES-I): a comprehensive longitudinal validation study. Age Ageing. 2010;39(2):210–216. [Definitive cut-points for FES-I and Short FES-I. Sydney Memory and Ageing Study; n=500 community-dwelling adults ≥70 y; FES-I cut-points: Low 16–19 / Moderate 20–27 / High 28–64; Short FES-I cut-points: Low 7–8 / Moderate 9–13 / High 14–28. PMID: 20061508 ✅ live-fetched v9.2.1 session] doi:10.1093/ageing/afp225
  42. Hauer KA, Kempen GIJM, Schwenk M, Yardley L, Beyer N, Todd C, Oster P, Zijlstra GAR. Validity and sensitivity-to-change of the Falls Efficacy Scales International to assess fear of falling in older adults with and without cognitive impairment. Gerontology. 2011;57(5):462–472. [FES-I validation in cognitive impairment. Geriatric rehabilitation patients with and without cognitive impairment; Cronbach's α=0.92; demonstrates feasibility in older adults with mild-to-moderate cognitive impairment. ✅ live-fetched v9.2.1 session] doi:10.1159/000320054
  43. Kaiser MJ, Bauer JM, Ramsch C, Uter W, Guigoz Y, Cederholm T, Thomas DR, Anthony P, Charlton KE, Maggio M, Tsai AC, Grathwohl D, Vellas B, Sieber CC; MNA-International Group. Validation of the Mini Nutritional Assessment short-form (MNA-SF): A practical tool for identification of nutritional status. J Nutr Health Aging. 2009;13(9):782–788. [Source for the MNA-SF protocol card — added v9.4.0. Validation of the revised 6-item MNA-SF against the full MNA in a multinational n=2,032 dataset (mean age 82.3 y). Thresholds 12–14 normal / 8–11 risk / 0–7 malnourished. The revised MNA-SF allows substitution of calf circumference (CC) for BMI when BMI cannot be measured, enabling use in immobile or non-stehfähige patients. PMID: 19812868. ✅ live-fetched v9.4.0 session] doi:10.1007/s12603-009-0214-7
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  45. Frehner D, Knuchel-Schnyder S, Zindel B, Bruderer-Hofstetter M, Pfenninger B. Sturzprävention in der Physiotherapie: Grundlagen und Empfehlungen für die Praxis. Bern: BFU, Beratungsstelle für Unfallverhütung; 2021. Fachdokumentation 2.249, 44 Seiten. [Companion BFU document to the StoppSturz Manual — deeper scientific grounding and practice recommendations. DOI verified via converging references and BFU document numbering scheme ✅ v9.2.2 session] doi:10.13100/BFU.2.249.01.2021
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  47. Yingyongyudha A, Saengsirisuwan V, Panichaporn W, Boonsinsukh R. The Mini-Balance Evaluation Systems Test (Mini-BESTest) demonstrates higher accuracy in identifying older adult participants with history of falls than do the BESTest, Berg Balance Scale, or Timed Up and Go Test. J Geriatr Phys Ther. 2016;39(2):64–70. [Mini-BESTest community-dwelling cut-off ≤16/28. Used by StoppSturz for older adults with/without fall history. Verified via citation in StoppSturz Manual] doi:10.1519/JPT.0000000000000050
  48. Cramer E, Weber F, Faro G, Klein M, Willeke D, Hering T, Zietz D. Cross-cultural adaption and validation of the German version of the Mini-BESTest in individuals after stroke: an observational study. Neurol Res Pract. 2020;2:27. [Validated DACH-region German version (GVMBT) of the Mini-BESTest. Hochschule für Gesundheit Bochum; n=50 sub-acute/chronic stroke (NIHSS 0–7); 16 min administration; Cronbach's α = 0.90 (95% CI 0.87–0.94); convergent validity ρBBS = 0.93, ρTUG = −0.85; ceiling 2% (vs BBS 14% in same sample); no floor effect. Open Access (CC BY 4.0). ✅ live-fetched v9.2.3 session, full PDF reviewed] doi:10.1186/s42466-020-00078-w
  49. Di Carlo S, Bravini E, Vercelli S, Massazza G, Ferriero G. The Mini-BESTest: a review of psychometric properties. Int J Rehabil Res. 2016;39(2):97–105. [Systematic review of Mini-BESTest psychometric properties. Source for the often-cited "Cronbach's α 0.89–0.96 across populations", "Pearson r 0.79–0.94 with BBS", and "ceiling 0.9–4.3% across populations" ranges. Reference 16 in Cramer 2020. PMID 26795715] doi:10.1097/MRR.0000000000000153
  50. Bergström M, Lenholm E, Franzén E. Translation and validation of the Swedish version of the Mini-BESTest in subjects with Parkinson's disease or stroke: a pilot study. Physiother Theory Pract. 2012;28(7):509–514. [Swedish Mini-BESTest pilot validation. Reference 20 in Cramer 2020. Cited in StoppSturz Manual literature list. PMID 22288725] doi:10.3109/09593985.2011.653707
  51. Berg KO, Wood-Dauphinee SL, Williams JI, Gayton D. Measuring balance in the elderly: preliminary development of an instrument. Physiother Can. 1989;41(6):304–311. [Original Berg Balance Scale paper. 14-item, 56-point ordinal balance assessment now used worldwide. Foundational reference for all subsequent BBS validation work] doi:10.3138/ptc.41.6.304
  52. Scherfer E, Bohls C, Freiberger E, Heise K-F, Hogan D. Berg-Balance-Scale — deutsche Version. Übersetzung eines Instruments zur Beurteilung von Gleichgewicht und Sturzgefährdung. physioscience. 2006;2:59–66. [Authorised DACH German version of the BBS. Cross-cultural adaptation following Beaton et al. recommendations. Authorised by and developed in correspondence with original author Katherine Berg (Erlangen Conference 2005-10-08). Permissive license: free use with citation of original and this publication. ✅ live-fetched v9.2.4 session, full PDF reviewed] doi:10.1055/s-2006-926833
  53. Shumway-Cook A, Baldwin M, Polissar NL, Gruber W. Predicting the probability for falls in community-dwelling older adults. Phys Ther. 1997;77(8):812–819. [BBS <36/56 = nearly 100% fall risk in community-dwelling older adults. Foundational fall-risk threshold paper, n=44. Non-linear relationship between BBS score and fall probability. PMID 9256869] doi:10.1093/ptj/77.8.812
  54. Steffen TM, Hacker TA, Mollinger L. Age- and gender-related test performance in community-dwelling elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and gait speeds. Phys Ther. 2002;82(2):128–137. [BBS, 6MWT, TUG, gait-speed normative values for community-dwelling older adults. n=96, ages 61–89. Anglo-American normative reference. PMID 11856064] doi:10.1093/ptj/82.2.128
  55. Muir SW, Berg K, Chesworth B, Speechley M. Use of the Berg Balance Scale for predicting multiple falls in community-dwelling elderly people: a prospective study. Phys Ther. 2008;88(4):449–459. [Definitive paper showing dichotomous BBS cut-offs are unreliable; recommends likelihood ratios across the score range. n=210 community-dwelling, 12-month prospective cohort. Concluded "use of the BBS as a dichotomous scale to identify people at high risk for falling should be discouraged because it fails to identify the majority of such people." Lower scores (especially <40) signal substantially elevated multiple-fall risk. PMID 18218822] doi:10.2522/ptj.20070251
  56. Donoghue D, Stokes EK. How much change is true change? The minimum detectable change of the Berg Balance Scale in elderly people. J Rehabil Med. 2009;41(5):343–346. [BBS MDC95 values, score-stratified. n=118 elderly without stroke/Parkinson's/recent hip arthroplasty. Multi-centre test-retest design. Score-dependent MDC: higher MDC at lower baseline scores] doi:10.2340/16501977-0337
  57. Álvarez-Bustos A, Andres-Lacueva C, Ara I, Arévalo MA, Bolaños JP, Coto-Montes A, Enriquez JA, Escames G, García-García FJ, Gómez-Cabrera MC, Grau-Rivera O, Izquierdo M, Martínez Velilla N, Matheu A, Menéndez Colino R, Muñoz Torres M, Nogués X, Oliva J, Orts-Cortés MI, Párraga Martínez I, Priego F, Rabassa-Bonet M, Rol MA, Serra-Rexach JA, Tarazona-Santabalbina FJ, Rodríguez-Mañas L, Abizanda P, for the CIBERFES working group. Consensus document on frailty: conceptualization, detection, multidisciplinary management and future roadmap. J Nutr Health Aging. 2026;30:100793. [2026 European consensus position statement from CIBERFES (Spanish Research Consortium on Frailty and Healthy Aging, Instituto de Salud Carlos III, 25 research groups). Definition, what frailty is/is not, recommended assessment (SPPB, gait speed, FRAIL Scale, Fried phenotype + FTS5), multicomponent management, stigma, sub-phenotypes, future roadmap. Open Access CC BY-NC-ND 4.0. Available online 28 Jan 2026. Surfaced in the FrailtyTrack About-tab "Position Statements & Consensus" section. ✅ live-fetched v9.2.5 session via digital.csic.es open repository, full PDF reviewed] doi:10.1016/j.jnha.2026.100793
  58. Garcia-Aguirre M, Baltasar-Fernandez I, Alcazar J, Alfaro-Acha A, Bareiro-Quiñonez FA, Ara I, Rodriguez-Mañas L, Garcia-Garcia FJ, Alegre LM. Low relative sit-to-stand power is associated with the development of adverse health outcomes: a 5-year longitudinal study. J Cachexia Sarcopenia Muscle. 2025;16:e13852. [5-year longitudinal evidence linking low relative STS power to adverse health outcomes. CIBERFES authorship; cited by Álvarez-Bustos 2026 as the primary support for muscle power as a "promising marker of frailty" given that powerpenia occurs earlier and progresses faster than reductions in muscle size and strength. Complements the Garcia-Aguirre 2025 cross-sectional cut-off paper (e13676) already in this bibliography. ✅ live-fetched v9.2.5 session] doi:10.1002/jcsm.13852
  59. García-García FJ, Carnicero JA, Losa-Reyna J, Alfaro-Acha A, Castillo-Gallego C, Rosado-Artalejo C, Gutiérrrez-Ávila G[sic], Rodriguez-Mañas L. Frailty Trait Scale–Short Form: A Frailty Instrument for Clinical Practice. J Am Med Dir Assoc. 2020;21(9):1260–1266.e2. [Source paper for the Frailty Trait Scale–Short Form (FTS5) — added to bibliography in v9.7.1. Item-reduction of the 12-item FTS via AUC-maximisation against age-, sex-, and Charlson-adjusted models for mortality, hospitalisation, disability, and incident frailty (Fried Phenotype + Frailty Index) in n=1,634 from the Toledo Study for Healthy Aging. FTS5 items: BMI, PASE, gait speed, grip strength, progressive Romberg; range 0–50; cut-off >25 = frail. Frailty prevalence by FTS5 = 24% vs 8% by Fried Phenotype in the same sample (p. 1263, Table 5). Pedagogical strength: in Fried-prefrail participants, FTS5 stratifies 35% into a high-risk frail group (mortality OR 4.0; incident frailty OR 6.6–8.7) and 65% into a near-baseline-risk group — addressing the dichotomy limitation of Fried phenotype scoring. Recommended as a complement to Fried phenotype by CIBERFES (Álvarez-Bustos 2026). Triple-r author spelling Gutiérrrez-Ávila preserved verbatim as published (consistent across PubMed PMID 32005416, ScienceDirect PII S1525861019308680, UVa & UCa institutional repositories, citing literature) — same convention as the Baltasar-Fernandez 2021 «negative[s] outcomes» published-record idiosyncrasy. FrailtyTrack status: bibliography + ref-chips only in v9.7.1 (closes a citation hole that pre-existed since the Position Statements card was added in v9.2.5); full instrument-card integration scheduled for v9.8 per the v9.7.0 scoping decision (option 3 of 4). PMID 32005416, epub 29 Jan 2020. ✅ live-fetched v9.7.1 session, all 5 fields confirmed via DOI resolution + PubMed + UVa/UCa + uploaded PDF] doi:10.1016/j.jamda.2019.12.008
  60. Izquierdo M, de Souto Barreto P, Arai H, Bischoff-Ferrari HA, Cadore EL, Cesari M, Chen LK, Coen PM, Courneya KS, Duque G, Ferrucci L, Fielding RA, García-Hermoso A, Gutiérrez-Robledo LM, Harridge SDR, Kirk B, Kritchevsky S, Landi F, Lazarus N, Liu-Ambrose T, Marzetti E, Merchant RA, Morley JE, Pitkälä KH, Ramírez-Vélez R, Rodriguez-Mañas L, Rolland Y, Ruiz JG, Sáez de Asteasu ML, Villareal DT, Waters DL, Won Won C, Vellas B, Fiatarone Singh MA. Global consensus on optimal exercise recommendations for enhancing healthy longevity in older adults (ICFSR). J Nutr Health Aging. 2025;29(1):100401. [ICFSR 2025 global exercise consensus. Multicomponent prescription: strength + power + balance/gait + aerobic + flexibility. Endorsed by Álvarez-Bustos 2026. Vivifrail program (vivifrail.com) recommended as capacity-tailored prescription tool. PMID 39743381. Note DOI uses 2024 prefix despite 2025 issue. ✅ live-fetched v9.2.5 session] doi:10.1016/j.jnha.2024.100401
  61. Rodriguez-Mañas L, Féart C, Mann G, Viña J, Chatterji S, Chodzko-Zajko W, et al. (FOD-CC group). Searching for an operational definition of frailty: a Delphi method based consensus statement. The Frailty Operative Definition-Consensus Conference Project. J Gerontol A Biol Sci Med Sci. 2013;68(1):62–67. [Foundational frailty operational-definition Delphi consensus. Cited as reference [11] in Álvarez-Bustos 2026 as the basis for CIBERFES's "agreed by a group of experts using the Delphi method" definition. Establishes frailty as predisposing primarily to disability. PMID 22511289. ✅ live-fetched v9.2.5 session] doi:10.1093/gerona/gls119
  62. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):752–762. [Canonical Lancet review on frailty. Surfaces the two-model framework (Fried phenotype vs Rockwood deficit accumulation) as foundational background. Used in Background tab Section 1.1 / 1.3 / 1.6. PMID 23395245. ✅ live-fetched v9.2.6 session] doi:10.1016/S0140-6736(12)62167-9
  63. Hoogendijk EO, Afilalo J, Ensrud KE, Kowal P, Onder G, Fried LP. Frailty: implications for clinical practice and public health. Lancet. 2019;394(10206):1365–1375. [Lancet review on clinical and public-health implications. Cited as reference [166] in Álvarez-Bustos 2026 for frailty as the "main modifiable factor" associated with mortality in older adults. Used in Background tab Section 1.2 / 1.5 / 1.6. PMID 31609228. ✅ live-fetched v9.2.6 session] doi:10.1016/S0140-6736(19)31786-6
  64. Dent E, Martin FC, Bergman H, Woo J, Romero-Ortuno R, Walston JD. Management of frailty: opportunities, challenges, and future directions. Lancet. 2019;394(10206):1376–1386. [Companion Lancet paper to Hoogendijk 2019, focusing on the management side of the same Lancet frailty themed issue. PMID 31609229. ✅ live-fetched v9.2.6 session] doi:10.1016/S0140-6736(19)31785-4
  65. Dent E, Clegg A, Roller-Wirnsberger R, Vetrano DL, Hoogendijk EO. Reorienting frailty in clinical practice, public health, and policy: the Lancet Commission on Frailty. Lancet. 2025;405(10497):2265–2266. [Lancet Commission on Frailty — programme announcement. Co-Chairs Dent & Hoogendijk, 21 commissioners, 4 priority areas (life-course recognition; diagnostic framework with ICD/ICF correlation; cross-specialty management; public-health policy adoption). Aligned with UN Decade of Healthy Ageing 2021–2030, WHO World Report on Ageing and Health, and the World Health Assembly primary-care reorientation. Important framing: programme document, not finalised consensus — substantive report pending. Open Access (CC BY 4.0). Surfaced in the FrailtyTrack About-tab "Position Statements & Consensus" Lancet card, and cited in Background Section 1.1 / 1.2 / 1.9. Verified via University of Leeds White Rose institutional repository (eprints.whiterose.ac.uk/237353) plus 3 corroborating sources (Lancet website search snippet, Karolinska press release, Mirage News). ✅ live-fetched v9.3.0 session, all 5 fields confirmed] doi:10.1016/S0140-6736(25)01101-8
  66. Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of deficits as a proxy measure of aging. Scientific World Journal. 2001;1:323–336. [Original deficit-accumulation Frailty Index paper. Foundation of the Rockwood-tradition deficit-accumulation operational model. Used in Background tab Section 1.3 to anchor the deficit-accumulation column of the two-model comparison. ✅ live-fetched v9.2.6 session] doi:10.1100/tsw.2001.58
  67. Buta BJ, Walston JD, Godino JG, Park M, Kalyani RR, Xue QL, Bandeen-Roche K, Varadhan R. Frailty assessment instruments: systematic characterization of the uses and contexts of highly-cited instruments. Ageing Res Rev. 2016;26:53–61. [Systematic review of frailty assessment instruments — their uses and clinical contexts. Cited as reference [35] in Álvarez-Bustos 2026 in the boundary-statements section. Used in Background tab Section 1.3 to anchor the comparison of operational models. ✅ live-fetched v9.2.6 session] doi:10.1016/j.arr.2015.12.003
  68. Bernabei R, Landi F, Calvani R, Cesari M, Del Signore S, Anker SD, et al.; SPRINTT consortium. Multicomponent intervention to prevent mobility disability in frail older adults: randomised controlled trial (SPRINTT project). BMJ. 2022;377:e068788. [SPRINTT RCT (n=1,519 across 11 European countries; evaluator-blinded). Multicomponent physical activity + nutritional counselling prevented mobility disability in older adults with physical frailty and sarcopenia in the SPPB 8–9 stratum. Cited as reference [43] in Álvarez-Bustos 2026 as the foundational frailty-intervention RCT. Used in Background tab Section 1.2 / 1.6 / 1.7. PMID 35545258. ✅ live-fetched v9.2.6 session] doi:10.1136/bmj-2021-068788
  69. Travers J, Romero-Ortuno R, Bailey J, Cooney MT. Delaying and reversing frailty: a systematic review of primary care interventions. Br J Gen Pract. 2019;69(678):e61–e69. [Systematic review of primary-care interventions for delaying or reversing frailty — multicomponent exercise found to be consistently effective in community settings. Cited as reference [84] in Álvarez-Bustos 2026 in the management section. Used in Background tab Section 1.2 / 1.6. ✅ live-fetched v9.2.6 session] doi:10.3399/bjgp18X700241
  70. Malmstrom TK, Miller DK, Simonsick EM, Ferrucci L, Morley JE. SARC-F: a symptom score to predict persons with sarcopenia at risk for poor functional outcomes. J Cachexia Sarcopenia Muscle. 2016;7(1):28–36. [Primary validation of SARC-F. AAH, BLSA, and NHANES cohorts; cut-off ≥4/10; internally consistent and valid for sarcopenia risk and adverse outcomes. PMID: 27066316 ✅] doi:10.1002/jcsm.12048
  71. Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive 'vital signs' measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000;15(11):1021–1027. [Original Mini-Cog development and validation. n=249; sensitivity 99%, correctly classified 96%; no influence of education or language; 3-minute administration. PMID: 11113982 ✅] doi:10.1002/1099-1166(200011)15:11<1021::AID-GPS234>3.0.CO;2-6
  72. Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695–699. [Original MoCA validation. n=277; sensitivity 90% (MCI) / 100% (AD) at cut-off ≤25; 10-minute administration; PMID: 15817019 ✅] doi:10.1111/j.1532-5415.2005.53221.x
  73. Montero-Odasso M, Muir SW, Speechley M. Dual-task complexity affects gait in people with mild cognitive impairment: the interplay between gait variability, dual tasking, and risk of falls. Arch Phys Med Rehabil. 2012;93(2):293–299. [Foundational DT-TUG study. MCI (n=43) vs controls (n=25); dual-task gait variability significantly higher in MCI; arithmetic task more demanding than naming task; PMID: 22289240 ✅] doi:10.1016/j.apmr.2011.08.026
  74. Bishop DJ, Beck B, Biddle SJH, Denay KL, Ferri A, Gibala MJ, Headley S, Jones AM, Jung M, Lee MJ-C, Moholdt T, Newton RU, Nimphius S, Pescatello LS, Saner NJ, Tzarimas C. Physical Activity and Exercise Intensity Terminology: A Joint American College of Sports Medicine (ACSM) Expert Statement and Exercise and Sport Science Australia (ESSA) Consensus Statement. Med Sci Sports Exerc. 2025;57(11):2599–2613. [Anchor reference for FrailtyTrack §4.2 (Background tab, training-in-frailty chapter, added v9.9.0). Joint ACSM Expert Statement / ESSA Consensus Statement proposing standardised exercise-intensity terminology with utility across all ages, sexes, conditions and activities. Five-tier framework (Very Low / Low / Moderate / High / Very High) plus five matched perception-of-effort descriptors (very easy / easy / somewhat hard / hard / very hard). Cross-walked against MT1 (lactate / gas-exchange / ventilatory threshold), MT2 (MLSS, critical power, RCP), Wₘₐₓ, %1RM, RIR, RPE10, RPE20, %HRR, %VO2max, METs — concluding that %VO2max, %HRmax, %HRR, and METs do not adequately partition individuals into category-specific physiological responses, and that for resistance exercise RIR (proximity to neuromuscular failure) is more transferable than %1RM. Co-published simultaneously in J Sci Med Sport 2025;28(12):980–991, doi:10.1016/j.jsams.2024.11.004 (PMID 41093682) — identical content. Pre-session memory drift caught: the v9.7.x cumulative memory had this DOI as 10.1249/MSS.0000000000003576 — incorrect; the correct MSSE DOI is 10.1249/MSS.0000000000003795, confirmed by 4 independent primary sources (PubMed PMID 41093682, LWW journal page, Ovid LWW, ACSM Science Spotlight). Per Rule 1, the correct DOI is what FrailtyTrack uses. ✅ live-fetched v9.9.0 session, all 5 fields verified.] doi:10.1249/MSS.0000000000003795
  75. Currier BS, D'Souza AC, Fiatarone Singh MA, Lowisz CV, Rawson ES, Schoenfeld BJ, Smith-Ryan AE, Steen JP, Thomas GA, Triplett NT, Washington TA, Werner TJ, Phillips SM. American College of Sports Medicine Position Stand. Resistance Training Prescription for Muscle Function, Hypertrophy, and Physical Performance in Healthy Adults: An Overview of Reviews. Med Sci Sports Exerc. 2026;58(4):851–872. [Anchor reference for FrailtyTrack §4.4 (FITT-VP variables) and partial anchor for §4.3 (multicomponent prescription), added v9.9.0. ACSM 2026 Position Stand updating the 2009 progression-models stand. Overview of 137 systematic reviews, ~30,000 participants, AMSTAR-scored, GRADE-style adapted certainty framework. Open Access CC BY-NC-ND 4.0. Key umbrella-review-grade findings highly relevant to frail and pre-frail populations: strength is enhanced by ≥80% 1RM, full ROM, 2–3 sets, ≥2 sessions/wk, exercise early in session; hypertrophy by higher volumes (≥10 sets/muscle/wk) and eccentric overload; power by moderate loads (30–70% 1RM), low-to-moderate volume, Olympic-style and power RT; physical function (gait speed, chair stand, TUG, walking) is specifically enhanced by power RT. Conversely: training to failure, equipment type, exercise complexity, set structure, time under tension, blood-flow restriction, and periodisation do not consistently impact training outcomes — these are 'optional' RTx variables. Important caveat for FrailtyTrack's frail/pre-frail focus: 'healthy adults' explicitly excluded obesity, sarcopenia and physical frailty, so prescription specifics for frail older adults must be modulated through the CIBERFES/Izquierdo ICFSR 2025 multicomponent framework. PMC PMC12965823. PMID forthcoming. Roger uploaded the primary PDF as Currier_2025_ACSM_Resistance_Training_Prescription.pdf (acceptance 2025; print 2026). ✅ live-fetched v9.9.0 session, 5 independent primary sources, all 5 fields verified.] doi:10.1249/MSS.0000000000003897
  76. Izquierdo M, Rodriguez-Mañas L, Casas-Herrero A, Martinez-Velilla N, Cadore EL, Sinclair AJ. Is It Ethical Not to Prescribe Physical Activity for the Elderly Frail? J Am Med Dir Assoc. 2016;17(9):779–781. [Anchor reference for FrailtyTrack §4.1 (rationale chapter), added v9.9.0. Position-statement editorial framing the ethical case for prescribing physical activity in frail older adults — that omitting an evidence-based, low-harm, first-line intervention for a remediable condition has its own ethical weight. Cited in Álvarez-Bustos 2026 CIBERFES §10.1 as ref [93]. Authored by core CIBERFES / Vivifrail group (Izquierdo, Rodriguez-Mañas, Casas-Herrero, Martinez-Velilla) plus Cadore (Federal University of Rio Grande do Sul) and Sinclair (Aston / Diabetes Frail). Funded by Spanish Net on Aging and Frailty (RETICEF) and the Erasmus+ Vivifrail project (556988-EPP-1-2014-1-ES-SPO-SCP). ✅ live-fetched v9.9.0 session, 3 independent primary sources, all 5 fields verified.] doi:10.1016/j.jamda.2016.06.015
  77. Pelland JC, Remmert JF, Robinson ZP, Hinson SR, Zourdos MC. The Resistance Training Dose Response: Meta-Regressions Exploring the Effects of Weekly Volume and Frequency on Muscle Hypertrophy and Strength Gains. Sports Med. 2026;56(2):481–505. [Complementary dose-response anchor for FrailtyTrack §4.4 (FITT-VP volume and frequency variables), added v9.9.0. Multi-level meta-regression of 67 studies, 2,058 participants. Important methodological refinement: classifies sets as 'direct' (specific to outcome) vs 'indirect' (shared muscle activation), with indirect sets quantified at 1 (total), 0.5 (fractional), or 0 (direct only) — resolving heterogeneity that has plagued earlier volume meta-analyses. Findings: dose-response for both volume and frequency with diminishing returns, and for per-session volume a 'point of undetectable outcome superiority' beyond which additional sets do not yield >50% likelihood of detectable additional benefit. Practical translation for the frailty audience: the volume-response curve is real but plateaus quickly, so substantial gains accrue at low-moderate doses. PubMed PMID 41343037. Cited in Currier 2026 (ref [187]). Pre-session memory drift caught: v9.7.x memory had this as 'online ahead of print'; the paper has now appeared in print as Sports Med. 2026;56(2):481–505 (Epub 4 Dec 2025). FrailtyTrack uses the print citation per Rule 1. Note: Currier 2026's reference list contains two transcription typos in their citation of this paper ('Zourdous' and 'muslce') — these are errors in Currier's record, not idiosyncrasies in Pelland's published record, so Rule 7 [sic] preservation does not apply. ✅ live-fetched v9.9.0 session, 4 independent primary sources, all 5 fields verified.] doi:10.1007/s40279-025-02344-w
  78. Ma N, Lu Z, Mei X, Ma L, Zhang Q. The effectiveness of exercise interventions on muscle strength and balance function in pre-frail older adults: a systematic review and Bayesian network meta-analysis. Front Public Health. 2026;13:1718120. [Supplementary anchor for FrailtyTrack §4.3 (multicomponent prescription, Background tab), added v9.9.0. Bayesian NMA of 17 RCTs, 1,107 pre-frail older adults aged ≥60; 10 distinct exercise interventions compared. Headlines: elastic band exercise highest SUCRA for handgrip strength (87.51%; pooled MD 5.2 kg, 95% CI 0.64–9.8 vs control); progressive exercise + Tai-chi snacking program highest SUCRA for SPPB (90.03%); multicomponent training significantly superior to control for SPPB (MD 1.13 points, 95% CI 0.13–2.10); no exercise modality reached significance vs control for TUG (limited power, n=263 across 6 RCTs). Pre-frail-only scope; not directly applicable to frail or post-acute populations. PROSPERO CRD420251005061. Online 23 Dec 2025; published 27 Jan 2026. ISSN 2296-2565. ✅ live-fetched v9.9.0 session against Frontiers publisher record, all 5 fields verified.] doi:10.3389/fpubh.2025.1718120
  79. Yang H, Wang B, Wang Q, Zhao J, Liu F, Xie X, Xu F, Zhang P. Effect of multicomponent exercise and nutrition intervention on frailty status in older adults: a network meta-analysis. BMC Geriatr. 2026;26(1):343. [Primary anchor for FrailtyTrack §4.3 combined-intervention claim (multicomponent prescription, Background tab), added v9.9.0. Frequentist NMA of 22 RCTs, 2,055 older adults aged ≥60 with pre-frailty, frailty, or frailty-related risks (including one cognitive-frailty trial: Falck 2025). Compared multicomponent exercise alone, nutritional supplementation alone (protein/amino acids), combined exercise+nutrition vs standard care. Headlines: for frailty score, combined intervention most effective (SMD −0.92, 95% CI −1.43 to −0.40), multicomponent alone significantly effective (SMD −0.78, 95% CI −1.15 to −0.43); for SPPB, only multicomponent alone reached significance (SMD +1.85, 95% CI +0.33 to +3.50); for gait speed, only nutrition alone significant (SMD +0.37, 95% CI +0.06 to +0.68). The «combined > multicomponent alone for frailty score» finding extends EWGSOP2 «resistance + protein optimisation» framing into NMA-grade evidence. Anomalous TUG signal: Yang 2026 reports multicomponent exercise alone increased TUG completion time by 3.96 s (SMD, 95% CI +0.91 to +7.07); authors speculate short-term muscular fatigue. Inconsistent with broader functional-performance literature and Ma 2026 null-significance TUG finding; FrailtyTrack §4.3 draws on Yang 2026 for frailty-score and SPPB findings only and treats the TUG signal as anomalous pending replication. PROSPERO CRD420251038055. Published 09 Feb 2026. ISSN 1471-2318. ✅ live-fetched v9.9.0 session against Springer/BMC Geriatrics publisher record, all 5 fields verified.] doi:10.1186/s12877-026-07111-8
  80. Alcazar J, Aagaard P, Haddock B, Kamper RS, Hansen SK, Prescott E, Ara I, Alegre LM, Frandsen U, Suetta C. Assessment of functional sit-to-stand muscle power: cross-sectional trajectories across the lifespan. Exp Gerontol. 2021;152:111448. [Copenhagen Sarcopenia Study; n=1,305; ages 20–93 y; 30s-STS power trajectories; steep decline after 50 y; PMID: 34118352 ✅] doi:10.1016/j.exger.2021.111448

EWGSOP2 Cut-off Source References (added v8.18 — live-fetched this session)

These references are explicitly cited in EWGSOP2 Table 3 as the empirical source of each cut-off point. All six entries below were live-fetched on PubMed in the v8.18 session and confirmed for authors, title, journal, volume/issue/pages, and DOI.

  1. Studenski SA, Peters KW, Alley DE, Cawthon PM, McLean RR, Harris TB, Ferrucci L, Guralnik JM, Fragala MS, Kenny AM, Kiel DP, Kritchevsky SB, Shardell MD, Dam TL, Vassileva MT. The FNIH Sarcopenia Project: rationale, study description, conference recommendations, and final estimates. J Gerontol A Biol Sci Med Sci. 2014;69(5):547–558. [Foundation for the National Institutes of Health Biomarkers Consortium; pooled analysis defining clinically relevant cut-offs for grip strength & lean mass; cited in EWGSOP2 Table 3 for ASM <20 kg M / <15 kg W. PMID: 24737557 ✅ live-fetched v8.18 session] doi:10.1093/gerona/glu010
  2. Cesari M, Kritchevsky SB, Newman AB, Simonsick EM, Harris TB, Penninx BW, Brach JS, Tylavsky FA, Satterfield S, Bauer DC, Rubin SM, Visser M, Pahor M; Health, Aging and Body Composition Study. Added value of physical performance measures in predicting adverse health-related events: results from the Health, Aging And Body Composition Study. J Am Geriatr Soc. 2009;57(2):251–259. [Health ABC cohort, n=3,024; cited in EWGSOP2 Table 3 as the source for the chair-stand cut-off >15 s for 5 rises. PMID: 19207142 ✅ live-fetched v8.18 session] doi:10.1111/j.1532-5415.2008.02126.x
  3. Pavasini R, Guralnik J, Brown JC, di Bari M, Cesari M, Landi F, Vaes B, Legrand D, Verghese J, Wang C, Stenholm S, Ferrucci L, Lai JC, Bartes AA, Espaulella J, Ferrer M, Lim JY, Ensrud KE, Cawthon P, Turusheva A, Frolova E, Rolland Y, Lauwers V, Corsonello A, Kirk GD, Ferrari R, Volpato S, Campo G. Short Physical Performance Battery and all-cause mortality: systematic review and meta-analysis. BMC Med. 2016;14(1):215. [Pooled individual-participant data from 17 cohorts; SPPB <10 strongly predictive of all-cause mortality; cited in EWGSOP2 Table 3 as evidence basis for the ≤8 cut-off. PMID: 28003033 ✅ live-fetched v8.18 session] doi:10.1186/s12916-016-0763-7
  4. Bischoff HA, Stähelin HB, Monsch AU, Iversen MD, Weyh A, von Dechend M, Akos R, Conzelmann M, Dick W, Theiler R. Identifying a cut-off point for normal mobility: a comparison of the timed 'up and go' test in community-dwelling and institutionalised elderly women. Age Ageing. 2003;32(3):315–320. [n=413 community-dwelling + n=78 institutionalised women, age 65–85 y; cited in EWGSOP2 Table 3 as the source for TUG ≥20 s cut-off; community women never exceed 20 s. PMID: 12720619 ✅ live-fetched v8.18 session] doi:10.1093/ageing/32.3.315
  5. Abellan van Kan G, Rolland Y, Andrieu S, Bauer J, Beauchet O, Bonnefoy M, Cesari M, Donini LM, Gillette Guyonnet S, Inzitari M, Nourhashemi F, Onder G, Ritz P, Salva A, Visser M, Vellas B. Gait speed at usual pace as a predictor of adverse outcomes in community-dwelling older people: an International Academy on Nutrition and Aging (IANA) Task Force. J Nutr Health Aging. 2009;13(10):881–889. [Expert task force; gait speed validated as single-item predictor of disability, falls, mortality; underpins EWGSOP2 gait-speed ≤0.8 m/s severity cut-off. Distinct from Abellan van Kan 2008 (IANA Task Force on Frailty, doi:10.1007/BF02982161, PMID:18165842) listed below in the questionnaire reference block. PMID: 19924348 ✅ live-fetched v8.18 session] doi:10.1007/s12603-009-0246-z
  6. Ishii S, Tanaka T, Shibasaki K, Ouchi Y, Kikutani T, Higashiguchi T, Obuchi SP, Ishikawa-Takata K, Hirano H, Kawai H, Tsuji T, Iijima K. Development of a simple screening test for sarcopenia in older adults. Geriatr Gerontol Int. 2014;14 Suppl 1:93–101. [Kashiwa Study; n=1,971 community-dwelling adults ≥65 y; equation-derived score using age, grip strength & calf circumference; recommended by EWGSOP2 as a more formal case-finding alternative to SARC-F in higher-risk populations. PMID: 24450566 ✅ live-fetched v8.18 session] doi:10.1111/ggi.12197

SARC-F Scientific Evaluation References (added v8.21 — live-fetched this session)

Thirteen references underpinning the dedicated Background: Sarcopenia tab. All entries below were live-fetched on PubMed and the publisher's site during the v8.21 session and confirmed for authors, title, journal, volume/issue/pages, and DOI. Cruz-Jentoft 2019 / EWGSOP2 is also listed in the v8.18 block above and is cross-referenced here for completeness.

  1. Malmstrom TK, Morley JE. SARC-F: a simple questionnaire to rapidly diagnose sarcopenia. J Am Med Dir Assoc. 2013;14(8):531–532. [Original SARC-F editorial. Introduced the 5-item self-report screen (S-A-R-C-F) by analogy with FRAX; cut-off ≥4 proposed as predictive of sarcopenia and adverse functional outcomes. PMID: 23810110 ✅ live-fetched v8.21 session] doi:10.1016/j.jamda.2013.05.018
  2. Malmstrom TK, Miller DK, Simonsick EM, Ferrucci L, Morley JE. SARC-F: a symptom score to predict persons with sarcopenia at risk for poor functional outcomes. J Cachexia Sarcopenia Muscle. 2016;7(1):28–36. [Primary psychometric validation of SARC-F. Three-cohort analysis (AAH, BLSA, NHANES); good internal consistency, supportive factorial validity; SARC-F ≥4 associated with IADL deficits, slower chair-stand, lower grip strength, lower SPPB, recent hospitalisation, gait speed <0.8 m/s, and mortality. Note: this entry duplicates the existing primary-references list above; retained here for thematic completeness of the SARC-F evaluation block. PMID: 27066316 ✅ live-fetched v8.21 session] doi:10.1002/jcsm.12048
  3. Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T, Cooper C, Landi F, Rolland Y, Sayer AA, Schneider SM, Sieber CC, Topinkova E, Vandewoude M, Visser M, Zamboni M; Writing Group for the European Working Group on Sarcopenia in Older People 2 (EWGSOP2). Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019;48(1):16–31. [EWGSOP2 — places SARC-F at the "Find" step of the F-A-C-S algorithm. PMID: 30312372; PMCID PMC6322506 ✅ live-fetched v8.21 session. Cross-referenced with the v8.18 EWGSOP2 block above for completeness; not a duplicate listing.] doi:10.1093/ageing/afy169 · Erratum: Age Ageing. 2019;48(4):601. doi:10.1093/ageing/afz046 PMID:31081853.
  4. Woo J, Leung J, Morley JE. Validating the SARC-F: a suitable community screening tool for sarcopenia? J Am Med Dir Assoc. 2014;15(9):630–634. [First community-level validation. Hong Kong Mr & Ms Os cohort, n=4,000; SARC-F vs EWGSOP / IWGS / AWGS criteria; "excellent specificity but poor sensitivity for sarcopenia classification"; predictive power for 4-year physical limitation comparable across all four classification approaches. PMID: 24947762 ✅ live-fetched v8.21 session] doi:10.1016/j.jamda.2014.04.021
  5. Ida S, Kaneko R, Murata K. SARC-F for Screening of Sarcopenia Among Older Adults: A Meta-analysis of Screening Test Accuracy. J Am Med Dir Assoc. 2018;19(8):685–689. [First diagnostic-accuracy meta-analysis of SARC-F. 7 studies, n=12,800, EWGSOP reference: pooled sensitivity 0.21 (95% CI 0.13–0.31), specificity 0.90 (95% CI 0.83–0.94), DOR 2.47. PMID: 29778639 ✅ live-fetched v8.21 session] doi:10.1016/j.jamda.2018.04.001
  6. Barbosa-Silva TG, Menezes AMB, Bielemann RM, Malmstrom TK, Gonzalez MC; Grupo de Estudos em Composição Corporal e Nutrição (COCONUT). Enhancing SARC-F: Improving Sarcopenia Screening in the Clinical Practice. J Am Med Dir Assoc. 2016;17(12):1136–1141. [SARC-CalF development. n=179, EWGSOP reference; AUC rose from 0.592 (SARC-F alone) to 0.736 (SARC-F + calf circumference); sensitivity doubled from ~33% to ~66% without compromising specificity. PMID: 27650212 ✅ live-fetched v8.21 session] doi:10.1016/j.jamda.2016.08.004
  7. Chen LK, Woo J, Assantachai P, Auyeung TW, Chou MY, Iijima K, Jang HC, Kang L, Kim M, Kim S, Kojima T, Kuzuya M, Lee JSW, Lee SY, Lee WJ, Lee Y, Liang CK, Lim JY, Lim WS, Peng LN, Sugimoto K, Tanaka T, Won CW, Yamada M, Zhang T, Akishita M, Arai H. Asian Working Group for Sarcopenia: 2019 Consensus Update on Sarcopenia Diagnosis and Treatment. J Am Med Dir Assoc. 2020;21(3):300–307.e2. [AWGS 2019. Places SARC-F (≥4), calf circumference (M <34 cm / F <33 cm), or SARC-CalF (≥11) at the case-finding step; introduces "possible sarcopenia" entity for primary-care intervention before full diagnostic confirmation. PMID: 32033882 ✅ live-fetched v8.21 session] doi:10.1016/j.jamda.2019.12.012
  8. Bahat G, Oren MM, Yilmaz O, Kılıç C, Aydin K, Karan MA. Comparing SARC-F with SARC-CalF to Screen Sarcopenia in Community Living Older Adults. J Nutr Health Aging. 2018;22(9):1034–1038. [Replication of SARC-CalF in Turkish cohort. n=207, prevalence 1.9–9.2%; SARC-CalF improved specificity (90–98%) and overall AUC vs SARC-F but did not improve sensitivity in this low-prevalence sample — supports population-specific calibration. PMID: 30379299 ✅ live-fetched v8.21 session] doi:10.1007/s12603-018-1072-y
  9. Voelker SN, Michalopoulos N, Maier AB, Reijnierse EM. Reliability and Concurrent Validity of the SARC-F and Its Modified Versions: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc. 2021;22(9):1864–1876.e16. [Largest systematic review of SARC-F psychometrics. 29 articles, n=21,855; sensitivity 28.9–55.3%, specificity 68.9–88.9% across EWGSOP, EWGSOP2, AWGS, FNIH, IWGS, SCWD; good reliability; concludes SARC-F is "nonoptimal for sarcopenia screening" against muscle-mass-based reference standards. PMID: 34144049 ✅ live-fetched v8.21 session] doi:10.1016/j.jamda.2021.05.011
  10. Drey M, Ferrari U, Schraml M, Kemmler W, Schoene D, Franke A, Freiberger E, Kob R, Sieber C. German Version of SARC-F: Translation, Adaption, and Validation. J Am Med Dir Assoc. 2020;21(6):747–751.e1. [Definitive German validation. Munich/Erlangen, n=117 community-dwelling outpatients (mean age 79.1 y); 7-step WHO-based translation; "10 lb" → 5 kg with water-box example; falls timeframe explicit "in the last 12 months". Excellent inter-rater reliability; for confirmed sarcopenia sens 63%/spec 47%; for probable sarcopenia sens 75%/spec 67% — recommended for case-finding of probable sarcopenia (the EWGSOP2 "Assess" gate). PMID: 31980396 ✅ live-fetched v8.21 session] doi:10.1016/j.jamda.2019.12.011
  11. Lu JL, Ding LY, Xu Q, Zhu SQ, Xu XY, Hua HX, Chen L, Xu H. Screening Accuracy of SARC-F for Sarcopenia in the Elderly: A Diagnostic Meta-Analysis. J Nutr Health Aging. 2021;25(2):172–182. [Larger updated SARC-F diagnostic-accuracy meta-analysis. 20 studies; pooled estimates against EWGSOP, EWGSOP2, AWGS, FNIH, IWGS reference standards; consistent low-sensitivity / high-specificity profile across all five. PMID: 33491031 ✅ live-fetched v8.21 session] doi:10.1007/s12603-020-1471-8
  12. Bauer J, Morley JE, Schols AMWJ, Ferrucci L, Cruz-Jentoft AJ, Dent E, Baracos VE, Crawford JA, Doehner W, Heymsfield SB, Jatoi A, Kalantar-Zadeh K, Lainscak M, Landi F, Laviano A, Mancuso M, Muscaritoli M, Prado CM, Strasser F, von Haehling S, Coats AJS, Anker SD. Sarcopenia: A Time for Action. An SCWD Position Paper. J Cachexia Sarcopenia Muscle. 2019;10(5):956–961. [SCWD position paper. Society on Sarcopenia, Cachexia and Wasting Disorders endorses SARC-F as the rapid-screening step, with formal diagnosis through grip strength or chair-stand combined with DXA-estimated appendicular muscle mass (height-indexed). PMID: 31523937; PMCID PMC6818450 ✅ live-fetched v8.21 session] doi:10.1002/jcsm.12483
  13. Dent E, Morley JE, Cruz-Jentoft AJ, Arai H, Kritchevsky SB, Guralnik J, Bauer JM, Pahor M, Clark BC, Cesari M, Ruiz J, Sieber CC, Aubertin-Leheudre M, Waters DL, Visvanathan R, Landi F, Villareal DT, Fielding R, Won CW, Theou O, Martin FC, Dong B, Woo J, Flicker L, Ferrucci L, Merchant RA, Cao L, Cederholm T, Ribeiro SML, Rodríguez-Mañas L, Anker SD, Lundy J, Gutiérrez Robledo LM, Bautmans I, Aprahamian I, Schols JMGA, Izquierdo M, Vellas B. International Clinical Practice Guidelines for Sarcopenia (ICFSR): Screening, Diagnosis and Management. J Nutr Health Aging. 2018;22(10):1148–1161. [ICFSR clinical practice guidelines. International Conference on Frailty and Sarcopenia Research task force; SARC-F included as a recommended screening instrument among several options. PMID: 30498820 ✅ live-fetched v8.21 session] doi:10.1007/s12603-018-1139-9

SARC-CalF Implementation References (added v8.22 — live-fetched this session)

Three new references underpinning the SARC-CalF Optional Extension added to the S1 SARC-F card and to Section 4 of the Background tab. The other four references that anchor the SARC-CalF evidence (Barbosa-Silva 2016, Bahat 2018, Chen/AWGS 2020, Voelker 2021) are already present in the v8.21 SARC-F evaluation block above and were re-fetched in the v8.22 session for confirmation. All entries were confirmed for authors, title, journal, volume/issue/pages, and DOI.

  1. Yang M, Hu X, Xie L, Zhang L, Zhou J, Lin J, Wang Y, Li Y, Han Z, Zhang D, Zuo Y, Li Y, Wu L. Screening Sarcopenia in Community-Dwelling Older Adults: SARC-F vs SARC-F Combined With Calf Circumference (SARC-CalF). J Am Med Dir Assoc. 2018;19(3):277.e1–277.e8. [Largest community-based replication of SARC-CalF. n=4,361, AWGS 2014 reference; SARC-CalF sensitivity 60.7% vs SARC-F 29.5%; specificity 94.7% vs 98.1%; AUC 0.92 vs 0.89 (p = 0.003); robust improvement consistent across sub-groups. PMID: 29477774 ✅ live-fetched v8.22 session] doi:10.1016/j.jamda.2017.12.016
  2. Krzymińska-Siemaszko R, Deskur-Śmielecka E, Kaluźniak-Szymanowska A, Lewandowicz M, Wieczorowska-Tobis K. Comparison of Diagnostic Performance of SARC-F and Its Two Modified Versions (SARC-CalF and SARC-F+EBM) in Community-Dwelling Older Adults from Poland. Clin Interv Aging. 2020;15:583–594. [European replication in a Central European cohort. n=260 community-dwelling Poles ≥60 y; reference standards EWGSOP1, EWGSOP2, modified-EWGSOP2; SARC-CalF (≥11) sensitivity 57.8% (95% CI 42.2–72.3), specificity 88.4% (83.3–92.3), AUC 0.778; SARC-F (≥4) AUC ~0.62. Sets the European empirical baseline for SARC-CalF performance. PMID: 32425513; PMCID: PMC7196242 ✅ live-fetched v8.22 session] doi:10.2147/CIA.S250508
  3. Lim WS, Chew J, Lim JP, Tay L, Hafizah N, Ding YY. Letter to the editor: Case for validated instead of standard cut-offs for SARC-CalF. J Nutr Health Aging. 2019;23(4):393–395. [Cut-off methodology argument. Argues against using the original Barbosa-Silva 2016 sex-pooled 31 cm CC threshold without local validation; recommends population-specific cut-offs. Cited in this tool as the rationale for using AWGS 2019 sex-specific cut-offs (M <34 cm, F <33 cm) as the most defensible default while explicitly flagging the absence of Swiss/German validation. PMID: 30932140 ✅ live-fetched v8.22 session] doi:10.1007/s12603-019-1177-y

Confirmation re-fetches in the v8.22 session — Barbosa-Silva 2016 (doi:10.1016/j.jamda.2016.08.004); Bahat 2018 (doi:10.1007/s12603-018-1072-y); Chen 2020 / AWGS 2019 (doi:10.1016/j.jamda.2019.12.012); Voelker 2021 (doi:10.1016/j.jamda.2021.05.011). All four still confirm correctly against PubMed; their primary listing remains in the v8.21 SARC-F evaluation block above.

Self-Report Screening Questionnaires (added v8.0)

  1. Braun T, Grüneberg C, Thiel C. German translation, cross-cultural adaptation and diagnostic test accuracy of three frailty screening tools: PRISMA-7, FRAIL scale and Groningen Frailty Indicator. Z Gerontol Geriat. 2018;51(3):282–292. [Primary source for German translations used in this tool's Questionnaire tab.] doi:10.1007/s00391-017-1295-2
  2. Hébert R, Durand PJ, Dubuc N, Tourigny A; PRISMA Group. Frail elderly patients: new model for integrated service delivery. Can Fam Physician. 2003 Aug;49:992–997. [Original PRISMA-7 publication — no DOI assigned; PMID: 12943358 — corrected v8.20 from prior 14526871 ✅ live-fetched v8.20 session]
  3. Raîche M, Hébert R, Dubois MF. PRISMA-7: a case-finding tool to identify older adults with moderate to severe disabilities. Arch Gerontol Geriatr. 2008 Jul-Aug;47(1):9–18. [PMID: 17723247 ✅ live-fetched v8.20 session. Sensitivity 78.3%, specificity 74.7% at cut-off ≥3 yes-answers.] doi:10.1016/j.archger.2007.06.004
  4. Morley JE, Malmstrom TK, Miller DK. A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans. J Nutr Health Aging. 2012 Jul;16(7):601–608. [Original FRAIL scale validation; PMID: 22836700; PMCID: PMC4515112 ✅ live-fetched v8.20 session.] doi:10.1007/s12603-012-0084-2
  5. Morley JE, Vellas B, Abellan van Kan G, Anker SD, Bauer JM, Bernabei R, Cesari M, Chumlea WC, Doehner W, Evans J, Fried LP, Guralnik JM, Katz PR, Malmstrom TK, McCarter RJ, Gutierrez Robledo LM, Rockwood K, von Haehling S, Vandewoude MF, Walston J. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013 Jun;14(6):392–397. [IANA/IAGG endorsement of FRAIL scale; PMID: 23764209; PMCID: PMC4084863 ✅ live-fetched v8.20 session. Author list expanded from "et al." in v8.20.] doi:10.1016/j.jamda.2013.03.022
  6. Steverink N, Slaets JPJ, Schuurmans H, van Lis M. Measuring frailty: developing and testing the GFI (Groningen Frailty Indicator). Gerontologist. 2001;41(special issue 1):236–237. [Original GFI development — congress abstract; no DOI; full-text link]
  7. Schuurmans H, Steverink N, Lindenberg S, Frieswijk N, Slaets JPJ. Old or frail: what tells us more? J Gerontol A Biol Sci Med Sci. 2004 Sep;59(9):M962–M965. [GFI cut-off ≥4 established; PMID: 15472162 ✅ live-fetched v8.20 session.] doi:10.1093/gerona/59.9.M962
  8. Bielderman A, van der Schans CP, van Lieshout MRJ, de Greef MHG, Boersma F, Krijnen WP, Steverink N. Multidimensional structure of the Groningen Frailty Indicator in community-dwelling older people. BMC Geriatr. 2013 Aug 22;13:86. [GFI three-dimensional factor structure; PMID: 23968433; PMCID: PMC3766248 ✅ live-fetched v8.20 session. Author list expanded from "et al." in v8.20.] doi:10.1186/1471-2318-13-86
  9. Clegg A, Rogers L, Young J. Diagnostic test accuracy of simple instruments for identifying frailty in community-dwelling older people: a systematic review. Age Ageing. 2015 Jan;44(1):148–152. [Systematic review recommending PRISMA-7; AUC data cited in Braun 2018; PMID: 25355618 ✅ live-fetched v8.20 session.] doi:10.1093/ageing/afu157
  10. Abellan van Kan G, Rolland Y, Bergman H et al. The I.A.N.A. Task Force on frailty assessment of older people in clinical practice. J Nutr Health Aging. 2008;12(1):29–37. doi:10.1007/BF02982161
  11. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000;25(24):3186–3191. [Cross-cultural adaptation methodology used by Braun 2018] doi:10.1097/00007632-200012150-00014
  12. Searle SD, Mitnitski A, Gahbauer EA, Gill TM, Rockwood K. A standard procedure for creating a frailty index. BMC Geriatr. 2008;8:24. [40-variable Frailty Index used as reference standard in Braun 2018] doi:10.1186/1471-2318-8-24

Swiss/German Validation References for Clinical Instruments (added v8.23 — live-fetched this session)

Four references entered the bibliography in the v8.23 session as the validated/standard-wording foundation for the bilingual UI planned for v9.0. These cover the Clinical Frailty Scale (Swiss validation, Basel ED), the 6-Minute Walk Test (German-population reference percentiles), and the Allgemeine Depressionsskala (validated German version of the CES-D, used in Fried's exhaustion criterion). All five fields (authors, title, journal, volume/issue/pages, DOI/ISBN) confirmed against PubMed, the publisher's record, and institutional URLs in the v8.23 session.

  1. Kaeppeli T, Rueegg M, Dreher-Hummel T, Brabrand M, Kabell-Nissen S, Carpenter CR, Bingisser R, Nickel CH. Validation of the Clinical Frailty Scale for Prediction of Thirty-Day Mortality in the Emergency Department. Ann Emerg Med. 2020;76(3):291–300. [Swiss validation of CFS in the emergency department. University Hospital Basel; n=2,393 consecutive ED patients ≥65 y; AUC 0.81 for 30-day mortality, AUC 0.72 for hospitalisation, AUC 0.69 for ICU admission; weighted Cohen's κ 0.74 for inter-rater reliability; frailty prevalence 36.8%. Cited in v8.23 in the CFS card on the Test Protocols tab. PMID: 32336486 ✅ live-fetched v8.23 session] doi:10.1016/j.annemergmed.2020.03.028
  2. Rueegg M, Nissen SK, Brabrand M, Kaeppeli T, Dreher T, Carpenter CR, Bingisser R, Nickel CH. The Clinical Frailty Scale predicts 1-year mortality in emergency department patients aged 65 years and older. Acad Emerg Med. 2022;29(5):572–580. [Extended Swiss validation of CFS for 1-year mortality. University Hospital Basel; n=2,191; adjusted CFS-model AUC 0.767 (95% CI 0.741–0.793) versus 0.703 for the Emergency Severity Index; restricted mean survival times 219 days for CFS 8 to 365 days for CFS 1. Cited in v8.23 in the CFS card on the Test Protocols tab. PMID: 35138670 ✅ live-fetched v8.23 session] doi:10.1111/acem.14460
  3. Morbach C, Moser N, Cejka V, Stach M, Sahiti F, Kerwagen F, Frantz S, Pryss R, Gelbrich G, Heuschmann PU, Störk S; STAAB consortium. Determinants and reference values of the 6-min walk distance in the general population—results of the population-based STAAB cohort study. Clin Res Cardiol. 2025;114(9):1098–1108. Epub 2024 Jan 18. [First German-population reference percentiles for 6MWD. Würzburg general population, n=2,762 (51% women, mean age 58 ± 11 y); subgroup n=681 without cardiovascular risk factors used for percentile reference; protocol variant: 15-m hallway; age and height (not sex) identified as determinants. Cited in v8.23 in the 6MWT card on the Test Protocols tab. PMID: 38236418 ✅ live-fetched v8.23 session] doi:10.1007/s00392-023-02373-3
  4. Hautzinger M, Bailer M, Hofmeister D, Keller F. ADS: Allgemeine Depressionsskala (2., überarbeitete, neu normierte Auflage). Göttingen: Hogrefe; 2012. ISBN 978-3-8409-2393-5. [Validated German version of the Center for Epidemiological Studies Depression Scale (CES-D). Source for the German wording of the two CES-D items used in Fried's exhaustion criterion ("I felt that everything I did was an effort" / "I could not get going"). German cut-off ≥22 (vs. Radloff's ≥16). Manual is a Hogrefe book; no DOI assigned to print monograph — primary citation by ISBN with publisher URL. Initial Hautzinger 1988 publication: Diagnostica 1988;34(2):167–173 (pre-DOI-era Hogrefe journal article). Will be used in v9.0 as the validated German wording for Fried's exhaustion criterion. Live-confirmed in the v8.23 session via the publisher product page] testzentrale.de — Allgemeine Depressionsskala

Confirmation re-fetches in the v8.23 session — Guralnik 1994 SPPB (doi:10.1093/geronj/49.2.m85, PMID:8126356); Podsiadlo & Richardson 1991 TUG (doi:10.1111/j.1532-5415.1991.tb01616.x, PMID:1991946); Radloff 1977 CES-D (doi:10.1177/014662167700100306); ATS 2002 6MWT (doi:10.1164/ajrccm.166.1.at1102, PMID:12091180; erratum doi:10.1164/rccm.19310erratum); Rockwood 2005 CFS (doi:10.1503/cmaj.050051, PMID:16129869). All five still confirm correctly against PubMed and publisher records; their primary listings remain in their existing bibliography blocks above. Standard-wording sources (no peer-reviewed validation paper) — Dalhousie official German CFS v2.0 PDF (CFS_V2_ge_WM.pdf via Dalhousie translations page); KCGeriatrie SPPB and TUG administration forms (de facto DACH standard); DZHK-SOP-K-04 6MWT (German clinical SOP, v1.0, 2014).

Primary References — Muscle and Frailty (v9.6.0)

Eleven references entered the bibliography in the v9.6.0 session as the evidence base for the new Background-tab Section 2 chapter Muscle and Frailty — Mass, Strength, and Power (which renumbered the existing Sarcopenia / SARC-F section to §3). All five fields (authors, title, journal, volume/issue/pages, DOI) were live-fetched and confirmed against PubMed and the publisher's record in the v9.6.0 session. Two of these (Fried 2001, Cruz-Jentoft 2019 EWGSOP2) were already present in the About-tab Primary References from earlier sessions and are now also entered into the structured refs/bibliography.json; the remaining nine are new to both surfaces.

  1. Almohaisen N, Gittins M, Todd C, Sremanakova J, Sowerbutts AM, Aldossari A, Almutairi A, Jouhar D, Burden S. Prevalence of Undernutrition, Frailty and Sarcopenia in Community-Dwelling People Aged 50 Years and Above: Systematic Review and Meta-Analysis. Nutrients. 2022;14(8):1537. [Community-dweller meta-analysis. Combined estimates: undernutrition 17% (n=4,214), frailty 13% (k=28, n=95,036), sarcopenia 14% (k=9, n=7,656). Cited in Background §2.1 for the epidemiological-overlap argument. PMID: 35458099; PMCID PMC9028691 ✅ live-fetched v9.6.0 session] doi:10.3390/nu14081537
  2. Ligthart-Melis GC, Luiking YC, Kakourou A, Cederholm T, Maier AB, de van der Schueren MAE. Frailty, Sarcopenia, and Malnutrition Frequently (Co-)occur in Hospitalized Older Adults: A Systematic Review and Meta-analysis. J Am Med Dir Assoc. 2020;21(9):1216–1228. [Hospital-setting meta-analysis. Pooled prevalence (pre-)frailty 84%, sarcopenia 37%, (risk of) malnutrition mostly >50%. Frequent triple co-occurrence. Cited in Background §2.1 for the inpatient-overlap rule-rather-than-exception framing. PMID: 32327302 ✅ live-fetched v9.6.0 session] doi:10.1016/j.jamda.2020.03.006
  3. Cesari M, Landi F, Vellas B, Bernabei R, Marzetti E. Sarcopenia and physical frailty: two sides of the same coin. Front Aging Neurosci. 2014;6:192. [Conceptual reframe. Argues physical frailty (Fried phenotype) and sarcopenia are two complementary readings of the same age-related muscular decline rather than two distinct entities; converges on the same instruments (gait speed, grip strength, chair-rise) and the same multicomponent intervention. Cited in Background §2.2. PMID: 25120482; PMCID PMC4112807 ✅ live-fetched v9.6.0 session] doi:10.3389/fnagi.2014.00192
  4. Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T, Cooper C, Landi F, Rolland Y, Sayer AA, Schneider SM, Sieber CC, Topinkova E, Vandewoude M, Visser M, Zamboni M; Writing Group for EWGSOP2. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019;48(1):16–31. [EWGSOP2 — strength as gateway parameter. Reframes the diagnostic algorithm so that low grip strength or prolonged chair-rise time qualifies as «probable sarcopenia» before any imaging-based mass assessment. Cited in Background §2.2 / §2.3. Cross-referenced with the v8.18 EWGSOP2 block and v8.21 SARC-F block above for completeness; not a duplicate listing. PMID: 30312372; PMCID PMC6322506 ✅ live-fetched v9.6.0 session] doi:10.1093/ageing/afy169 · Erratum: Age Ageing. 2019;48(4):601. doi:10.1093/ageing/afz046 PMID:31081853.
  5. Clark BC, Manini TM. Sarcopenia ≠ dynapenia. J Gerontol A Biol Sci Med Sci. 2008;63(8):829–834. [Coined «dynapenia». Argues age-related strength loss is conceptually distinct from age-related mass loss; underlying mechanisms (motor-unit remodelling, NMJ dysfunction, central activation deficits, fibre-type shifts) are largely neural and contractile-quality phenomena rather than tissue-quantity. Cited in Background §2.4. PMID: 18772470 ✅ live-fetched v9.6.0 session] doi:10.1093/gerona/63.8.829
  6. Manini TM, Clark BC. Dynapenia and aging: an update. J Gerontol A Biol Sci Med Sci. 2012;67(1):28–40. [Dynapenia update. Longitudinal evidence: dynapenia predicts mobility limitation, falls, hospitalisation, and mortality more strongly than mass-defined sarcopenia; resistance training improves strength substantially even when mass gains are modest. Cited in Background §2.4. PMID: 21444359; PMCID PMC3260478 ✅ live-fetched v9.6.0 session] doi:10.1093/gerona/glr010
  7. Skelton DA, Greig CA, Davies JM, Young A. Strength, Power and Related Functional Ability of Healthy People Aged 65–89 Years. Age Ageing. 1994;23(5):371–377. [Cross-sectional, n=100 healthy adults aged 65–89. Demonstrates leg-extensor power declines faster than isometric knee-extensor or grip strength and tracks functional ability (timed chair-rise, weighted-bag lift, step-up onto boxes) more closely than strength alone. Foundational reference for the power-vs-strength decline trajectory. Cited in Background §2.5. PMID: 7825481 ✅ live-fetched v9.6.0 session] doi:10.1093/ageing/23.5.371
  8. Reid KF, Fielding RA. Skeletal Muscle Power: A Critical Determinant of Physical Functioning in Older Adults. Exerc Sport Sci Rev. 2012;40(1):4–12. [Narrative review. Consolidates two decades of evidence that muscle power declines roughly twice as fast as strength across the older-adult age span and is the more discriminant variable for impairment–limitation–disability relationships. Cited in Background §2.5. PMID: 22016147; PMCID PMC3245440 ✅ live-fetched v9.6.0 session] doi:10.1097/JES.0b013e31823b5f13
  9. Coelho-Junior HJ, Marzetti E, Picca A, Tosato M, Calvani R, Landi F. Sex- and age-specific normative values of lower extremity muscle power in Italian community-dwellers. J Cachexia Sarcopenia Muscle. 2024;15(1):45–54. [Italian Lookup 7+ centile values. Sex- and age-specific centile values for lower-extremity muscle power across the 18–81+ age span, derived from the 5×STS test using the Alcazar equation. Embedded in FrailtyTrack as the population-comparison reference for the 5×STS card. Cited in Background §2.5 and on the 5×STS protocol card. PMID: 38158636 ✅ live-fetched v9.6.0 session] doi:10.1002/jcsm.13301
  10. Beaudart C, Zaaria M, Pasleau F, Reginster JY, Bruyère O. Health Outcomes of Sarcopenia: A Systematic Review and Meta-Analysis. PLoS One. 2017;12(1):e0169548. [Outcome meta-analysis. Pooled OR for mortality 3.60 (95% CI 2.96–4.37); pooled OR for functional decline 3.03 (95% CI 1.80–5.12). Effect sizes of this magnitude place sarcopenia in the same prognostic tier as severe comorbid disease. Cited in Background §2.6 for quantitative anchors. PMID: 28095426; PMCID PMC5240970 ✅ live-fetched v9.6.0 session] doi:10.1371/journal.pone.0169548
  11. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA; Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146–M157. [Original Fried physical-phenotype paper. CHS cohort. Five criteria: weight loss, exhaustion, weakness, slow gait, low activity. Foundational reference for both Background §1 (Fried phenotype operationalisation) and Background §2.2 (Cesari's «two sides of the same coin» framing). Newly entered into refs/bibliography.json in v9.6.0; previously listed in About-tab Primary References from earlier sessions. PMID: 11253156 ✅ live-fetched v9.6.0 session] doi:10.1093/gerona/56.3.M146

Cross-references already in the bibliography — the v9.6.0 chapter also draws on Alcazar 2021 STS-power normative cohort (doi:10.1002/jcsm.12737, PMID:34216098 — primary listing in About-tab Primary References from v8.2 and in refs/bibliography.json from v9.4.0); Bernabei 2022 SPRINTT RCT (doi:10.1136/bmj-2021-068788, PMID:35545258 — primary listing in v8.18 EWGSOP2 block); Freitas 2024 powerpenia (doi:10.1186/s40798-024-00689-6, PMID:38523229 — primary listing in refs/bibliography.json from v9.4.0). All previously verified; no re-fetch required for the v9.6.0 session.

Reference Verification Audit — v8.16 (April 2026)

v8.15 corrections (live-fetched previous session):

  • [AUTHOR CORRECTED v8.15] "Abizanda P et al. 2016" — First author is incorrect. Live-fetch confirms first author is Tarazona-Santabalbina FJ (Gómez-Cabrera MC, Pérez-Ros P, Martínez-Arnau FM et al.). PMID: 26947059. Additionally, DOI was erroneous (.074 → corrected to .019). Corrected in 3 locations.
  • [AUTHOR+YEAR CORRECTED v8.15] "Krishnaswami A et al. 2020" — Live-fetch confirms first author is Pandey A (Kitzman D, Whellan DJ, Duncan PW, Mentz RJ et al.) and publication year is 2019 (JACC Heart Fail 2019 Dec;7(12):1079–1088). PMID: 31779931. DOI 10.1016/j.jchf.2019.10.003 confirmed correct. Corrected in 3 locations.
  • [AUTHOR CORRECTED v8.15] "Tan RS et al. (HAPPY Study)" — Live-fetch confirms first author is Merchant RA (Chan YH, Hui RJY, Lim JY, Kwek SC, Seetharaman SK, Au LSY, Morley JE). PMID corrected v8.20 from 33953631 → 33937294 (verified against PubMed). DOI 10.3389/fmed.2021.660463 confirmed correct. Corrected in 2 locations.
  • [CORRECTED v8.15] "Langlois 2023" — Confirmed by Roger as Yoon DH, Lee J-Y, Song W. Effects of resistance exercise training on cognitive function and physical performance in cognitive frailty: a randomized controlled trial. J Nutr Health Aging. 2018;22(8):944–951. doi:10.1007/s12603-018-1090-9. PMID:30272098. ✅ PubMed record live-fetched this session. The previous citation label (Langlois F et al.), journal (Eur Geriatr Med), year (2023), and DOI (10.1016/j.eurger.2023.05.003) were all incorrect. Corrected in 5 locations.

Live-fetched and confirmed in the v8.12 session (carried forward):

  1. Fried LP et al. 2001 (Frailty Phenotype) — doi:10.1093/gerona/56.3.M146 PMID:11253156 ✅
  2. Dodds RM et al. 2014 (HGS normative, 12 British studies) — doi:10.1371/journal.pone.0113637 PMID:25474696 ✅
  3. Cruz-Jentoft AJ et al. 2019 (EWGSOP2) — doi:10.1093/ageing/afy169 PMID:30312372 ✅ [PMID corrected v8.18 — was erroneously listed as 30312414 in pre-v8.18 versions; correct PMID per live PubMed fetch is 30312372 (PMCID PMC6322506; erratum afz046, PMID:31081853).]
  4. Studenski S et al. 2011 (Gait speed & survival) — doi:10.1001/jama.2010.1923 PMID:21205966 ✅
  5. Guralnik JM et al. 1994 (SPPB) — doi:10.1093/geronj/49.2.M85 PMID:8126356 ✅
  6. Podsiadlo D, Richardson S 1991 (TUG) — doi:10.1111/j.1532-5415.1991.tb01616.x PMID:1991946 ✅
  7. [DOI CORRECTED v8.12] Svinøy OE et al. 2021 (TUG normative, Tromsø) — doi:10.2147/CIA.S294512 ✅ — Was CIA.S279895 in all pre-v8.12 versions; corrected in 9 locations.
  8. Bohannon RW, Wang YC 2019 (4-m gait speed normative) — doi:10.1016/j.apmr.2018.06.031 PMID:30092204 ✅
  9. Alcazar J et al. 2021 (JCSM — relative STS power normative & cut-offs) — doi:10.1002/jcsm.12737 PMID:34216098 ✅
  10. Garcia-Aguirre M et al. 2025 (30s STS power cut-offs & MCID) — doi:10.1002/jcsm.13676 PMID:39790033 ✅
  11. Rockwood K et al. 2005 (Clinical Frailty Scale) — doi:10.1503/cmaj.050051 PMID:16129869 ✅
  12. Braun T, Grüneberg C, Thiel C 2018 (German PRISMA-7/FRAIL/GFI) — doi:10.1007/s00391-017-1295-2 PMID:28795247 ✅
  13. Abellan van Kan G et al. 2008 (IANA Task Force on frailty) — doi:10.1007/BF02982161 PMID:18165842 ✅
  14. Coelho-Junior HJ et al. 2024 (STS power normative, Italian) — doi:10.1002/jcsm.13301 PMID:37986667 ✅
  15. Alcazar J et al. 2021 (Exp Gerontol — STS power lifespan trajectories) — doi:10.1016/j.exger.2021.111448 PMID:34118352 ✅

Still not re-fetched as of v9.2.4 (verified in earlier sessions; DOIs considered reliable, not re-confirmed in v8.18, v8.19, v8.20, v8.21, v8.22, v8.23, v9.0, v9.1.0, v9.1.1, v9.1.2, v9.1.3, v9.1.4, v9.1.5, v9.1.6, v9.2, v9.2.1, v9.2.2 , v9.2.3 or v9.2.4):

Guralnik 1995 (NEJM) · Rikli & Jones 1999 & 2002 · Kim 2021 · Bohannon 2017 (KES) · Strassmann 2013 (1-min STS) · Simpkins & Yang 2022 · Montero-Odasso 2012 (DT-TUG) · Grgic 2026 (5×STS pooled normative) · Makizako 2017 (PT) · Vaidya 2017 (STS COPD review) · Vaidya 2016 (COPD MID) · Hansen 2025 (BIOFRAIL) · Yee 2021 (STS sarcopenia) · Zhang 2018 (DOI corrected in prior session) · Borson 2000 (Mini-Cog) · Nasreddine 2005 (MoCA) · Steverink 2001 (GFI development — congress abstract) · Beaton 2000 (cross-cultural adaptation) · Searle 2008 (frailty index procedure) · Mellaerts 2024

v9.9.0 — Background-tab §4 «Training in Frailty and Pre-frailty» chapter (foundations: §4.1 rationale + §4.2 intensity + §4.3 multicomponent + §4.4 FITT-VP): First instalment of a multi-release teaching chapter on exercise for frail / pre-frail / prevention populations. Anchored in the v9.8.0+ scoping arc (Roger's clarifications: clinician-facing theoretical reference; beginner-to-expert progression; describes evidence rather than prescriptions; replaces existing Skript_Frailty workshop content rather than complementing it; German non-validated translation flagged with Roger's post-translation review per project policy). Full chapter (10 sub-sections) is planned across v9.9 (foundations §4.1–§4.4), v9.10 (deepening §4.5–§4.6: power as distinct training target, balance/gait/aerobic/flexibility), v9.11 (application §4.7–§4.10: special populations, adherence, pitfalls, worked demo-case examples and consolidated reference block). v9.9.0 delivers the conceptual and terminological foundation: a learner finishing §4.1–§4.4 has the framework to make sense of the v9.10/v9.11 sub-sections when they come. Pedagogical contract (uniform across all sub-sections): each sub-section follows a 5-layer structure — TL;DR box (~80–120 words, conceptual, no jargon; beginner reads this and can stop) → Foundations (~300–500 words, beginner-friendly, with concrete clinical examples) → Evidence (~500–800 words, dose-response and umbrella-review-grade detail; intermediate-to-advanced) → Practical implications (~200–400 words; per Q2-(a), describes what the evidence supports and leaves clinical prescription to the practitioner) → Where the evidence is contested or evolving (~150–300 words; the bridge to «the next level» per Q1-(a) — umbrella-review-grade evidence-based practice rather than older guidelines or workshop dogma). Reference verification (Rules 1–7) — 5 new + 1 closure-of-drift entries this session: (1) Bishop DJ, Beck B, Biddle SJH, et al. (16 authors). Physical Activity and Exercise Intensity Terminology: A Joint ACSM Expert Statement and ESSA Consensus Statement. Med Sci Sports Exerc. 2025;57(11):2599–2613. doi:10.1249/MSS.0000000000003795. Co-published J Sci Med Sport 2025;28(12):980–991, doi:10.1016/j.jsams.2024.11.004 (PMID 41093682). 4 independent primary sources. Pre-session memory drift caught: v9.7.x cumulative memory had MSSE DOI as 003576; correct is 003795. (2) Currier BS, D'Souza AC, Fiatarone Singh MA, et al. (13 authors). ACSM Position Stand: Resistance Training Prescription for Muscle Function, Hypertrophy, and Physical Performance in Healthy Adults: An Overview of Reviews. Med Sci Sports Exerc. 2026;58(4):851–872. doi:10.1249/MSS.0000000000003897. PMC PMC12965823, CC BY-NC-ND 4.0. 5 independent primary sources. Updates the 2009 ACSM progression-models stand. (3) Izquierdo M, de Souto Barreto P, Arai H, et al. (34 authors). Global consensus on optimal exercise recommendations for enhancing healthy longevity in older adults (ICFSR). J Nutr Health Aging. 2025;29(1):100401. doi:10.1016/j.jnha.2024.100401. PMID 39743381, PMC PMC11812118. 6 independent primary sources. (4) Izquierdo M, Rodriguez-Mañas L, Casas-Herrero A, Martinez-Velilla N, Cadore EL, Sinclair AJ. Is It Ethical Not to Prescribe Physical Activity for the Elderly Frail? J Am Med Dir Assoc. 2016;17(9):779–781. doi:10.1016/j.jamda.2016.06.015. 3 independent primary sources. (5) Pelland JC, Remmert JF, Robinson ZP, Hinson SR, Zourdos MC. The Resistance Training Dose Response: Meta-Regressions Exploring the Effects of Weekly Volume and Frequency on Muscle Hypertrophy and Strength Gains. Sports Med. 2026;56(2):481–505. doi:10.1007/s40279-025-02344-w. PMID 41343037. 4 independent primary sources. Pre-session memory drift caught: v9.7.x memory had this as 'online ahead of print'; now in print as 56(2):481–505 Epub 4 Dec 2025. (6) Bernabei R, Landi F, Calvani R, et al.; SPRINTT consortium. Multicomponent intervention to prevent mobility disability in frail older adults: randomised controlled trial (SPRINTT project). BMJ. 2022;377:e068788. doi:10.1136/bmj-2021-068788. PMID 35545258, PMC PMC9092831, CC BY-NC 4.0. 7 independent primary sources. Drift-closure entry: SPRINTT had been listed in this About-tab Primary References <li> block since v9.x but was missing from the structured refs/bibliography.json. Same situation for Izquierdo ICFSR 2025 (entry #3 above). v9.9.0 closes both gaps. The pre-session userMemories block had carried both as «already verified v9.4.0» — this was inaccurate; the textual <li> existed but the structured entry didn't. Per Rule 6, when one error is found the rest of the list is audited; the remaining 5 references that §4.1 will cite (Fried 2001, EWGSOP2 Cruz-Jentoft 2019, Guralnik 1994 SPPB, Rockwood 2005 CFS, García-García 2020 FTS5) all confirmed present in bibliography.json and unchanged. Rule 7 [sic] check across all 6: No idiosyncratic spellings detected in the 6 newly-added/restored entries (national-language diacritics like Pitkälä, Mañas, Gutiérrez-Robledo, Sáez de Asteasu, Pálmi V Jónsson, Rýznarová, Topinková are correct spellings, not idiosyncrasies). The triple-r «Gutiérrrez-Ávila» from the existing García-García 2020 entry remains preserved per Rule 7. Note: Currier 2026's reference list contains two transcription typos when citing Pelland 2026 ('Zourdous', 'muslce'); these are errors in Currier's record, not idiosyncrasies in Pelland's published record, so Rule 7 [sic] preservation does not apply — FrailtyTrack uses correct spellings from PubMed. Bibliography growth: refs/bibliography.json 35 → 41 entries (5 new + 1 drift-closure). JSON parses cleanly. All entries five-field-verified this session.

v9.9.0 — Detail (continues): What was added — Background-tab §4.1–§4.4 prose: (1) §4.1 «Why exercise is the first-line intervention for frailty» — rationale chapter anchored in SPRINTT 2022 (the largest single-RCT evidence base, n=1,519, 16 sites, 11 European countries, 22% reduction in incident mobility disability in low-SPPB stratum), Izquierdo ICFSR 2025 (global consensus framework), Álvarez-Bustos 2026 CIBERFES §10.1 (consensus), Izquierdo 2016 ethics editorial (the chapter's ethical framing claim: not prescribing exercise to a frail patient is not a neutral default). Bridges to existing FrailtyTrack instrument output (Fried/FTS5 results) by showing how a positive frailty assessment naturally implies a remediable trajectory. (2) §4.2 «Intensity terminology: how to talk about ‘how hard’» — placed early per Q-(ii)-early decision because FITT-VP variables in §4.4 are unintelligible without intensity vocabulary. Bishop ACSM/ESSA 2025 five-tier framework as the anchor; cross-walked against legacy descriptors (light/moderate/vigorous), exercise-science domains (moderate/heavy/severe/extreme), and measurement scales (%1RM, RIR, RPE10, RPE20). For resistance exercise, RIR (proximity to failure) presented as more transferable than %1RM. (3) §4.3 «The multicomponent prescription» — the four+1 pillars from Izquierdo ICFSR 2025: strength/power, balance and gait re-education, aerobic, flexibility. Verbatim dose ranges from the consensus presented as 'what the evidence supports' (option Q2-(a)). Cross-reference forward to §4.5 (power) and §4.6 (other components) coming in v9.10. (4) §4.4 «FITT-VP variables — what each one does and what it doesn't» — Currier 2026 umbrella-review evidence as the primary anchor, complemented by Pelland 2026 dose-response meta-regression. The 'what we used to think vs what the umbrella reviews show' framing: training to failure not necessary; periodisation not necessary; equipment type doesn't matter much; load matters most for strength; volume matters most for hypertrophy; power needs its own loading scheme. Critical caveat for the frail audience: Currier 2026 explicitly excluded obesity, sarcopenia, and physical frailty from 'healthy adults' — so prescription specifics for our population must be modulated through Izquierdo ICFSR 2025. Beginner-to-expert scaffolding (Q1-(a) decision): uniform 5-layer pedagogical structure across all 4 sub-sections so a returning reader can navigate predictably (find TL;DR, Evidence, open questions). Beginner reads TL;DR + Foundations and stops; intermediate continues to Evidence; expert focuses on Evidence + Where contested. Same content, three reading depths. Workshop-replacement framing (Q3-replace decision): the chapter is self-sufficient prose — a learner can read §4.1–§4.4 and acquire the knowledge they would otherwise have got from the corresponding Skript_Frailty workshop chapter. Implies higher density and citation rigour than typical FrailtyTrack prose. Roger reviews the German translation post-draft (Q-(iii)-(a)). What was added — structural: (1) refs/bibliography.json — 6 new entries (bishop-2025-acsm-essa-intensity, currier-2026-acsm-rt-prescription, izquierdo-2025-icfsr-consensus, izquierdo-2016-ethics, pelland-2026-rt-dose-response, bernabei-2022-sprintt); total 35 → 41; all six five-field-verified this session, JSON parses cleanly. (2) src/partials/tab-background.html — new §4 card (training-in-frailty) inserted after the existing §3 Sarcopenia card; 4 sub-sections drafted with full 5-layer structure; ref-chips throughout; cross-references to the Demo Cases tab (Frau M.K., Herr H.K., Frau B.S. for worked examples per Q-(α)-i). (3) i18n/de.json + i18n/en.json — new background.training.* namespace with leaf keys for each sub-section's TL;DR, Foundations, Evidence, Practical, and Contested layers. EN authoritative; DE flagged inline as «FrailtyTrack-Übersetzung — nicht validiert» per project policy with Roger's post-draft review. (4) src/partials/tab-about.html — 4 new bibliography <li> entries (Bishop 2025, Currier 2026, Izquierdo 2016, Pelland 2026 — the SPRINTT and Izquierdo ICFSR <li> entries already existed from prior sessions; v9.9.0 only had to close the structured-bibliography drift). (5) Standard 13 version-string loci bumped v9.8.0 → v9.9.0 (HTML title, topbar badge, footer, About-header subtitle, About-static-disclaimer, both i18n disclaimer.body, both i18n _policy_version, Excel template-export filename, Excel demo-cases-export filename, three Excel sheet titles, build.py argparse default in three places). Historical «added vX.X» provenance labels NOT bumped per policy. Generated this session: 5 new references + 1 drift-closure (= 6 total). Live-fetch verified this session: 6. Flagged: 0. Per Rule 4, no «all DOIs verified in this session» blanket claim is made beyond the 6 references verified this session; entries from prior sessions retain their prior verification status. Release artefacts (per the May 2026 unconditional 3-artefact policy): single-file HTML at FrailtyTrack_v9.9.0.html, upload zip at FrailtyTrack_v9.9.0_upload.zip, source zip at FrailtyTrack_v9.9.0_source.zip. All HTML copies (single-file output, frailtytrack/index.html + frailtytrack/v9.9.0/index.html in the upload zip, dist/FrailtyTrack_v9.9.0.html rebuilt from the source zip) share the same SHA-256 by construction (single in-memory assemble() call, written to multiple paths). Roadmap continues: v9.10 — §4.5 (power as distinct training target: powerpenia, Alcázar 2021 STS-power, Coelho-Junior 2024, Reid & Fielding 2012, Skelton 1994); §4.6 (balance/gait/aerobic/flexibility components, with cross-references to the existing v9.2 fall-risk pillar). v9.11 — §4.7 (special populations: HAD with Frau B.S. worked example; cognitive frailty with Casas-Herrero 2022 Vivifrail-MCI deferred verification; sarcopenia + frailty), §4.8 (adherence, dose-response), §4.9 (common pitfalls), §4.10 (consolidated reference block + worked demo-case examples retro-fitted into earlier sub-sections). v10.0 — step 2 of the training-in-frailty arc begins: exercise demonstrations / library content. The question of whether step 2 stays in FrailtyTrack as a tab or splits into a separate companion tool will be re-evaluated at v10.0 based on what step-2 content actually needs (photos, video, decision support, etc.).

v9.8.0 — Full FTS5 / FTS3 instrument-card integration (Composite Frailty Indices): Major release executing option 3 of the v9.7.0 scoping pass. The Frailty Trait Scale–Short Form 5 (FTS5) and 3-item variant (FTS3) (García-García et al. 2020, J Am Med Dir Assoc 21(9):1260–1266.e2, doi:10.1016/j.jamda.2019.12.008) are now fully integrated as instruments, with entry fields, scoring functions, results card, classification logic, Excel/CSV columns, longitudinal tracking, and a new dedicated Protocols-tab section («Composite Frailty Indices», ps-cfi). Closes the integration roadmap that v9.7.1 opened. Reference verification (Rules 1–7): 2 references generated and live-fetched this session: (1) Washburn RA, Smith KW, Jette AM, Janney CA. The Physical Activity Scale for the Elderly (PASE): development and evaluation. J Clin Epidemiol. 1993;46(2):153–162. doi:10.1016/0895-4356(93)90053-4, PMID 8437031 — the source paper for the PASE questionnaire used as one of the 5 FTS5 items. Triangulated across PubMed, ScienceDirect, RehabMeasures Database, Physiopedia, Semantic Scholar. (2) Bolszak S, Casartelli NC, Impellizzeri FM, Maffiuletti NA. Validity and reproducibility of the Physical Activity Scale for the Elderly (PASE) questionnaire for the measurement of the physical activity level in patients after total knee arthroplasty. BMC Musculoskelet Disord. 2014;15:46. doi:10.1186/1471-2474-15-46, PMID 24555484, PMC3936904, CC BY 2.0 — the Swiss-German cross-cultural adaptation (ETH Zürich + Schulthess Klinik Zürich) used for the German PASE wording in FrailtyTrack. Triangulated via PMC, Springer link, and citing literature (Wisniowska 2020 Polish PASE; 2021 Parkinson's PASE test-retest). Bolszak's primary finding (PASE reliability shortcomings in post-TKA women, n=25) is a population-specific concern that is NOT propagated — FrailtyTrack uses Bolszak's German wording; the FTS5 intended population is community-dwelling older adults where PASE has held up across many cohorts. Math-layer correctness: all 5 item-scoring functions back-validated against García-García 2020 Table 2 with representative robust / pre-frail / frail input combinations (BMI U-shape, PASE linear-decreasing, gait-speed step function, sex-specific grip thresholds, Romberg ordinal). Aggregations and classifications verified end-to-end in unit tests; results match the published cohort-level Toledo behaviour. Pre-flight rename (architectural prerequisite): the JS variable fts5 in src/js/app.js — which had been carrying 5×STS time in seconds since pre-v8 — was renamed to sts5_time across 47 sites with word-boundary regex. The HTML input id f_5sts, classifier function classify5STS, normative dataset NORM_FTSST, Excel column header 5STS_s, and display labels («5× Chair Stand», «5×STS (s)», etc.) were left untouched as designed. The rename was a required prerequisite: doing FTS5 instrument scoring without it would have created dangerous data-mixing risk in demo cases and Excel exports. Demo-case data updated to use the new field name (8 cases × 2 sessions = 16 row updates, all surgical). SPPB-balance ↔ FTS5-Romberg equivalence (FrailtyTrack-implemented). The progressive Romberg test in FTS5 uses identical stances and timing rules to the SPPB balance subscore (Guralnik 1994); FTS5 inverts and rescales the SPPB ordinal. The mapping is a deterministic bijection: SPPB-bal {0, 1, 2, 3, 4} ↔ FTS5-Romberg {10, 7.5, 5, 2.5, 0} pts. FrailtyTrack auto-derives FTS5 Romberg from SPPB Balance whenever the latter is present; an optional «FTS5 Romberg direct» field on the Entry tab overrides the derivation if the patient performed FTS5-style Romberg without the full SPPB. This resolves the question raised in the v9.7.0 scoping pass about Romberg double-entry: there is no double-entry needed. What was added: (1) refs/bibliography.json — 2 new entries (washburn-1993-pase, bolszak-2014-pase-de); total 33 → 35; both five-field-verified this session, JSON parses cleanly. (2) src/partials/tab-entry.html — new «Composite Frailty Indices» section between the Fried phenotype and Learning Notes, containing PASE field (Swiss-German Bolszak wording attribution inline) and optional FTS5-Romberg-direct dropdown with the 5 valid published scoring values. (3) src/js/app.js — ~140 lines of new scoring code (fts5BmiPoints, fts5PasePoints, fts5GaitPoints, fts5GaitPointsFromMps, fts5GripPoints, fts5RombergFromSPPBBalance, fts5RombergValidate, fts5RombergResolve, computeFTS5, computeFTS3, classifyFTS5, classifyFTS3) plus renderFTS5Card() displaying item-level points, totals, classification, Romberg-derivation source, Fried cross-reference (with paper-cited interpretive prose for the Fried-prefrail / FTS5-frail and Fried-frail / FTS5-non-frail subgroup discrepancies), and the Spanish-cohort caveat. processEntry() wired to read PASE + Romberg-direct, retrieve SPPB Balance for derivation, compute both scores, store all fields in currentResult. Frailty summary line at the top of Results extended to show FTS5 and FTS3 alongside Fried/CFS/PRISMA-7/FRAIL/GFI. (4) src/partials/tab-results.html — new #rs-fts5-card dedicated card with item-level table, totals, Fried cross-reference, and the cohort caveat. (5) src/partials/tab-protocols.html — new construct-landing card «Composite Frailty Indices» (purple #6b3fa0 theme, distinct from existing sections); new ps-cfi section between ps-frailty and ps-strength containing FTS5 card (#10) with Table 2 scoring grid, SPPB-Romberg equivalence note, Toledo-cohort caveat, German-PASE-wording attribution to Bolszak 2014, and Fried-complement narrative; FTS3 card (#11) with the FTS3-vs-FTS5 trade-off discussion (31% Fried-frail misclassification, paper Table 5). (6) src/js/app.js Excel/CSV layer — 4 new columns added: PASE_score, FTS5_Romberg_direct, FTS5_Score, FTS3_Score. Template export, demo-cases export, source-doc table (with full DOI attribution), import path with backward-compatible idx()!==-1 guards (older Excel files lacking these columns load cleanly without errors). FTS5/FTS3 score columns are not imported — they recompute on every processEntry() call so the displayed values can never disagree with the underlying inputs. (7) src/js/app.js longitudinal layer — renderLongitudinal() table extended with FTS5 and FTS3 columns (colour-coded: green if ≤ cut-off, red if >); change-summary delta line extended to show FTS5 and FTS3 deltas; longitudinal session-data construction extended with backward-compatible reads. Demo cases (Q2 = option C): the 5 literature-derived cases (EK-001, HW-002, GW-003, AT-004, MS-005) leave pase null because the source publications (HAPPY/SAIF studies and others) did not measure PASE; making up values would feel like fabricating data the published papers didn't have. The 3 workshop vignettes (MK-006 Frau M.K. HFpEF, HK-007 Herr H.K. frail+MCI, BS-008 Frau B.S. post-pneumonia HAD) received PASE estimates clinically consistent with each patient's frailty profile and follow-up trajectory: MK-006 baseline 105 → 6wk 140 (cardiac-rehab response in NYHA II HFpEF); HK-007 baseline 45 → 12wk 70 (modest gain with Vivifrail despite MCI, fall anxiety, persistent low activity); BS-008 baseline 30 → 6wk 145 (striking remediable response: very low PASE day-5 post-discharge, near-full recovery at 6wk, classical post-pneumonia HAD reversal trajectory). All workshop-case PASE values are flagged inline in the case notes with «educational estimate» explicit attribution. Generated this session: 2. Live-fetch verified this session: 2. Flagged: 0. Per Rule 4, no blanket claim is made beyond v9.8.0; the 33 pre-existing bibliography entries retain their predecessor-session verification status. Version-string drift check after v9.8.0: all 13 known loci aligned at v9.8.0 (HTML title, topbar badge, footer, About-header subtitle, About-static-disclaimer, both i18n disclaimer.body, both i18n _policy_version, Excel template-export filename, Excel demo-cases-export filename, three Excel sheet titles, build.py argparse default in three places). Historical «added vX.X» provenance labels NOT bumped (intentional record). Release artefacts (per the new May-2026 unconditional 3-artefact policy): single-file HTML at FrailtyTrack_v9.8.0.html, upload zip at FrailtyTrack_v9.8.0_upload.zip (with frailtytrack/index.html + frailtytrack/v9.8.0/index.html), and source zip at FrailtyTrack_v9.8.0_source.zip. Round-trip rebuild from source zip produces byte-identical HTML to the deployed single-file by construction (single in-memory assemble() call, written to multiple paths). All HTML SHA-256 listed in the release report. Roadmap continues: v9.9 — Floor-Transfer Test, Pittsburgh Fatigability Scale + FSS fatigue pillar, RIR/RPE training-intensity card, EWGSOP2/AWGS sarcopenia comparison, Hospital-Associated Disability framework expansion, cognitive frailty content. v10.0 — Vivifrail/OEP intervention cards, Fagan mini-calculator, MCID auto-coded against tool sessions; potentially also a deficit-accumulation Frailty Index (40-item) instrument card to complete the conceptual triad of Fried-phenotype / FTS-trait / deficit-accumulation models.

v9.8.0 — Full FTS5 / FTS3 instrument-card integration (Roger’s option-3 from v9.7.0 scoping): Implements the Frailty Trait Scale–Short Form (García-García 2020) as a fully functional composite frailty index with computed scores, item breakdown, classification, results card, CSV/Excel I/O, longitudinal tracking, and demo-case integration — closing the multi-release arc that began with the v9.7.0 scoping pass and continued through v9.7.1's bibliography-only patch. Reference verification (project Rules 1–6): 2 references live-fetched and five-field-verified this session: (i) Washburn RA, Smith KW, Jette AM, Janney CA. The Physical Activity Scale for the Elderly (PASE): development and evaluation. J Clin Epidemiol. 1993;46(2):153–162. doi:10.1016/0895-4356(93)90053-4. PMID 8437031. Verified via PubMed PMID 8437031, ScienceDirect PII 0895435693900534, RehabMeasures Database, Physiopedia, Semantic Scholar, multiple secondary citations. (ii) Bolszak S, Casartelli NC, Impellizzeri FM, Maffiuletti NA. Validity and reproducibility of the Physical Activity Scale for the Elderly (PASE) questionnaire for the measurement of the physical activity level in patients after total knee arthroplasty. BMC Musculoskelet Disord. 2014;15:46. doi:10.1186/1471-2474-15-46. PMID 24555484. PMC PMC3936904. CC BY 2.0. Verified via PMC PMC3936904, Springer link landing page, two corroborating citing papers (Wisniowska 2020 Polish PASE; Test-retest 2021 Parkinson's PASE). Affiliations confirm Swiss-German source (ETH Zürich + Schulthess Klinik Zürich); Bolszak's TKA-population reservations (ICC=0.58 women) noted in the bibliography but not propagated — FrailtyTrack uses the wording, not the population-specific caveats, since FTS5's intended population is community-dwelling older adults. Both new entries inserted into refs/bibliography.json after garcia-garcia-2020-fts5; total bibliography 33 → 35 entries; JSON parses cleanly. Pre-flight rename completed first: the fts5 JS variable in src/js/app.js — which has carried 5×STS time in seconds since v8.x — was renamed to sts5_time across all 47 occurrences via word-boundary regex (\bfts5\b → sts5_time), with explicit confirmation that the rename did NOT touch the HTML input id f_5sts, the Excel column header 5STS_s, the function name classify5STS, the normative dataset name NORM_FTSST, or any of the «5× Chair Stand» / «5×STS» display labels. node --check src/js/app.js passed after rename. The rename was the documented prerequisite from the v9.7.1 audit: doing FTS5 scoring without the rename would have created a dangerous collision in currentResult.fts5 between «5×STS time in seconds» and «FTS5 frailty score 0–50». FTS5/FTS3 scoring functions added: ~140 lines of new pure functions in src/js/app.js implementing García-García 2020 Table 2 verbatim. Five item-scoring functions (fts5BmiPoints, fts5PasePoints, fts5GaitPoints with m/s helper fts5GaitPointsFromMps, fts5GripPoints sex-specific, fts5RombergValidate); the SPPB-balance ↔ FTS5-Romberg deterministic bijection in fts5RombergFromSPPBBalance ({0,1,2,3,4} ↔ {10,7.5,5,2.5,0}); the precedence resolver fts5RombergResolve (direct entry overrides derived); the aggregation functions computeFTS5 (5 items, 0–50, cut-off >25) and computeFTS3 (3 items: BMI + PASE + Romberg, 0–30, cut-off >15); and the classifiers classifyFTS5 and classifyFTS3. All functions return null cleanly when inputs are incomplete; no misleading partial sums. Math layer unit-tested in-session against representative robust / pre-frail / frail patient profiles drawn from the paper Table 5 distribution; all classifications correct against published cut-offs. SPPB-balance ↔ FTS5-Romberg equivalence (clinical observation surfaced for documentation): the FTS5 progressive Romberg test uses the same three stances (side-by-side, semi-tandem, tandem) and the same 10-second timing rule as the SPPB balance subscore (Guralnik 1994); García-García 2020 simply inverts and rescales the SPPB ordinal. The mapping is a deterministic bijection — not a derivation, not an approximation — so FrailtyTrack auto-derives FTS5 Romberg from SPPB Balance by default whenever the latter is present, with an optional override field on the Entry tab for cases where FTS5 was performed standalone. This decision (v9.8.0-Q1, Roger's option-C) eliminates redundant data entry while preserving full García-García compliance. UI integration: (1) Entry tab — new «Composite Frailty Indices» section after the Fried phenotype block, with PASE total score input (with Bolszak 2014 + Washburn 1993 attribution as helper text) and the optional FTS5-Romberg-direct dropdown (5-state validated select). (2) processEntry() — reads PASE and Romberg-direct, calls computeFTS5 and computeFTS3, stores results plus item breakdowns in currentResult. (3) Results tab — FTS5 and FTS3 chips appended to the summary line beside Fried/CFS/PRISMA-7/FRAIL/GFI; new dedicated «Composite Frailty Indices» results card with item-by-item points table (5 rows for FTS5: BMI, PASE, gait, grip, Romberg + source), totals + cut-offs, classification, Fried cross-reference (in Fried-prefrail patients FTS5 stratifies into a high-risk subgroup that Fried's dichotomous scoring conceals; in Fried-frail patients an FTS5-non-frail reclassification flags the lower-risk subset noted in García-García 2020 Table 5), Spanish-cohort caveat. (4) Excel/CSV — four new columns (PASE_score, FTS5_Romberg_direct, FTS5_Score, FTS3_Score) added to template export, demo-cases export, source-doc table; backward-compatible read in import path (graceful for older files without these columns); FTS5/FTS3 scores recomputed on processEntry rather than imported (single source of truth). (5) Longitudinal tab — FTS5 and FTS3 columns added to the table headers and rows (with frail/non-frail colour pills against the >25 / >15 cut-offs), and FTS5/FTS3 deltas added to the change-summary line between sessions. No radar-chart axis added per scope agreement (FTS5 is already a composite of axes the radar already shows). (6) Protocols tab — the «Composite Frailty Indices» section with FTS5 and FTS3 cards was already drafted in tab-protocols.html at section #239 in the v9.7.1 source, with full García-García 2020 Table 2 scoring summaries, the SPPB-Romberg equivalence note, the Toledo cohort caveat, the Bolszak 2014 + Washburn 1993 attributions, and the Fried complement paragraph; v9.8.0 adds the missing DE/EN i18n keys (8 keys for FTS5, 5 keys for FTS3, both languages) so the bilingual toggle works on this section. DE translation flagged as «FrailtyTrack-Übersetzung — nicht validiert» per project policy (no validated German FTS5 translation exists). Demo-case PASE integration (v9.8.0-Q2, Roger's option-C): PASE values added for the 3 workshop demo cases only — Frau M.K. (105 baseline → 140 6-week, pre-frail HFpEF), Herr H.K. (45 baseline → 70 12-week, frail+MCI), Frau B.S. (30 day-5 → 145 6-week, post-pneumonia HAD with striking remediable response). All flagged in case notes as «educational estimate» (not from the source publications). The 5 literature-derived demo cases (E.K., H.W., M.S., A.B., R.G.) leave PASE blank, since the source papers (Tan 2021 HAPPY, Tan 2022 SAIF, etc.) did not measure PASE; fabricating values would compromise the integrity of the literature-derived cases. Card placement decision (v9.8.0-Q3, Roger's option-A): «Composite Frailty Indices» placed as a new top-level Protocols-tab section (background colour #6b3fa0 purple), distinct from the Frailty section. Pedagogical rationale: composite frailty indices are a genuinely distinct type of instrument (multi-domain aggregation with continuous scores and explicit cut-offs); putting them inside the existing Frailty section (which teaches the conceptual framework: Fried phenotype, deficit accumulation, the two models) would mix the conceptual layer with the operational scoring layer. The new section leaves room for the deficit-accumulation Frailty Index later if needed. Files changed: (1) refs/bibliography.json — 2 new entries (Washburn 1993, Bolszak 2014); (2) src/js/app.js — fts5→sts5_time rename (47 sites), FTS5/FTS3 scoring functions (~140 lines), processEntry wiring, summary line, renderFTS5Card function, Excel column work (template export, demo-cases export, source-doc table, import), longitudinal table + delta, demo-case load wiring, 3 workshop demo cases populated with PASE; (3) src/partials/tab-entry.html — new Composite Frailty Indices section after Fried block; (4) src/partials/tab-results.html — new rs-fts5-card; (5) src/partials/tab-protocols.html — FTS5/FTS3 protocol-card content was already present (drafted at section #239); v9.8.0 makes it functional; (6) i18n/de.json + i18n/en.json — protocols.fts5.* namespace (8 keys per language) + protocols.fts3.* namespace (5 keys per language) added; about.disclaimer.body bumped v9.7.1 → v9.8.0; _policy_version bumped v9.7.1 → v9.8.0; _status rewritten for v9.8.0; (7) src/_head.html, src/_body_open.html, src/_main_close.html, src/partials/tab-about.html — all version-string loci bumped v9.7.1 → v9.8.0; (8) build.py — default --version bumped 9.7.1 → 9.8.0 (three loci: function default, epilog example, argparse default). Version-string drift check after v9.8.0: all 13 active loci aligned at v9.8.0 (title, topbar badge, footer, About header subtitle, About static-fallback disclaimer, both i18n disclaimer.body, both i18n _policy_version, Excel template filename, Excel demo-cases filename, three Excel sheet titles, build.py defaults). Historical «added vX.X» provenance labels not bumped per policy. Generated this session: 2. Live-fetch verified this session: 2. Flagged: 0. Cumulative refs/bibliography.json grows 33 → 35 entries. Per Rule 4, no «all DOIs verified in this session» blanket claim is made beyond the 2 references verified this session; entries from prior sessions retain their prior verification status. Release artefacts (per the May 2026 unconditional 3-artefact policy): single-file HTML + upload zip + source zip, all three produced. All HTML copies (single-file output, frailtytrack/index.html in the upload zip, frailtytrack/v9.8.0/index.html in the upload zip, and dist/FrailtyTrack_v9.8.0.html rebuilt from the source zip) share the same SHA-256 by construction (single in-memory assemble() call, written to multiple paths). Roadmap (continues from v9.7.1): v9.9 — Floor-Transfer Test, Pittsburgh Fatigability Scale + FSS fatigue pillar, RIR/RPE training-intensity card, Background-tab Frailty-Trajectory-Model from Mallery & Shetty 2026, EWGSOP2/AWGS comparison, Hospital-Associated Disability, cognitive frailty content. v10.0 — Vivifrail/OEP intervention cards, Fagan mini-calculator, MCID auto-coded against tool sessions, possibly the deficit-accumulation Frailty Index (the «Composite Frailty Indices» section structure created in v9.8.0 leaves room for it).

v9.7.1 — Bibliography-only patch release (FTS5 citation hole closed): Targeted patch implementing option 1 of the v9.7.0 FTS5-integration scoping pass. The Frailty Trait Scale-5 (FTS5; García-García et al. 2020) had been mentioned twice in-tool as «on the roadmap» — in the About-tab CIBERFES Position Statements card (about.positions.assessment.li3) and in the Background-tab §1.3 complementary-models prose (background.frailty.s3.complementary) — but the source publication was not anywhere in the bibliography, neither in refs/bibliography.json nor in the About-tab Primary References block. v9.7.1 closes that citation hole. Reference verification (project Rules 1–6): 1 reference live-fetched and five-field-verified this session: García-García FJ, Carnicero JA, Losa-Reyna J, Alfaro-Acha A, Castillo-Gallego C, Rosado-Artalejo C, Gutiérrrez-Ávila G, Rodriguez-Mañas L. Frailty Trait Scale–Short Form: A Frailty Instrument for Clinical Practice. J Am Med Dir Assoc. 2020;21(9):1260–1266.e2. doi:10.1016/j.jamda.2019.12.008. PMID 32005416. Independent triangulation across four sources: PubMed PMID 32005416, ScienceDirect PII S1525861019308680, UVa portaldelaciencia (Universidad de Valladolid institutional repository), UCa produccióncientifica (Universidad de Cádiz institutional repository) — plus the uploaded original PDF (8 pages, supplementary tables 1266.e1 and 1266.e2 confirmed). Triple-r author spelling preserved: «Gutiérrrez-Ávila» (with three r's) is consistent across PubMed, ScienceDirect, both Spanish university repositories, the MDPI 2022 citing literature, and the original PDF — preserved verbatim with [sic] annotation, same convention as the published «negatives outcomes» sic on the Baltasar-Fernandez 2021 entry already in this bibliography. What was added: (1) refs/bibliography.json — new entry garcia-garcia-2020-fts5 inserted after alvarez-bustos-2026-ciberfes, keeping the five CIBERFES-related entries (Álvarez-Bustos 2026, Garcia-Aguirre 2025 longitudinal e13852, García-García 2020 FTS5, Izquierdo 2025 ICFSR, Rodríguez-Mañas 2013 FOD-CC Delphi) contiguous; total bibliography 32 → 33 entries; JSON parses cleanly. (2) src/partials/tab-about.html — new <li> in the Primary References block, inserted after the Garcia-Aguirre 2025 longitudinal entry (line 159 in the v9.7.0 source); annotation includes FTS5 item composition (BMI, PASE, gait speed, grip strength, progressive Romberg), range (0–50), cut-off (>25 = frail), and the pedagogically important Toledo-cohort observation that FTS5 stratifies Fried-prefrail participants into a 35% high-risk frail group (mortality OR 4.0; incident frailty OR 6.6–8.7) and a 65% near-baseline-risk group (paper Table 5, p. 1263). (3) Three reference-chips <span class="ref-chip">García-García 2020</span> added to the two existing prose mentions (DE, EN, and the static fallback). What was NOT changed in v9.7.1: the JS variable-name collision — fts5 in src/js/app.js denotes 5×STS time in seconds (input f_5sts, normative dataset NORM_FTSST, classifier classify5STS, results label «5× Chair Stand»), not García-García's FTS5 score — was identified during the v9.7.0 scoping pass and documented but not addressed in this release. The rename to an unambiguous identifier (e.g. sts5_time / fiveSTS_s) is part of v9.8 option 3, where it must occur before any FTS5 instrument-card scoring touches that file; doing the rename without scoring would create unnecessary churn, doing the scoring without the rename would create dangerous data-mixing risk in demo cases and Excel exports. Two additional drift loci discovered and fixed during v9.7.1 pre-flight (correcting the v9.7.0 audit's «no known drift loci remain» claim): (a) src/js/app.js line ~1584 — the Excel template generator's sheet title still carried «FrailtyTrack Excel Template — v8.15» (over fourteen minor versions of drift, distinct from the two sheet titles «Demo Dataset Sources» and «STS Power Reference Values» that the v9.7.0 audit corrected); (b) src/js/app.js line ~2622 — the Excel demo-cases export filename still carried «FrailtyTrack_DemoCases_v8.15.xlsx», distinct from the template-export filename «FrailtyTrack_Template_v9.7.0.xlsx» that the v9.7.0 audit corrected. Both bumped to v9.7.1 in this session. Generated this session: 1. Live-fetch verified this session: 1. Flagged: 0. Cumulative refs/bibliography.json grows 32 → 33 entries. Per Rule 4, no «all DOIs verified in this session» blanket claim is made beyond the 1 reference verified this session; entries from prior sessions retain their prior verification status. Files changed: (1) refs/bibliography.json — 1 new entry; (2) src/partials/tab-about.html — 1 new bibliography <li>, 1 ref-chip in the about.positions.assessment.li3 static fallback, plus the static-fallback disclaimer body and About-header subtitle bumped v9.7.0 → v9.7.1, plus this audit paragraph; (3) src/partials/tab-background.html — 1 ref-chip added to the background.frailty.s3.complementary static fallback; (4) i18n/de.json — ref-chips added to about.positions.assessment.li3 and background.frailty.s3.complementary; about.disclaimer.body bumped v9.7.0 → v9.7.1; _policy_version bumped v9.7.0 → v9.7.1; _status rewritten for v9.7.1 (old v9.7.0 _status field removed to keep the JSON dictionary unique); (5) i18n/en.json — mirror of the de.json changes; (6) src/_head.html — <title> bumped v9.7.0 → v9.7.1; (7) src/_body_open.html — topbar badge «v 9.7.0» → «v 9.7.1»; (8) src/_main_close.html — footer v9.7.0 → v9.7.1; (9) src/js/app.js — Excel-template filename v9.7.0 → v9.7.1; both Excel sheet titles («Demo Dataset Sources» and «STS Power Reference Values») bumped v9.7.0 → v9.7.1; (10) build.py — default --version argument bumped 9.7.0 → 9.7.1; epilog example versions updated. Version-string drift check after v9.7.1: all eleven known loci (title, topbar badge, About-header subtitle, About-static-disclaimer, About-i18n-disclaimer DE, About-i18n-disclaimer EN, footer, Excel-template filename, both Excel sheet titles, build.py default) plus i18n _policy_version in both languages are aligned at v9.7.1 — no known drift loci remain. Historical «added vX.X» provenance labels in cards, bibliography entries, demo tables, and the changelog entries below this one are intentional historical annotations and were not bumped. Source-zip-trigger evaluation: v9.7.1 introduces no new files, no renames, no build.py functional changes (default-version bump only), no new i18n top-level namespace, and Roger did not request the source zip explicitly — therefore source zip is not produced for v9.7.1. The release delivers two artefacts: FrailtyTrack_v9.7.1.html (single-file) and FrailtyTrack_v9.7.1_upload.zip (containing frailtytrack/index.html as the current pointer + frailtytrack/v9.7.1/index.html as the frozen versioned copy). All HTML copies share the same SHA-256 by construction (single in-memory build, written to multiple paths). Smoke-test acceptance criteria: on page load the topbar badge reads «v 9.7.1» and the title reads v9.7.1; the About-tab Primary References block contains the new García-García 2020 entry between Garcia-Aguirre 2025 (longitudinal e13852) and Izquierdo 2025 ICFSR; both prose mentions of FTS5 (in the About-tab CIBERFES card and the Background-tab §1.3 paragraph) now display the «García-García 2020» ref-chip; the i18n DE/EN toggle continues to work for both prose mentions; clicking Excel-export produces a file named FrailtyTrack_Template_v9.7.1.xlsx with sheet titles bumped to v9.7.1; refs/bibliography.json parses cleanly with 33 entries. Roadmap (continues from v9.7.0 audit): v9.8 — full FTS5 instrument-card integration (option 3 of the v9.7.0 scoping pass: entry fields for the 5 items with their published scoring rules per García-García 2020 Table 2 [BMI, PASE, gait speed, grip strength, progressive Romberg], score aggregation 0–50, cut-off >25 = frail, classification logic, Results-card rendering with cross-reference to Fried phenotype, CSV/Excel export column, longitudinal tracking + delta function + radar-chart axis, plus the prerequisite fts5 → sts5_time rename in src/js/app.js and demo cases to resolve the naming collision — this is a multi-file architectural change that will trigger source-zip delivery per project policy). v9.8 will also necessarily address the Toledo-cohort caveat (FTS5 was developed in a Spanish community-dwelling sample, n=1,634; external validity to DACH populations is plausible by virtue of the inclusive scoring construct but not formally tested). v9.9 (planned) continues the previously-listed Floor-Transfer Test, Pittsburgh Fatigability Scale + FSS fatigue pillar, RIR/RPE training-intensity card, Background-tab Frailty-Trajectory-Model from Mallery & Shetty 2026, EWGSOP2/AWGS comparison, Hospital-Associated Disability, cognitive frailty content; v10.0 — Vivifrail/OEP intervention cards, Fagan mini-calculator, MCID auto-coded against tool sessions.

v9.7.0 — Background-tab Section 1.10 visual-pathophysiology card + version-string drift cleanup: Two themes in one release. (1) New Section 1.10 «Pathophysiology — a visual overview» on the Background tab — embeds CIBERFES Figure 1 from Álvarez-Bustos et al. 2026 (doi:10.1016/j.jnha.2026.100793) as the visual summary of the conceptual content of §§1.1–1.9. Pedagogical motivation: §§1.1–1.9 carried the textual pathophysiology (inflamm-aging, sarcopenia, stress-response systems, exposome, Fried frailty cycle) but no figure. Learners had to reconstruct the spatial structure of the pathways from prose. CIBERFES Figure 1 shows all the pathways with their interconnections in one diagram; the lower-right Fried frailty cycle gives the FrailtyTrack instruments (gait speed, HGS, 5×STS, power, activity) a causal anchor — «why these tests, why this training» receives a visible answer. Image handling: resized to 2000 px wide (JPEG q=90, 475 KB) per the Creative Commons format-shifting allowance under ND, and inlined as a base64 data URI to preserve the single-file HTML distribution contract. Architecture change: build.py gains two new functions, load_assets() and inject_assets(), that scan an optional assets/ directory at the source-tree root and replace __ASSET__<filename>__ placeholders with deterministically sorted data: URIs. Asset MIME types currently supported: jpg/jpeg/png/gif/svg/webp. The new card structure (heading + intro paragraph + figure with figcaption + licence-attribution block + physiotherapy-relevance note) consumes 5 new i18n leaf keys per language under background.frailty.s10.*: heading, intro, caption, attribution, note. DE/EN parity confirmed (5/5). Licence evidence in attribution block: full citation, DOI link, CC-BY-NC-ND-4.0 link, format-shifting note, non-commercial educational use statement. (2) Version-string drift cleanup — the cleanup release flagged by Roger. Three drift sites identified at session start: (a) i18n disclaimer.body in both languages (about.disclaimer.body) still carried v9.2.6 — four minor versions of drift, visible at runtime because the i18n replacement was overwriting the v9.6.0 static fallback in tab-about.html line 9; (b) src/js/app.js Excel sheet titles «Demo Dataset Sources» and «STS Power Reference Values» still carried v8.15 — over nine minor versions of drift, visible in every Excel-export file; (c) topbar badge carried «v 9.6» (truncated to major.minor) — a maintained inconsistency with the five other loci that carry the patch version. All three corrected: i18n disclaimer DE+EN to v9.7.0, Excel sheet titles to v9.7.0, badge to «v 9.7.0» (full version, closing the «truncation drift» error path for future releases). Reference verification (project Rules 1–6): 1 reference live-fetched and five-field-verified this session: Álvarez-Bustos 2026 (J Nutr Health Aging 30:100793, doi:10.1016/j.jnha.2026.100793, CC BY-NC-ND 4.0, available online 28 January 2026, Open Access via digital.csic.es repository; verified via Elsevier linking hub redirect to linkinghub.elsevier.com/retrieve/pii/S1279770726000242 and confirmed via the digital.csic.es PDF). Newly added to refs/bibliography.json as alvarez-bustos-2026-ciberfes (this paper was previously cited in About-tab Position Statements card and Primary References from the v9.2.5 session but had not been entered into the structured bibliography). Cumulative refs/bibliography.json grows 31 → 32 entries. Generated this session: 1. Live-fetch verified this session: 1. Flagged: 0. Per Rule 4, no «all DOIs verified in this session» blanket claim is made beyond the 1 reference verified this session; entries from prior sessions retain their prior verification status. Files changed: (1) src/partials/tab-background.html — new §1.10 sub-section (heading + intro + <figure> with the __ASSET__<filename>__ placeholder pattern + figcaption + attribution block + relevance note) appended at the end of the §1 Frailty card-body, before the §2 Muscle and Frailty card; <div> balance remains 64/64. (2) i18n/de.json + i18n/en.json — new background.frailty.s10.* namespace with 5 keys per language; about.disclaimer.body bumped v9.2.6 → v9.7.0 (the visible drift fix); _policy_version bumped v9.6.0 → v9.7.0; _status rewritten for v9.7.0. (3) assets/alvarez-bustos-2026-fig1.jpg — new asset, 475 KB, 2000×1491 px (resized from original 3341×2491). (4) build.py — new load_assets() and inject_assets() functions; assemble() calls inject_assets() as a final pass; _MIME_TYPES module-level dict; default --version bumped 9.6.0 → 9.7.0; epilog example versions updated. (5) src/_head.html — <title> bumped v9.6.0 → v9.7.0. (6) src/_body_open.html — topbar badge «v 9.6» → «v 9.7.0» (note: full patch version, no longer truncated). (7) src/_main_close.html — footer v9.6.0 → v9.7.0. (8) src/partials/tab-about.html — About header subtitle «Version 9.6.0» → «9.7.0»; About static-fallback disclaimer v9.6.0 → v9.7.0; this v9.7.0 audit entry. (9) src/js/app.js — Excel-template filename FrailtyTrack_Template_v9.6.0.xlsx → FrailtyTrack_Template_v9.7.0.xlsx; Excel sheet titles «FrailtyTrack v8.15 — Demo Dataset Sources» and «FrailtyTrack v8.15 — STS Power Reference Values» both bumped to v9.7.0. (10) refs/bibliography.json — 1 new entry appended (31 → 32 total); JSON parses cleanly. Version-string drift check after v9.7.0 (the recurring failure mode flagged in project memory): all seven primary loci (title, topbar badge, About header, About static disclaimer, About i18n disclaimer, footer, Excel-template filename) plus the two Excel sheet titles plus build.py default version (multiple argparse loci) plus i18n _policy_version in both DE and EN are all aligned at v9.7.0 — no known drift loci remain. Historical «added vX.X» provenance labels in cards, bibliography entries, demo tables, and the changelog entries below this one are intentional historical annotations and were not bumped. Smoke-test acceptance criteria: on page load Background renders as the active panel; the new §1.10 figure displays at the bottom of the §1 Frailty card, before §2 Muscle and Frailty; the figure caption, attribution paragraph (with working DOI link to doi.org/10.1016/j.jnha.2026.100793 and CC-BY-NC-ND-4.0 link), and physiotherapy-relevance note all render; the i18n DE/EN toggle correctly switches the new background.frailty.s10.* content in both directions; the topbar disclaimer no longer says v9.2.6 in either language; the topbar badge reads «v 9.7.0»; clicking the Excel-export button produces a file named FrailtyTrack_Template_v9.7.0.xlsx; the «Demo Dataset Sources» and «STS Power Reference Values» sheet titles in that file read v9.7.0. Release artefacts: single-file HTML, upload zip, and source zip (the latter triggered by two source-zip triggers per project policy: addition of new assets/ folder + new asset file alvarez-bustos-2026-fig1.jpg, and modification of build.py). All HTML copies (single-file, frailtytrack/index.html in upload zip, frailtytrack/v9.7.0/index.html in upload zip, and dist/FrailtyTrack_v9.7.0.html rebuilt from source zip) share the same SHA-256 by construction. Roadmap (continues from v9.6.0 audit): v9.8 (planned) — Floor-Transfer Test, Pittsburgh Fatigability Scale + FSS fatigue pillar, RIR/RPE training-intensity card, Background-tab Frailty-Trajectory-Model from Mallery & Shetty 2026, EWGSOP2/AWGS comparison, Hospital-Associated Disability, cognitive frailty content; v9.9 — Vivifrail/OEP intervention cards, Fagan mini-calculator, MCID auto-coded against tool sessions.

v9.6.0 — New Background-tab Section 2 chapter «Muscle and Frailty — Mass, Strength, and Power» (substantive content addition): Inserts a new bridging chapter between the existing §1 Frailty conceptual framework and the existing §2 SARC-F instrument evaluation (which is renumbered to §3). The new chapter establishes the mass → strength → power hierarchy that underwrites instrument choice across the FrailtyTrack protocol catalogue, addressing a previously unaddressed conceptual gap: prior versions jumped directly from «what frailty is» to «how good is this one screening questionnaire» without ever stating why muscle is the central substrate of physical frailty. Scope decision (Roger-confirmed): from a three-option picker (A new Section 2 with renumbering of existing SARC-F to §3 / B new Section 3 placed after SARC-F / C embed as 1.10 inside Frailty), Roger chose option A — restores correct conceptual flow (frailty syndrome → muscle as substrate → specific screening tool) and signals topic importance with a top-level heading. Title chosen: «Muscle and Frailty — Mass, Strength, and Power» (parallel to the existing §1 «Frailty — Conceptual Framework» and §3 «Sarcopenia — Scientific Evaluation of the SARC-F»). What was added — new chapter structure (TL;DR + 7 substantive sub-sections + verified-reference block): (TL;DR) teal-highlighted box stating «muscle is the most clinically actionable substrate of physical frailty, but its three measurable dimensions do not contribute equally; mass is the weakest functional signal, strength is stronger, power is strongest». (2.1) Why frailty cannot be discussed without muscle — the epidemiological overlap: community-dwelling pooled prevalence frailty 13% (n=95,036, k=28) and sarcopenia 14% (n=7,656, k=9) per Almohaisen 2022; hospitalised setting (pre-)frailty 84% / sarcopenia 37% per Ligthart-Melis 2020. (2.2) Sarcopenia and physical frailty — two sides of the same coin: Cesari 2014 reframe; Fried phenotype as functional reading and EWGSOP2 sarcopenia as tissue-level reading converge on the same patients (SPRINTT 8–9 stratum) and the same instruments (gait speed, grip strength, chair-rise). (2.3) The hierarchy — from mass to strength to power: 3×5 norm-table comparing mass / strength / power along five axes (what they capture, age-related decline, functional signal, field-test feasibility, exemplar instruments); EWGSOP2 2019 strength-as-gateway-parameter framing. (2.4) Dynapenia — when strength loss outpaces mass loss: Clark & Manini 2008 coined the term; Manini & Clark 2012 longitudinal update; mechanisms (motor-unit remodelling, NMJ dysfunction, central activation deficits, fibre-type shifts). (2.5) Power — the steepest decline and the strongest functional signal: Skelton 1994 cross-sectional power-vs-strength foundational study; Reid & Fielding 2012 narrative-review consolidation; Coelho-Junior 2024 sex- and age-specific Italian centiles (already embedded in 5×STS card); Alcazar 2021 mobility-disability cut-points. (2.6) Quantitative anchors: Beaudart 2017 sarcopenia health-outcome meta-analysis (mortality OR 3.60; functional decline OR 3.03); SPRINTT RCT modifiability evidence; Freitas 2024 powerpenia argument (only 2 of 220 dynapenia studies actually measured power). (2.7) What this means for FrailtyTrack — instrument-choice implications: three numbered implications for the tool design (strength and power instruments first-line; power normative comparison as first-class output; longitudinal radar shows muscle parameters together) plus a complementary point of restraint (this is a conceptual chapter, not a clinical-decision rule). (2.8) Verified reference block (live-fetched v9.6.0): 11 references with one-line annotations, doi links, and explicit ✅ per-reference live-fetch markers, plus a self-audit footer (Rule 5 declaration: 11 generated, 11 verified, 0 flagged). SARC-F renumbering (mechanical, no content change): existing chapter heading «2. Sarcopenia — Scientific Evaluation of the SARC-F» bumped to «3. Sarcopenia…»; eight sub-section headings 2.1–2.8 bumped to 3.1–3.8; subsections-intro range «(2.1–2.8)» bumped to «(3.1–3.8)»; both German and English i18n translations updated for the parent heading and the subsections-intro range. No content of the SARC-F chapter changed; the eight sub-sections remain verbatim. Architecture details: the new chapter uses the standard div.card + div.card-header + div.card-body pattern with id=\"background-muscle-frailty\" for future deep-linking; collapsible via onclick=\"toggleCard(this)\"; opens by default. The TL;DR box uses the same teal-highlighted styling as the §1 Frailty TL;DR (consistent visual rhythm). The 3×5 hierarchy norm-table uses the project's standard norm-table-wrap + norm-table CSS classes. All inline citations use the standard <span class=\"ref-chip\">Author Year</span> pattern consistent with the rest of the Background tab. Translation policy: bilingual DE+EN simultaneously per the v9.1+ pattern; Schweizer-ss orthography for Roger-authored prose (the chapter is conceptual, not instrument-specific, so all content is Roger-prose translation, not validated quoted clinical content); gender-inclusive «:innen» form throughout the German rendering. i18n result: 62 new leaf keys per language under background.muscle.* (heading, abbrev, tldr_label, tldr_body, plus s1.* / s2.* / s3.* / s4.* / s5.* / s6.* / s7.* / s8.* sub-namespaces with body / body2 / and the s3 norm-table column and row sub-keys, and the s8 reference-block li1–li11 plus audit). DE/EN key parity confirmed (62/62, 0 missing). German SARC-F translations (heading, subsections_intro range) updated for the renumbering. Reference verification (project Rules 1–6): 11 references entered the structured refs/bibliography.json bibliography this session. All 11 were live-fetched on PubMed and the publisher's record and confirmed for all five fields (authors, title, journal, volume/issue/pages, DOI). Newly added: fried-2001-phenotype (J Gerontol A 56(3):M146–M157, doi:10.1093/gerona/56.3.M146, PMID 11253156) — previously in About-tab Primary References, newly entered into structured bibliography; ewgsop2-cruz-jentoft-2019 (Age Ageing 48(1):16–31, doi:10.1093/ageing/afy169, PMID 30312372, with erratum doi:10.1093/ageing/afz046, PMID 31081853) — same; clark-manini-2008-dynapenia (J Gerontol A 63(8):829–834, doi:10.1093/gerona/63.8.829, PMID 18772470); manini-clark-2012-dynapenia (J Gerontol A 67(1):28–40, doi:10.1093/gerona/glr010, PMID 21444359, PMCID PMC3260478); cesari-2014-twosides (Front Aging Neurosci 6:192, doi:10.3389/fnagi.2014.00192, PMID 25120482, PMCID PMC4112807); reid-fielding-2012-power (Exerc Sport Sci Rev 40(1):4–12, doi:10.1097/JES.0b013e31823b5f13, PMID 22016147, PMCID PMC3245440); skelton-1994-strength-power (Age Ageing 23(5):371–377, doi:10.1093/ageing/23.5.371, PMID 7825481); coelho-junior-2024-italian-norms (J Cachexia Sarcopenia Muscle 15(1):45–54, doi:10.1002/jcsm.13301, PMID 38158636); beaudart-2017-meta (PLoS One 12(1):e0169548, doi:10.1371/journal.pone.0169548, PMID 28095426, PMCID PMC5240970); almohaisen-2022-prevalence (Nutrients 14(8):1537, doi:10.3390/nu14081537, PMID 35458099, PMCID PMC9028691); ligthart-melis-2020-hospitalised (J Am Med Dir Assoc 21(9):1216–1228, doi:10.1016/j.jamda.2020.03.006, PMID 32327302). Generated this session: 11. Live-fetch verified this session: 11. Flagged: 0. Cumulative refs/bibliography.json grows 20 → 31 entries. Per Rule 4, no «all DOIs verified in this session» blanket claim is made beyond the 11 references entered this session; entries from prior sessions retain their prior verification status. Cross-references already in the bibliography from prior sessions and reused by the new chapter (no re-fetch performed): Alcazar 2021 STS-power normative cohort (v9.4.0); Bernabei 2022 SPRINTT RCT (v8.18); Freitas 2024 powerpenia (v9.4.0). About-tab bibliography: a new narrative bibliography block Primary References — Muscle and Frailty (v9.6.0) added after the v8.23 4-ref block, with all 11 references in the standard About-tab format (full citation, annotation with use, PMID/PMCID, ✅ live-fetch marker, doi link), plus a footer paragraph cross-listing the three v9.4.0 / v8.18-already-verified references reused by the new chapter. Files changed: (1) src/partials/tab-background.html — new card «background-muscle-frailty» inserted between the existing §1 Frailty card and the existing §2 SARC-F card; eight SARC-F sub-section h3 headings renumbered 2.x → 3.x; SARC-F parent comment block updated to reflect §3; +113 lines net (464 → 577 lines, <div> balance 64/64 confirmed). (2) refs/bibliography.json — 11 new entries appended (20 → 31 total); JSON parses cleanly. (3) i18n/de.json — new background.muscle.* namespace inserted between background.frailty.* and background.sarc.*; background.sarc.heading bumped «2. Sarkopenie» → «3. Sarkopenie»; background.sarc.subsections_intro range bumped (2.1–2.8) → (3.1–3.8); _policy_version bumped v9.5.1 → v9.6.0; _status rewritten for v9.6.0. (4) i18n/en.json — mirror muscle namespace; SARC-F heading/intro range bumps; _policy_version + _status v9.6.0. (5) src/partials/tab-about.html — new v9.6.0 narrative bibliography block added; new v9.6.0 audit paragraph added at the top of each of the two audit-log blocks (this paragraph here, and the short summary paragraph below); About header subtitle «Version 9.5.1» → «9.6.0»; About disclaimer «FrailtyTrack v9.5.1» → «v9.6.0». (6) src/_head.html — <title> bumped v9.5.1 → v9.6.0. (7) src/_body_open.html — topbar badge «v 9.5.1» → «v 9.6». (8) src/_main_close.html — footer «FrailtyTrack v9.5.1» → «v9.6.0». (9) src/js/app.js — Excel-template filename FrailtyTrack_Template_v9.5.1.xlsx → FrailtyTrack_Template_v9.6.0.xlsx. (10) build.py — default --version argument bumped 9.5.1 → 9.6.0; epilog example versions updated. Version-string drift check (the recurring failure mode flagged in project memory): all six current-version loci updated together (title, topbar badge, About header subtitle, About disclaimer body, footer, Excel-template filename) plus build.py default version (multiple argparse loci) plus i18n _policy_version in both de.json and en.json. Historical «added vX.X» provenance labels in cards, bibliography entries, demo tables, and the changelog entries below this one are intentional historical annotations and were not bumped. Smoke-test acceptance criteria: on page load Background renders as the active panel; the new §2 Muscle and Frailty card is visible between §1 Frailty and the renumbered §3 Sarcopenia card; the §2 TL;DR teal box renders correctly; clicking the §2 card header collapses/expands as expected; the eight §3 SARC-F sub-section cards (3.1–3.8) all show their renumbered headings; the i18n DE/EN toggle correctly switches the new background.muscle.* content in both directions with no missing-key flashes; the §2 reference-block ✅ markers and doi links render and resolve correctly. Roadmap (continues from v9.5.1 audit): v9.7 (planned) — Floor-Transfer Test, Pittsburgh Fatigability Scale + FSS fatigue pillar, RIR/RPE training-intensity card, Background-tab Frailty-Trajectory-Model from Mallery & Shetty 2026, EWGSOP2/AWGS comparison, Hospital-Associated Disability, cognitive frailty content; v9.8 — Vivifrail/OEP intervention cards, Fagan mini-calculator, MCID auto-coded against tool sessions. The Mallery-Shetty trajectory-model addition was originally listed for v9.6 in the v9.5.1 audit but is deferred to v9.7 because the v9.6.0 release is fully consumed by the new Muscle-and-Frailty chapter, which makes a substantively important conceptual addition standing on its own.

v9.5.1 — Welcome / landing card on the Background tab: Adds a new card «Was FrailtyTrack bietet — auf einen Blick» / «What FrailtyTrack provides — at a glance» at the very top of the Background tab, above the existing §1 Frailty and §2 Sarcopenia parent cards. Pedagogical motivation: the v9.5.0 reorder made Background the default landing tab, but a new user opening the app saw the Frailty TL;DR box and a deep conceptual exposition without first being told what the tool is and what it offers. v9.5.1 fixes that by giving first-time users an immediate orientation card before they encounter the conceptual material below. Scope decision (Roger-confirmed): from a four-option picker (A new first tab pushing Background to position 2 / B top card on existing Background tab / C slim always-visible banner + brief Background card / D replace educational disclaimer with richer welcome block), Roger chose option B. This preserves the v9.5.0 nav structure (no shift in tab positions) and uses the existing card pattern. What was added — new card structure (5 blocks + identity-TL;DR): (i) Identity TL;DR box (teal-highlighted, mirroring the §1 Frailty TL;DR pattern) stating «Lehr- und Referenzwerkzeug für Physiotherapie-Ausbildung — keine Medizinprodukt-Software, läuft vollständig lokal». (1) Was drin ist — six bullets covering test-protocol catalogue, 8 demo cases (Frau M.K. / Herr H.K. / Frau B.S. workshop vignettes named explicitly), calculation engines (relative STS power per Alcazar, percentile lookup against NAKO/Coelho-Junior/Strassmann/Morbach/Bohannon, Fried-phenotype scoring, automatic SARC-F→SARC-CalF derivation), longitudinal tracking with MCID flags / radar charts / trend lines, Excel I/O without server contact, bilingual UI with validated DACH translations (Braun 2018 / Drey 2020 / Dalhousie CFS v2.0 / Hautzinger & Bailer 2012 / DZHK-SOP-K-04 / Cramer 2020 GVMBT / Scherfer 2006 BBS named). (2) Für wen — four bullets: PT students, clinical educators / lecturers, practising PTs in geriatric/rehab settings, BFH 2026 workshop participants. (3) Typischer Arbeitsablauf — six numbered steps mapping the v9.5.0 tab order (Background → Demo Cases → Protocols → Entry → Results → Longitudinal) with the actual tab labels and emoji. (4) Was FrailtyTrack nicht tut — four bullets: not a medical device, no diagnosis/therapy on real patients, no data persistence (browser tab close = entries lost unless Excel-exported), no substitute for clinical judgment. (5) Schnellstart — three button-style direct links: scroll to §1 Frailty (in-tab anchor), switchTabDirect('demo'), switchTabDirect('protocols'). Architecture details: the new card uses the standard div.card + div.card-header + div.card-body pattern, opens by default (no .collapsed class on body), and is collapsible via onclick="toggleCard(this)" for users who want to dismiss it after first read. The card has id="background-welcome" for future deep-linking. The tab section-header subtitle was lightly extended to flag that the tab is now the explicit landing page («This tab is the landing page of FrailtyTrack»). The welcome-quick-start «→ §1 Frailty» button uses an in-tab smooth-scroll to #background-frailty rather than a tab switch, since §1 is on the same tab. Translation policy: bilingual DE+EN simultaneously per the v9.1+ pattern; Schweizer-ss orthography (z. B. «einschliesslich», «Schliessen des Tabs») for Roger-authored prose. The card text is fully Roger-prose (no validated quoted clinical content) and uses the «:innen» gender-inclusive form consistent with the existing Background tab. i18n result: 34 new leaf keys per language under background.welcome.* (heading, abbrev, identity_label, identity_body, plus inside.* / audience.* / workflow.* / notdoes.* / next.* sub-namespaces). Total i18n key count grows accordingly (DE: 0 missing, EN: 0 missing). Reference verification (project Rules 1–6): the welcome card is pure cross-reference content; all named sources (Alcazar, NAKO/Huemer 2023, Coelho-Junior 2024, Strassmann 2013, Morbach 2024, Bohannon 2017, Fried 2001, Braun 2018, Drey 2020, Dalhousie CFS Kaeppeli 2020/Rueegg 2022, Hautzinger & Bailer 2012 ADS, DZHK-SOP-K-04, Cramer 2020 GVMBT, Scherfer 2006 BBS) are already present in refs/bibliography.json and/or the About-tab bibliography from prior sessions. Generated this session: 0. Live-fetch verified this session: 0. Flagged: 0. Cumulative bibliography state unchanged from v9.5.0 / v9.4.0 (20 entries in refs/bibliography.json; full About-tab bibliography unchanged). Per Rule 4, no «all DOIs verified in this session» claim is made. Version-string drift check: all six current-version loci updated together (title, topbar badge, About header subtitle, About disclaimer body, footer, Excel-template filename) plus build.py default version (two argparse loci) plus i18n _policy_version in both de.json and en.json. Historical «added vX.X» provenance labels in cards, bibliography entries, and demo tables left unchanged per standing project policy. Smoke-test acceptance criteria: on page load Background renders as the active panel with the welcome card visible at the top, opened by default; clicking the welcome card header collapses it; the three «Schnellstart» buttons resolve correctly (smooth-scroll to #background-frailty; tab switch to demo; tab switch to protocols); the existing §1 Frailty TL;DR box and the §2 Sarcopenia card remain unchanged below. Roadmap (unchanged from v9.5.0 audit): v9.6 (planned) — Floor-Transfer Test, Pittsburgh Fatigability Scale + FSS fatigue pillar, RIR/RPE training-intensity card, Background-tab Frailty-Trajectory-Model from Mallery & Shetty 2026, EWGSOP2/AWGS comparison, Hospital-Associated Disability, cognitive frailty content; v9.7 — Vivifrail/OEP intervention cards, Fagan mini-calculator, MCID auto-coded against tool sessions. The welcome card is intentionally focused on what the tool offers today; it will be lightly updated when v9.6 expands the Background section with the trajectory model.

v9.5.0 — Tab-order release (pure structural change): Reorders the top-level navigation so the Background tab (Frailty + Sarcopenia) is in the first position and is the default landing tab; Demo Cases moves to position 2; Test Protocols moves to position 3; the remaining order (Entry → Results → Longitudinal → About) is unchanged. Pedagogical motivation: a first-time user now reads «what frailty is and why early detection matters» before navigating to literature-derived demonstration cases, and only then enters the dense protocol catalogue. This makes the introductory pathway match the workshop script's narrative arc (concept → cases → instruments) rather than dropping the reader straight into the instruments. Scope contract: structural-only release. No changes to clinical cards, normative data, formulae, demo-case content, bibliography entries, i18n content keys, JS calculation logic, Excel I/O behaviour, or any verification status of existing references. Files changed: (1) build.py — partial concatenation order reshuffled to place tab-background.html first, then tab-demo.html, then tab-protocols.html; default --version bumped 9.4.0 → 9.5.0; epilog example versions updated. (2) src/_body_open.html — nav-tab buttons reordered (Background, Demo Cases, Test Protocols, Entry, Results, Longitudinal, About); active class on nav button moved from Test Protocols to Background; topbar version badge bumped v 9.4 → v 9.5; trailing source comment updated to reflect Background as new tab 1. (3) src/partials/tab-protocols.html — active class removed from <div id="tab-protocols">. (4) src/partials/tab-background.html — active class added to <div id="tab-background"> so Background renders by default on page load. (5) src/_head.html — <title> bumped v9.4.0 → v9.5.0. (6) src/_main_close.html — footer version bumped v9.4.0 → v9.5.0. (7) src/partials/tab-about.html — About header subtitle «Version 9.4.0 — May 2026» bumped to 9.5.0; About disclaimer «FrailtyTrack v9.4.0 ist ausschliesslich» bumped to v9.5.0. (8) src/js/app.js — Excel-template filename bumped FrailtyTrack_Template_v9.4.0.xlsx → FrailtyTrack_Template_v9.5.0.xlsx (current-version string carried in the saved download filename, distinct from the historical-provenance «added v9.4.0» column annotation in the same file which was correctly left unchanged). (9) i18n/de.json and i18n/en.json — _policy_version bumped to v9.5.0 and _status rewritten to describe the v9.5.0 reorder; runtime content keys (topbar.*, nav.*, disclaimer.*, about.*, quest.*, protocols.*, background.*) untouched. (10) Boundary-block partial files renamed to reflect new positions: _between_protocols_and_bg.html → _between_demo_and_protocols.html; _between_demo_and_entry.html → _between_protocols_and_entry.html; both file contents rewritten to describe the new transitions. _between_bg_and_demo.html, _between_entry_and_results.html, _between_results_and_long.html, _between_long_and_sts.html, and _between_sts_and_about.html retained verbatim — their position relative to the surrounding tabs is unchanged by the reorder. Hidden-tab handling: the tab-sts-compare panel (reached via the «Full comparison →» buttons on the three STS protocol cards inside Test Protocols) is unchanged; it is still rendered after Longitudinal in source order, accessed only via switchTab('sts-compare') from inside the Protocols tab. Reference verification (project Rules 1–6): this is a pure structural release with no new references introduced and no changes to existing reference entries. The cumulative audit trail in the About-tab bibliography and in refs/bibliography.json remains at its v9.4.0 state (20 entries; last entries verified Kaiser 2009 and Freitas 2024 in the v9.4.0 session). Generated this session: 0. Live-fetch verified this session: 0. Flagged: 0. Per Rule 4, no «all DOIs verified in this session» claim is made — references retain their last-session verification status as recorded in earlier audit blocks. Version-string drift check (the recurring failure mode flagged in project memory): all six current-version loci updated together in a single coordinated edit set: (i) <title> in _head.html [v9.5.0]; (ii) topbar badge in _body_open.html [v 9.5]; (iii) About-tab header subtitle [Version 9.5.0]; (iv) About-tab disclaimer body [v9.5.0]; (v) page footer in _main_close.html [v9.5.0]; (vi) Excel-template filename in app.js [v9.5.0]; plus the build-script default version="9.5.0" in two argparse loci, plus i18n _policy_version in both de.json and en.json. Historical «added vX.X» provenance labels preserved: all labels in card headers (e.g., S2 Wadenumfang «added v9.4.0», MNA-SF «added v9.4.0», B5 Berg Balance «added v9.2.4»), bibliography entries, demo-table source notes, and changelog entries below this one are intentional historical annotations and were not bumped. Smoke-test acceptance criteria: on page load Background renders as the active panel; clicking through the seven nav buttons in left-to-right order traverses Background → Demo Cases → Test Protocols → Entry → Results → Longitudinal → About; the «Full comparison →» buttons inside the three STS cards still resolve to tab-sts-compare; switchTabDirect('background') calls from inside Test Protocols still activate the Background panel (the existing substring-matching heuristic in switchTabDirect is unchanged and is a known soft-fail in DE-mode for the «Hintergrund» nav label — pre-existing since v9.2.6, not addressed in this minor release). Roadmap continues unchanged from the v9.4.0 audit: Floor-Transfer Test (v9.6 candidate), Pittsburgh Fatigability Scale + FSS fatigue pillar (v9.6), RIR/RPE training-intensity card (v9.6), Vivifrail + OEP intervention cards (v9.7), Background-tab Frailty-Trajectory-Model from Mallery & Shetty 2026 (v9.6), EWGSOP2/AWGS comparison (v9.6), MCID auto-coded against tool sessions (v9.7). The structural reorder in v9.5.0 makes the Background tab the natural anchor for the upcoming Mallery-Shetty trajectory-model addition planned for v9.6.

v9.4.0 — Workshop-script alignment release (Skript_Frailty_BFH_2026_Hilfiker_v20): Aligns the protocol set and demo cases with the BFH 2026 workshop script. Scope decision (Roger-confirmed): standalone Calf Circumference (S2), MNA-SF (N1), Short FES-I entry-form integration, Powerpenia narrative pointer (Freitas 2024) on the existing 5×STS card, and three new demo cases bringing the total from 5 to 8. STS-power calculator was already present (v9.3 and earlier) — no formula changes. Excluded from v9.4 per scope: Floor-Transfer / Pittsburgh Fatigability / Vivifrail intervention card / EWGSOP2 operationalisation; deferred to v9.5–v9.8 in the roadmap below. What was added — Test Protocols tab (Sarkopenie construct): (1) New S2. Calf Circumference (Wadenumfang) standalone card — CC was previously embedded only inside the SARC-CalF extension. The standalone card makes the dual reuse explicit (CC feeds SARC-CalF AND MNA-SF F2 fallback) and adds the EWGSOP2 muscle-mass surrogate framing alongside the AWGS-2019 cut-off comparison. Protocol: knee 90° / non-stretch tape / thickest point / no compression / 0.5 cm precision. Cut-offs: SARC-CalF item +10 if ≤34 cm (♂) or ≤33 cm (♀); MNA-SF F2 fallback <31 cm = 0 / ≥31 cm = 3. (2) New N1. MNA-SF 6-item Mini Nutritional Assessment Short-Form card — thresholds 12–14 normal / 8–11 risk / 0–7 malnourished, with explicit PT-role section (screening only; GLIM diagnosis is dietitian/physician role) and the cascade pointer to dietitian referral at ≤11. What was added — existing 5×STS card: (3) New protocols.sts5.interp.li_powerpenia narrative line citing Freitas et al. 2024 — coined «powerpenia» for muscle-power loss as distinct from sarcopenia (mass) and dynapenia (strength), arguing it should be measured separately because only 2 of 220 dynapenia studies between 2008 and 2023 directly measured power. What was added — Enter Assessment tab: (4) New entry block «Sarcopenia · Nutrition · Fear of Falling» with 6 fields: f_calf_cm, f_sarcf, f_sarccalf (read-only auto), f_mna_sf, f_sfesi, f_fesi. CC and SARC-F have oninput="recalcSarcCalf()" for live derivation. What was added — JS: (5) New recalcSarcCalf() function deriving SARC-CalF as SARC-F + 10 if calf ≤ sex-specific cut-off (Barbosa-Silva 2016). (6) processEntry() extended to read calfCm/sarcf/sarcCalf/mnaSf/sFesi/fesi and add them to the result object. (7) loadDemoCase() extended to populate the new fields when a demo case provides them. (8) Excel template, save and import paths extended with 6 new columns: Calf_cm, SARC_F, SARC_CalF, MNA_SF, Short_FES_I, FES_I. Import is graceful for older files (column-presence check). Three new demo cases (added v9.4.0, indices 5/6/7): (9) Frau M.K., 78F — pre-frail HFpEF NYHA II, low STS-power, baseline + 6-week follow-up, CC 33.0→33.5 cm, MNA-SF 12→13, Short FES-I 11→9, SPPB 9→10 (workshop script Fall 1, REHAB-HF rationale). (10) Herr H.K., 84M — frail + MCI 18 months + 2 falls in past year, baseline + 12-week endpoint, HGS 24→26.5 kg, Short FES-I 18→13 (high→mod), MNA-SF 11→12, SPPB 5→7, CFS 6→5 (workshop script Fall 2, Vivifrail-Stufe-C / Casas-Herrero 2022 in MCI). (11) Frau B.S., 72F — post-pneumonia HAD with acute sarcopenia, day-5 baseline + 6-week mid-point, HGS 14→18 kg, CC 31→32.5 cm, MNA-SF 8→12, SPPB 6→10, SARC-CalF 14→1, Fried 4→0 — the textbook remediable Frailty trajectory (workshop script Fall 3, HAD framing Inoue 2024 + Marchiori 2017, remediable Frailty Mallery & Shetty 2026). Live-fetch verification (project Rules 1–6): 5 references live-fetched and five-field-checked in this session. (i) Alcazar 2021 (already in About-tab biblio from v8.2; re-confirmed): J Cachexia Sarcopenia Muscle 12(4):921–932, doi:10.1002/jcsm.12737, PMID 34216098. (ii) Kaiser 2009 (NEW): J Nutr Health Aging 13(9):782–788, doi:10.1007/s12603-009-0214-7, PMID 19812868. Verified across PubMed, Springer, PMC, ScienceDirect, the official MNA-Elderly site (mna-elderly.com), and ANDeAL. (iii) Kempen 2008 (already in About-tab biblio from v9.2.1; re-confirmed): Age Ageing 37(1):45–50, doi:10.1093/ageing/afm157, PMID 18032400. (iv) Delbaere 2010 (already in About-tab biblio from v9.2.1; re-confirmed): Age Ageing 39(2):210–216, doi:10.1093/ageing/afp225, PMID 20061508. (v) Freitas 2024 (NEW): Sports Med Open 10(1):27, doi:10.1186/s40798-024-00689-6, PMID 38523229, PMCID PMC10961295. Verified across Springer / Sports Medicine Open, PMC, and multiple secondary citations. Generated: 5. Verified: 5. Flagged: 0. Two new About-tab bibliography entries (Kaiser 2009 after the Hauer 2011 FES-I entry; Freitas 2024 after the Coelho-Junior 2024 power-normative entry). All five entries also in the structured refs/bibliography.json with verified_session: "v9.4.0" and five_field_check: "ok" — total bibliography.json grows 15 → 20 entries. STS-power formula reconciliation (no change): the script's chapter-on-Sarkopenie formula P[W] = mass × 0.9 × g × (0.5h − chairH) / (time × 0.1) reduces to 4.5 × g × (h − 2·chairH) / time, mathematically equivalent to the project-memory form P_rel = 0.9 × g × (h − 2·chairH) × reps / time with reps = 5. Both forms already implemented in v9.3 and earlier; no changes. Version-string drift fix (the recurring failure mode flagged in project memory): at the start of the session, the topbar badge read v 9.2 while the title read v9.3.0 — the badge had been lagging one minor version. v9.4.0 corrects all five loci together: title (v9.3.0→v9.4.0), topbar badge (v 9.2→v 9.4), About header subtitle (Version 9.3.0→9.4.0), About disclaimer (v9.3.0→v9.4.0), footer (v9.3.0→v9.4.0), and i18n _policy_version + _status in both en.json and de.json. Topbar badge demo-cases label updated 5→8. Historical provenance labels preserved as per project policy: «added v8.22», «added v8.21», etc. labels in cards and bibliography are intentional and have NOT been bumped. Only labels referring to the current release are written as «added v9.4.0». Deferred per pre-flight (v9.4 scope contract): Floor-Transfer Test (v9.5 candidate), Pittsburgh Fatigability Scale + FSS fatigue pillar (v9.5), RIR/RPE training-intensity card (v9.5), Vivifrail + OEP intervention cards (v9.7), background-tab Frailty-Trajectory-Model from Mallery & Shetty 2026 (v9.6), EWGSOP2/AWGS comparison (v9.6), MCID auto-coded against tool sessions (v9.6/v9.7).

v9.3.0 — Lancet Frailty Commission (Dent 2025) integration: First v9.3-series content release, following the v9.2.5 Position Statements & Consensus pattern. Scope decision: Roger chose «Substantial» integration (option C from a 4-option picker: Minimal — bibliography only / Moderate — v9.2.5-pattern About entry + bibliography / Substantial — Moderate + Section 1 Background reinforcement / Defer — track only, await Commission report). The Substantial option surfaces Dent 2025 as a sibling to the existing CIBERFES card and reinforces Background tab Section 1 with the Lancet Commission's public-health reframing. Why a sibling card rather than an extension of the CIBERFES card: Dent 2025 is structurally different from CIBERFES — it is a programme announcement (Lancet Commission launch Comment, 2 pages), not a finalised consensus document with operational recommendations. The CIBERFES card's structure (definition / what frailty is not / recommended assessment / management / stigma / sub-phenotypes) cannot be mirrored, because Dent 2025 does not yet make those operational claims. Instead, the new card uses a 5-block structure aligned to what the Commission has actually stated: stated goal (life-course reorientation) / four priority areas / policy alignments (UN Decade of Healthy Ageing, WHO World Report on Ageing and Health, World Health Assembly primary-care reorientation) / commissioner composition (21 commissioners, gender/geographic balance, LMIC and CALD emphasis) / status & complementarity to CIBERFES (programme document, report pending). What was added — About tab: (1) New collapsible card «The Lancet Commission on Frailty — Programme & Priorities» (id="position-statements-lancet") inserted as sibling immediately after the CIBERFES card, before the bibliography; (2) New bibliography entry for Dent 2025 inserted after Dent 2019 Mgmt to keep all four Lancet frailty papers (Clegg 2013, Hoogendijk 2019, Dent 2019, Dent 2025) clustered together. What was added — Background tab Section 1: (3) New sub-section 1.9 «Frailty as a public-health priority — the Lancet Commission's reframing» (3 framing paragraphs: prevalence/equity, four priority areas, policy alignments) appended after the existing Section 1.8 references; (4) Dent 2025 ref-chip added in Section 1.1 (definition) alongside Clegg 2013 / Fried 2001 / Hoogendijk 2019; (5) Dent 2025 ref-chip added in Section 1.2 li2 (strong outcome predictor) alongside Hoogendijk 2019 and Álvarez-Bustos 2026 — the Commission's framing that «this increased risk of adverse outcomes can only be partially explained by an individual's underlying comorbid conditions» directly reinforces this point; (6) Dent 2025 added as li11 in the Section 1.8 reference list. Voice policy: the Lancet Commission is consistently framed as a programme announcement rather than as operational consensus. Both the new About card and the new Background sub-section carry an explicit «report pending» status flag, with the position that FrailtyTrack continues to draw current operational guidance from CIBERFES 2026, ICFSR 2025, WHO ICOPE, and the SPRINTT RCT evidence base. The two consensus sources are presented as complementary — CIBERFES as a finalised consensus issuing operational recommendations now, the Lancet Commission as a multi-year programme of inquiry. Live-fetch verification (project Rule 1): 1 reference verified in this session via the University of Leeds White Rose Research Online institutional repository (eprints.whiterose.ac.uk/237353) returning the full Dublin Core / EPrints metadata record (authors, title, journal, volume 405, issue 10497, pages 2265–2266, DOI 10.1016/s0140-6736(25)01101-8, ISSN 0140-6736, publication dates: accepted 23 May 2025; published online 5 June 2025; in print 28 June 2025; CC-BY 4.0 licence). Cross-checked against three independent corroborating sources: (i) The Lancet website search snippet for the article landing page (PII confirmed); (ii) Karolinska Institutet press release confirming Vetrano's commissioner role (Mirage News, 9 June 2025); (iii) ResearchGate metadata listing the article in Vetrano's publication record. All five fields confirmed for Dent 2025: authors, title, journal, volume/issue/pages, DOI. Title discrepancy noted: the submitted manuscript provided by Roger has the title «Reorienting Frailty in Clinical Practice, Public Health and Policy: a Lancet Commission», while the published version of record is titled «Reorienting frailty in clinical practice, public health, and policy: the Lancet Commission on Frailty». The bibliography entry uses the version-of-record title. Translation policy: the new card and Section 1.9 use Schweizer-ss orthography in the German UI throughout (Roger-prose); two short verbatim quotes from the Commission's launch Comment (the stated goal and the WHO World Report «foremost geriatric syndrome» phrasing) preserved as published in English with German contextualisation. Section is fully bilingual (DE + EN simultaneously) per the v9.1+ pattern. Result: 24 new data-i18n keys; total 1083 → 1107 (DE: 0 missing, EN: 0 missing). 1 new bibliography entry (Dent 2025 Lancet Commission). 1 new About-tab card with semantic ID id="position-statements-lancet" for future deep-linking. 1 new Background sub-section 1.9 with 5 paragraph blocks. 3 ref-chip additions in Background Sections 1.1, 1.2 li2, and 1.8 li11. Architecture note: the new card mirrors the existing CIBERFES card's collapsible-card pattern (onclick="toggleCard(this)") so the bibliography below remains scroll-accessible. The Background sub-section is appended at the end of the Frailty section's card-body, after the existing Section 1.8 references and inside the same id="background-frailty" wrapper — no key renumbering of existing s6/s7/s8 keys required. Pedagogical implication surfaced: Section 1.9 explicitly draws the Commission's strongest implication for physiotherapy education — that frailty assessment is no longer specialist-only knowledge and belongs in every adult-orthopaedic, neurological, surgical, and oncological rehabilitation curriculum, not only the geriatric one. This complements the workshop script (Skript_Frailty_aarRehaSchinznach) and the existing Background Section 1.7 (Why physiotherapy is central). Roadmap continues: v9.3.1 (Hoogendijk 2019 Lancet review — potential expansion of the Position Statements pattern, candidate flagged in the v9.2.5 audit), v9.3.2 (Tinetti POMA — verify DACH source first; Schülein 2014 noted as POMA-vs-BBS comparison source), v9.3.3 (STOPPFall medication review tool — WFG-endorsed). The next Lancet Commission update will be tracked: when the Commission's substantive report is published, this card and the Section 1.9 sub-section will be expanded with operational content, and the «report pending» status flags will be removed.

v9.2.6 — Combined Background tab (Frailty + Sarcopenia): Structural and pedagogical release that turns the previous «Background: Sarcopenia» tab into a unified Background tab with two collapsible parent sections, in response to the question of whether a first-time user has anywhere in FrailtyTrack to read about what frailty is, why early detection matters, and how the tool's pieces fit together. Scope decision: Roger chose option B (merge into one Background tab) from a 4-option picker (A: standalone «Background: Frailty» tab / B: merge into one tab with two sections / C: smaller intro tab with mostly cross-refs / D: don't add a tab, expand Position Statements in About instead). Followed by three sub-decisions: bilingual DE+EN from day one, Frailty section sized for full pedagogical depth (~20-25 KB target, ~30 KB achieved), and Sarcopenia internal headers renumbered 1.→2.1 through 8.→2.8 with the «added in vX.X» provenance labels left untouched per the standing project rule. What was added — Frailty Section 1 (8 sub-sections): 1.1 What frailty is — the syndrome and its physiology (inflammaging, HPA axis, biomarkers context); 1.2 Why early detection matters (3 reasons: reversibility window, outcome predictor, effective interventions); 1.3 Two operational models — phenotype vs deficit accumulation (7-row comparison table: origin, construct, items, score, strength, limitation, best use); 1.4 Pre-frailty as the intervention window; 1.5 How FrailtyTrack supports the assessment pathway (5-row table mapping Screening / Diagnosis / Powerpenia marker / Fall risk / Sarcopenia coexistence to the existing FrailtyTrack cards); 1.6 Common misunderstandings (6 explicit common-misunderstanding refutations); 1.7 Why physiotherapy is central (Vivifrail, StoppSturz, ICFSR multicomponent context); 1.8 Key references with DOIs. Sarcopenia Section 2 changes: existing v8.21 content preserved verbatim, only header numbering changed: 1.→2.1, 2.→2.2, ..., 8.→2.8 via Python script (8/8 success). The TL;DR purple box and all 8 cards remain flat siblings within the new tab structure (parent Sarcopenia card opens with intro + TL;DR, then closes; the 8 sub-cards follow as siblings — less invasive than full nesting). Architecture changes: File renamed tab-background-sarcopenia.html → tab-background.html; wrapping div id="tab-background-sarcopenia" → div id="tab-background"; build.py partial reference updated; switchTab('background-sarcopenia') → switchTab('background') in _body_open.html; sole switchTabDirect('background-sarcopenia') in tab-protocols.html updated; nav-button label simplified to «📚 Background» / «📚 Hintergrund» (replacing the previous «📚 Background: Sarcopenia»). Voice policy: the Frailty section is pedagogical and balanced — not pushing a particular consensus position. Where there are contested choices (Fried vs Rockwood, intrinsic capacity vs frailty terminology, cognitive-frailty status), the section presents them evenhandedly and cross-links to the Position Statements section in About for users who want to see CIBERFES's specific positions. This complements rather than duplicates the Position Statements section. Live-fetch verification (project Rule 1): 7 sources verified in this session. (1) Clegg 2013 Lancet at doi:10.1016/S0140-6736(12)62167-9 — canonical Lancet review on frailty, foundational two-model framework. PMID 23395245. (2) Hoogendijk 2019 Lancet at doi:10.1016/S0140-6736(19)31786-6 — clinical and public-health implications, cited as ref [166] in Álvarez-Bustos 2026 for frailty as «main modifiable factor» for mortality. PMID 31609228. (3) Dent 2019 Lancet at doi:10.1016/S0140-6736(19)31785-4 — companion management-focused paper to Hoogendijk in the same Lancet themed issue. PMID 31609229. (4) Mitnitski 2001 at doi:10.1100/tsw.2001.58 — original deficit-accumulation Frailty Index paper, foundation of the Rockwood-tradition operational model. (5) Buta 2016 at doi:10.1016/j.arr.2015.12.003 — systematic review of frailty assessment instruments and clinical contexts; cited as ref [35] in Álvarez-Bustos 2026. (6) Bernabei 2022 SPRINTT at doi:10.1136/bmj-2021-068788 — multicomponent intervention RCT, n=1,519 across 11 European countries, evaluator-blinded, the foundational frailty-intervention RCT. PMID 35545258. (7) Travers 2019 at doi:10.3399/bjgp18X700241 — primary-care interventions for delaying/reversing frailty, multicomponent exercise consistently effective. Cross-references made bidirectional: the new Frailty Section 1.6 (common misunderstandings) cross-references the Position Statements section in About for the contested-position transparency; the new Section 2.x (sarcopenia) is referenced from Frailty Section 1.5 and 1.6. The 1.5 assessment-pathway table cross-references existing FrailtyTrack card identifiers (S1 SPPB, G1 Gait Speed, FRAIL questionnaire, Fried phenotype, CFS, 5xSTS-power, 30s STS-power, F0–F5 fall-risk cards, B4 Mini-BESTest, B5 Berg Balance Scale) without modifying those cards — pure additive cross-referencing. Translation policy: Schweizer-ss orthography throughout for Roger-authored prose; validated clinical content from existing v8.21 sarcopenia cards preserved as published. Section is fully bilingual (DE + EN simultaneously) per the v9.1+ pattern. Result: 91 new data-i18n keys; total 992 → 1083 (DE: 0 missing, EN: 0 missing). 7 new bibliography entries (Clegg 2013, Hoogendijk 2019, Dent 2019, Mitnitski 2001, Buta 2016, Bernabei 2022 SPRINTT, Travers 2019). Anchor IDs id="background-frailty" and id="background-sarcopenia" on the two parent cards to support future deep-linking. Pedagogical note: the Background tab now serves as the entry point for first-time FrailtyTrack users to understand why the tool exists and what the assessment pathway is; the workshop script (Skript_Frailty_aarRehaSchinznach) and the Background tab are designed to reinforce rather than overlap, with the script teaching the concept in depth and the tab teaching the concept-to-tool mapping. Roadmap continues: v9.2.7 (Tinetti POMA — verify DACH source first; Schülein 2014 Z Gerontol Geriatr 47(2):153-164 doi:10.1007/s00391-013-0492-x noted as POMA-vs-BBS comparison source), v9.2.8 (STOPPFall medication review tool — WFG-endorsed). Future v9.3 work could include the Lancet Frailty Commission (Dent 2025) integration following the Position Statements pattern.

v9.2.5 — Position Statements & Consensus section (CIBERFES 2026 integration): First content release that adds a conceptual-framework section rather than an additional clinical-instrument card. Scope decision: Roger chose «Moderate» integration (option B from a 4-option picker: Minimal — bibliography only / Moderate — new About-tab section + bibliography / Substantial — cross-refs from existing cards / Defer to workshop script revision). The Moderate option surfaces CIBERFES doctrine as conceptual scaffolding without modifying existing protocol cards. What was added: A new collapsible card «Position Statements & Consensus — Frailty Conceptual Framework» in the About tab, sitting between the educational-disclaimer block and the Primary References card (so the conceptual framing precedes the bibliography). The card surfaces 6 position blocks: (1) what frailty is — CIBERFES definition as age-associated phenotypic syndrome, pre-disability state, dynamic and reversible; (2) what frailty is not — not aging, not just a risk factor, not comorbidity/multimorbidity/disability, not sarcopenia, not the opposite of intrinsic capacity; (3) recommended assessment — SPPB / gait speed / FRAIL Scale screening + Fried phenotype + FTS5 diagnosis, plus muscle power as «promising marker» (powerpenia); (4) multicomponent management — CGA + multicomponent exercise (Izquierdo 2025 ICFSR consensus) + Vivifrail program + nutrition (1.2–1.5 g/kg/d protein, ≥30 kcal/kg/d, Mediterranean diet); (5) stigma and patient communication — CIBERFES rejects WHO intrinsic-capacity rebrand as «concealment», advocates destigmatisation strategies; (6) sub-phenotypes — cognitive frailty (CIBERFES hesitant), social vulnerability terminology (preferred over «social frailty»), comorbidity-class subtypes (still emerging). Voice policy: CIBERFES positions are presented as CIBERFES's view, not as house position. Some CIBERFES positions are aligned with broad international consensus (Fried phenotype primacy, multicomponent exercise, nutritional recommendations); others are contested (rejection of WHO intrinsic capacity, hesitation on cognitive frailty, anti-disability-in-frailty-scales argument). The card explicitly flags the contested positions as such, allowing the user/clinician to make their own evaluation. Live-fetch verification (project Rule 1): 4 sources verified in this session. (1) Álvarez-Bustos 2026 full paper at doi:10.1016/j.jnha.2026.100793 (Roger upload + live re-fetch via digital.csic.es/bitstream/10261/426525/1/consensus_alvarez_JNHA_2026.pdf open repository) — full PDF reviewed including 16 sections + 169 references + 2 conceptual figures. CIBERFES = Spanish Research Consortium on Frailty and Healthy Aging, 25 research groups, funded by Instituto de Salud Carlos III. Open Access CC BY-NC-ND 4.0. Available online 28 January 2026. Elsevier Masson SAS / SERDI Publisher. Published in J Nutr Health Aging 30:100793. (2) Garcia-Aguirre 2025 (longitudinal) at doi:10.1002/jcsm.13852 — 5-year longitudinal evidence: low relative STS power → adverse outcomes. J Cachexia Sarcopenia Muscle 16:e13852. CIBERFES authorship. Important distinction: this is the longitudinal outcomes Garcia-Aguirre 2025 paper (e13852) cited as ref [76] in Álvarez-Bustos 2026 — not the cross-sectional cut-off paper Garcia-Aguirre 2025 (e13676) which is already in FrailtyTrack's bibliography from v8.2. Both are by the same team. The new bibliography entry explicitly cross-references the e13676 paper to make this clear. (3) Izquierdo 2025 ICFSR consensus at doi:10.1016/j.jnha.2024.100401 — J Nutr Health Aging 29(1):100401. PMID 39743381. DOI quirk: the DOI uses the 2024 prefix despite the article being in the 2025 issue (epub 1 January 2025) — a common Elsevier/JNHA pattern that warrants the explicit annotation in the bibliography entry. Cited as ref [86] in Álvarez-Bustos 2026 as the multicomponent-exercise foundation. (4) Rodríguez-Mañas 2013 FOD-CC Delphi at doi:10.1093/gerona/gls119, PMID 22511289. Cited as ref [11] in Álvarez-Bustos 2026 as the foundational frailty operational-definition consensus. Translation policy: the new section uses Schweizer-ss orthography in the German UI (Roger-authored prose, with German validated quotes preserved as published). Section is fully bilingual (DE + EN simultaneously) per the v9.1+ pattern. Result: 26 new data-i18n keys; total 966 → 992 (DE: 0 missing, EN: 0 missing). 4 new bibliography entries (Álvarez-Bustos 2026, Garcia-Aguirre 2025 longitudinal e13852, Izquierdo 2025 ICFSR, Rodríguez-Mañas 2013 FOD-CC Delphi). Architecture note: the new card is collapsible (onclick="toggleCard(this)") so the bibliography below it remains scroll-accessible without forcing users to scroll past the long position-statement content first. The card uses semantic IDs (id="position-statements") to allow future deep-linking. Roadmap continues: v9.2.6 (Tinetti POMA — verify DACH source first; Schülein 2014 Z Gerontol Geriatr 47(2):153-164 doi:10.1007/s00391-013-0492-x noted as POMA-vs-BBS comparison source), v9.2.7 (STOPPFall medication review tool — WFG-endorsed). Position Statements section sets a precedent for future conceptual-framework additions; possible v9.3 work could include similar treatment of the Lancet Frailty Commission (Dent 2025) and the Hoogendijk 2019 Lancet review.

v9.2.4 — Standalone Berg Balance Scale card (B5 in Balance & Stepping construct): Continues the standalone instrument-card pattern established by v9.2.3 (Mini-BESTest). Scope: A new card B5 in the Balance & Stepping construct (after B1 OLS, B2 FSST, B3 DT-TUG, B4 Mini-BESTest) giving structure (14 items, 0–4 ordinal, max 56), the verbatim 14 item titles in Schweizer-ss German (per Scherfer 2006), materials, population-specific cut-offs, psychometrics, clinical-application guidance, and cross-references to S2 (StoppSturz Tabelle 1, where BBS is listed as a balance-specific focus test) and to B4 (Mini-BESTest comparison: BBS has substantial ceiling effects in higher-functioning patients while Mini-BESTest does not). License decision (different from B4 Mini-BESTest): Unlike OHSU's "All rights reserved" Mini-BESTest, the Scherfer 2006 DACH BBS translation was published in physioscience (Thieme Verlag) "der Fachöffentlichkeit zur kostenfreien Nutzung, verbunden mit der Bitte um Nennung der Original- sowie dieser Veröffentlichung" — an explicit permissive license with attribution requirement, equivalent to FES-I/ProFaNE and StoppSturz. The 14 verbatim item titles are therefore reproduced in B5 with proper attribution (Berg 1989 + Scherfer 2006). Live-fetch verification (project Rule 1): 6 sources verified in this session. (1) Scherfer 2006 full paper (Roger upload, 8-page PDF in Thieme physioscience format) — full PDF reviewed including translation methodology (Beaton et al. cross-cultural adaptation gold standard, 5-phase process with documented deviations: no naive translator, single back-translation), license clause, and the full 14-item layout in Abb. 1 with all 0–4 scoring categories. Translation team in correspondence with Katherine Berg via email and Erlangen Konferenz 08.10.2005. Validity/reliability of the German version itself "stehen noch aus". (2) Berg 1989 original at doi:10.3138/ptc.41.6.304 — Berg KO, Wood-Dauphinee SL, Williams JI, Gayton D. Physiother Can 1989;41(6):304-311. Note Scherfer 2006 cites only 3 authors but canonical literature is 4 authors with Gayton D added. (3) Shumway-Cook 1997 at doi:10.1093/ptj/77.8.812, PMID 9256869. Source for the <36/56 cut-off (nearly 100% fall risk in community-dwelling). (4) Steffen 2002 at doi:10.1093/ptj/82.2.128, PMID 11856064 — n=96 community-dwelling 61-89y, normative reference. (5) Muir 2008 at doi:10.2522/ptj.20070251, PMID 18218822, n=210 12-month prospective cohort. Important correction caught during Muir verification: the initial draft B5 card had a Muir row stating "Optimal für Vorhersage multipler Stürze; Cut-off ≤51/56" — but Muir's actual conclusion is the opposite. Muir explicitly argued against dichotomous cut-offs: "the use of the BBS as a dichotomous scale to identify people at high risk for falling should be discouraged because it fails to identify the majority of such people" and "the use of likelihood ratios preserves the gradient of risk across the whole range of scores". Scores <40 showed significant multiple-fall risk. The Muir row was rewritten and the cutoffs_note was updated to remove the ≤51 framing. (6) Donoghue 2009 at doi:10.2340/16501977-0337 — n=118 elderly, score-stratified MDC95 values for the BBS (multi-centre test-retest design). Translation policy: the 14 verbatim item titles in B5 use Schweizer-ss orthography (Füssen, Fussbank, Fuss vor dem anderen) consistent with the existing FrailtyTrack convention; Scherfer's original paper used German-Germany ß orthography but the Roger-prose-around-instruments policy treats item labels as labels (Schweizer-ss) rather than verbatim quoted body text. The 0–4 scoring descriptors per item are not reproduced inline (would expand the card considerably) — users are referred to the Scherfer 2006 PDF for the complete scoring sheet (free at Thieme, IGPTR.ch, Physio-Akademie ZVK). Cross-references resolved: S2 StoppSturz card now points to B5 for BBS detail (and to B4 for Mini-BESTest detail); the v9.2.3 audit's "Roadmap continues: v9.2.4 Berg Balance Scale Scherfer 2006" promise is closed. Result: 56 new data-i18n keys; total 910 → 966 (DE: 0 missing, EN: 0 missing). 6 new bibliography entries (Scherfer 2006, Berg 1989/Gayton, Shumway-Cook 1997, Steffen 2002, Muir 2008, Donoghue 2009). Construct landing chip and section header tagline updated to surface BBS in the Balance & Stepping construct. Roadmap continues: v9.2.5 (Tinetti POMA — verify DACH source first; Schülein 2014 Z Gerontol Geriatr 47(2):153-164 doi:10.1007/s00391-013-0492-x noted as POMA-vs-BBS comparison source), v9.2.6 (STOPPFall medication review tool).

v9.2.3 — Standalone Mini-BESTest card (B4 in Balance & Stepping construct): First standalone instrument card added outside the Fall Risk pillar restructure of v9.2.2. Scope: A new card B4 in the Balance & Stepping construct giving structure, subscales, materials, population-specific cut-offs, psychometrics, and clinical-application guidance for the Mini-BESTest. The card meta-describes the instrument (subscales, item titles, point values, scoring rules) but does not reproduce the verbatim 14-item patient instructions, scoring descriptors, or material specifications — per OHSU copyright (© 2005–2013 Oregon Health & Science University, "All rights reserved"). Same conservative approach as MoCA in v9.1.6 and ADS in v9.1.4. The validated official German version PDF (GVMBT, Cramer 2020) is freely downloadable from bfu.ch and bestest.us; FrailtyTrack links to those sources rather than reproducing them. Live-fetch verification (project Rule 1): 5 sources verified in this session. (1) Official Mini-BESTest German PDF at bfu.ch/media/pcqno5pu/minibestest_de.pdf — live-fetched, full 7-page PDF read. License confirmed: "© 2005–2013 Oregon Health & Science University. All rights reserved." Fay Horak, PhD copyright on every page footer. The PDF includes a translator credit page identifying the validated DACH version: "Übersetzung und Validierung durch: Prof. Dr. Dörte Zietz, Prof. Dr. Thomas Hering, Elena Cramer und Franziska Weber, Department für angewandte Gesundheitswissenschaften, Hochschule für Gesundheit Bochum" and citing the precursor Weber 2019 Hildesheim poster. (2) Cramer et al. 2020 full paper at doi:10.1186/s42466-020-00078-w — full PDF reviewed (uploaded to project knowledge by Roger). Open Access (CC BY 4.0). 7-author team: Cramer E, Weber F (joint first authors), Faro G, Klein M, Willeke D, Hering T, Zietz D (PI). Sample n=50 sub-acute/chronic stroke (NIHSS 0–7), mean age 64.6, recruited at 2 NRW rehab centres (VAMED Klinik Hattingen, Johanniter-Klinik am Rombergpark Dortmund). Key reported metrics: GVMBT mean 17.24 ± 6.71, range 5–28; Cronbach's α = 0.90 (95% CI 0.87–0.94); Spearman ρ with BBS = 0.93, with TUG = −0.85; ceiling effect 2% (vs BBS 14% in same sample, near 15% threshold); no floor effect; mean administration 16 min. Important correction caught while reading the full paper: Cramer 2020 does not report cut-offs, MCID, or MDC95 — the paper's purpose is translation/validation of the German wording, not clinical-decision threshold derivation. Population cut-offs cited in B4 (Yingyongyudha 16/28 community-dwelling, Tsang 17.5/28 chronic stroke, Mak 19/28 Parkinson's) come from peer-reviewed studies in their respective populations and are not attributable to Cramer 2020. The B4 card explicitly flags this distinction in cutoffs_note. The original Mini-BESTest administration time is 15 min (Franchignoni 2010); GVMBT is 16 min (Cramer 2020) — my draft conflated these and was corrected. (3) Tsang 2013 at doi:10.2522/ptj.20120454 — chronic stroke validation; cut-off 17.5/28, AUC 0.64. (4) Mak 2013 at doi:10.2340/16501977-1144, PMID 23673397 — Parkinson's 6-month prospective fall prediction; cut-off ≤19/28 (sensitivity 79%, specificity 67%). Verified at Hong Kong Polytechnic. (5) Yingyongyudha 2016 at doi:10.1519/JPT.0000000000000050, PMID 25794308 — community-dwelling Thai older adults n=200 mean age 70 y; cut-off 16/28 with AUC 0.84, sensitivity 85%, specificity 75%, accuracy 85%; this paper compared 4 instruments (Mini-BESTest, BESTest, BBS, TUG) with Mini-BESTest having highest AUC. Cross-references made bidirectional: B4 explicitly directs the clinician to S2 (StoppSturz) for the multi-population differential cut-off use; S2 was already pointing at "Karte v9.2.3" implicitly in v9.2.2's deferral note — this debt is now closed. Translation policy: B4 card is German-first content (Schweizer-ss orthography throughout the de.json), with English overlay in en.json. Item names ("Vom Sitzen zum Stehen", "Auf die Zehenspitzen stellen", etc.) are functional labels rather than copyrightable creative expression and so are reproduced in both DE and EN. Result: 51 new data-i18n keys; total 859 → 910 (DE: 0 missing, EN: 0 missing). 3 new bibliography entries (Cramer 2020 DACH, Di Carlo 2016 review, Bergström 2012 Swedish pilot). Construct landing chip and section header tagline updated to surface Mini-BESTest in the Balance & Stepping construct. Roadmap continues: v9.2.4 (Berg Balance Scale — Scherfer 2006), v9.2.5 (Tinetti POMA — verify DACH source first), v9.2.6 (STOPPFall medication review tool). Each as a standalone release with focused verification.

v9.2.2 — 3-framework picker UX + StoppSturz Schweiz (Fall Risk pillar restructure): Third content release within the v9.2 Fall Risk pillar; first release with significant UX restructuring inside a construct. Scope: (A) Restructured the Fall Risk Assessment construct so that, after clicking the construct landing card, users see a 3-framework picker (CDC STEADI / WFG 2022 / StoppSturz Schweiz) and click one to expand its cards; (B) Added StoppSturz Vorgehen Physiotherapie (Frehner et al. 2021, physioswiss / BFU / Gesundheitsförderung Schweiz) as the third framework with 3 new cards (S1 Algorithm with Szenarien A & B, S2 Risk Classification & Assessments incl. Tabelle 1 Fokustests, S3 Intervention Packages for low/moderate/high risk). Live-fetch verification (project Rule 1): 5 sources fetched in this session. (1) BFU StoppSturz portal at https://www.bfu.ch/stoppsturz/physiotherapie — live-fetched; portal is alive, multilingual DE/FR/IT (parachutes / stopcadute), 3-step framework (Erkennen → Abklären → Reduzieren), endorsed by physioswiss + Gesundheitsförderung Schweiz + BFU; current contact Ursula Meier Köhler. All Manual tools confirmed downloadable: TUG/5xSTS Testformulare, Mini-BESTest German PDF (bfu.ch/media/pcqno5pu/minibestest_de.pdf), FES-I Fragebogen, Wohnraumabklärung digital tool at check.bfu.ch. (2) StoppSturz Manual (Frehner D, Knuchel S, Gafner SC, Zindel B 2021) confirmed via BFU portal page; PDF 23 pages, version 05.08.2021; 4-author Arbeitsgruppe + ~10-person Begleitgruppe (incl. Anne-Gabrielle Mittaz Hager / HES-SO Valais-Wallis) + Projektleitung PHS Public Health Services. License: "Alle Rechte vorbehalten. Verwendung unter Quellenangabe (siehe Zitationsvorschlag) erlaubt." — equivalent to FES-I/ProFaNE permissive policy with attribution. (3) BFU Fachdokumentation 2.249 companion document (Frehner D, Knuchel-Schnyder S, Zindel B, Bruderer-Hofstetter M, Pfenninger B 2021), 44 pages: doi:10.13100/BFU.2.249.01.2021. The DOI did not directly fetch but was verified via converging references (the StoppSturz Manual cites it explicitly; multiple search results confirm the citation; the DOI structure 10.13100/BFU.{doc-num}.{ver}.{year} is consistent with BFU's known numbering scheme; the 44-page PDF is confirmed available on the BFU portal). (4) Franchignoni 2010 Mini-BESTest original: doi:10.2340/16501977-0537, J Rehabil Med 42(4):323–331 — live-fetched from medicaljournalssweden.se and ohsu.pure.elsevier.com. (5) Yingyongyudha 2016 Mini-BESTest community-dwelling cut-off (J Geriatr Phys Ther 39(2):64–70) — verified via citation in StoppSturz Manual; confirms cut-off ≤16/28. Cross-framework lineage explicit: the StoppSturz Manual itself states "Das StoppSturz Vorgehen Physiotherapie leitet sich ab von: CDC (2017). Algorithm for Fall Risk Screening, Assessment, and Intervention" — so StoppSturz is the Swiss adaptation of STEADI. The framework picker presents this lineage transparently: STEADI 2017 (USA, original) → StoppSturz 2021 (CH, Swiss-tailored physiotherapy adaptation); WFG 2022 (Global, evidence-based update with frailty linkage) is offered as a parallel choice. UX architecture: Pattern A (click-to-show-one-framework-at-a-time). 3 framework picker cards displayed at top of the Fall Risk Assessment section (orange-tinted gradient background, 2px orange border to match construct color); each picker card shows flag icon, title, origin/sponsor, description, and card count. Click a picker card → showFallRiskFramework(frameworkId) JS function hides all 3 framework groups, shows the requested one, auto-expands all card-bodies, marks the picker card .active (orange shadow), hides the empty-state hint, smooth-scrolls to the framework group. Switching frameworks is one click. No URL hash state — revisiting the construct resets to no-framework-selected (clean state, simple mental model). StoppSturz S1 (Algorithm): Szenarien A & B side-by-side (klinisch-anamnestischer Verdacht / ärztliche Verordnung), with Swiss-specific tariff position notes (7311 for complex patients, 7354 for travel time); Re-Assessment after max 2 series with GP feedback. StoppSturz S2 (Risk Classification & Assessments): 4-row tier classification table (3xNEIN/keine Beobachtung → gering; 1-3xJA + Tests unauffällig → gering; 1-3xJA + 1-2 Tests auffällig + ≤1 Sturz, keine Verletzungen → moderat; 1-3xJA + 1-2 Tests auffällig + ≥2 Stürze ODER Verletzungen → hoch); cut-offs TUG ≥13.5 s (Shumway-Cook 2000) and 5xSTS ≥12 s (Tiedemann 2008) / >23.8 s (Trommelen 2015 assisted living); Mini-BESTest meta-described (NOT verbatim reproduced — OHSU copyright, deferred to v9.2.3) with cut-offs ≤16/28 community (Yingyongyudha 2016), ≤17.5/28 stroke (Tsang 2013), ≤19/28 Parkinson (Mak 2013); FES-I cross-references existing card F5 in WFG group; Tabelle 1 Fokustests (4 domains: Gleichgewicht spezifisch, Kraft/Sensorik/Beweglichkeit, Kognition Multitask, Sturzangst) reproduced verbatim from StoppSturz Manual S. 10. StoppSturz S3 (Intervention Packages): All 3 risk-tier packages reproduced (gering = Beratung only; moderat = Gleichgewicht/Kraft/Gangsicherheit-Training + Beratung + Wohnraumberatung + Adhärenz; hoch = moderat-package + Zusatzmassnahmen + Notrufsysteme [Rotkreuz-Notruf] + Domizilbehandlung + interprofessioneller Austausch); WHO-Adhärenzdefinition (Sabaté 2003) cited; NICE 2019 cited as basis for "Gesamtpakete-not-individual-components" recommendation. Translation policy: StoppSturz is German-first content for the Swiss audience, Roger-prose Schweizer-ss orthography throughout the German JSON. English translation in en.json is FrailtyTrack-internal (no official English version of StoppSturz exists). Result: 111 new data-i18n keys; total 748 → 859 (DE: 0 missing; EN: 0 missing). 4 new bibliography entries (Frehner StoppSturz Manual 2021, Frehner BFU Fachdokumentation 2.249, Franchignoni 2010 Mini-BESTest, Yingyongyudha 2016 Mini-BESTest cut-off). New JS function showFallRiskFramework(id); new CSS classes .framework-picker, .framework-card, .framework-card.active, .frame-group, .fr-flag, .fr-title, .fr-origin, .fr-desc, .fr-cards-count, .framework-empty-hint, .framework-picker-grid, .framework-picker-intro. Sidebar finding: The Duc et al. 2023 F1000Research paper (doi:10.12688/f1000research.73636.2) on Swiss physiotherapy fall-risk practices lists Roger Hilfiker as co-author alongside Anne-Gabrielle Mittaz Hager (who is also on the StoppSturz Begleitgruppe) and others — flagged for awareness but not added to bibliography without explicit confirmation by Roger. Roadmap continues: v9.2.3 (Mini-BESTest standalone card with Schädler 2014 / Bergström 2012 DACH validation references), v9.2.4 (Berg Balance Scale — Scherfer 2006 Physioscience open-access), v9.2.5 (Tinetti POMA — verify DACH source first), v9.2.6 (STOPPFall medication review tool — WFG-endorsed). All as standalone releases with focused verification.

v9.2.1 — WFG 2022 + FES-I & Short FES-I (Fall Risk Assessment expansion): Second content release within the v9.2 Fall Risk pillar. Scope: Two new cards added to the existing Fall Risk Assessment construct: F4 World Falls Guidelines (WFG) 2022 Risk-Stratification Algorithm (Montero-Odasso et al., Age Ageing 2022) implementing the 3-tier (Low/Intermediate/High) decision tree alongside the CDC STEADI workflow (F0–F3); and F5 Falls Efficacy Scale International (FES-I) and Short FES-I (Yardley 2005 + Kempen 2008) implementing the WFG-recommended (GRADE 1A) standard instrument for concerns about falling. Live-fetch verification (project Rule 1): Five sources fetched and verified in this session. (1) Yardley 2005 (FES-I original 16-item development) confirmed: doi:10.1093/ageing/afi196, PMID 16267188, n=704 community-dwelling adults from UK/Germany/Netherlands/Switzerland/Greece, Cronbach's α=0.96, ICC=0.96. (2) Kempen 2008 (Short FES-I 7-item shortened version): doi:10.1093/ageing/afm157, items 2/4/6/7/9/15/16 from FES-I; range 7–28. (3) Manchester ProFaNE site (https://sites.manchester.ac.uk/fes-i/) live-fetched: confirms FES-I and Short FES-I are "available free of charge for use by researchers and clinicians providing they are appropriately referenced"; German FES-I is officially "Validated" status, German Short FES-I is "Translated" status; DACH contact = Klaus Hauer (Bethanien-Krankenhaus Heidelberg). (4) Hauer 2006 official German FES-I PDF (https://documents.manchester.ac.uk/display.aspx?DocID=38571) live-fetched: all 16 items captured verbatim. Note: Hauer's 2006 German uses "draussen" (Schweizer-ss compatible) but column headers use ß ("Sehr große Bedenken") since this is the German-Germany validated form. FrailtyTrack reproduces all 16 items exactly as in the validated PDF; the scale_note paraphrase in Roger-prose uses Schweizer-ss "grosse" instead. (5) Hauer 2006 official German Short FES-I PDF (DocID=38572) live-fetched: all 7 items verbatim. Cut-points from Delbaere et al. 2010 (Sydney Memory and Ageing Study, n=500): FES-I Low 16-19 / Moderate 20-27 / High 28-64; Short FES-I Low 7-8 / Moderate 9-13 / High 14-28. Cognitive impairment validation from Hauer et al. 2011 (Cronbach's α=0.92) added to bibliography. Translation policy: WFG paper has not been formally translated as a complete document into German; the F4 card uses Roger-prose Schweizer-ss with explicit "FrailtyTrack-Übersetzung — nicht validierter Wortlaut" flag in the attribution (analogous to the v9.2 STEADI translation handling). FES-I 16-item table uses validated German Hauer 2006 wording verbatim (with German-Germany ß orthography preserved as published); the surrounding Roger-prose Swiss UI uses ss orthography. Cross-references and clinical innovation: The WFG card explicitly cites frailty status (CFS ≥5 or Fried ≥3) as a high-risk fall marker — this linkage between FrailtyTrack's existing frailty cards and the Fall Risk pillar is a substantive clinical advance over STEADI alone and reflects global geriatric medicine consensus. The card also presents the WFG TUG >15 s threshold alongside the existing STEADI/CDC TUG ≥13.5 s threshold for clinical judgement (no edits to the existing TUG card — both thresholds are now visible side-by-side across cards). F4 (WFG): 44 i18n keys covering intro, entry section (4 li), gait section (4 li), 3-tier risk-stratification table (4 columns × 3 rows = 12 cells + 4 column headers + 1 heading), severity criteria (5 li), MFRA domain breakdown (6 li), frailty_note alert, and attribution. F5 (FES-I): 41 i18n keys including intro, 16-item Hauer 2006 verbatim table (q1–q16 + 3 column headers + 1 heading), scale_note (response scale 1-4), scoring section with Delbaere cut-points and proration formula (8 li), psychometrics section (Cronbach's α, ICC, WFG GRADE 1A endorsement, term-choice rationale, 7 li), and attribution. Result: 85 new data-i18n keys; total 663 → 748 (DE: 0 missing; EN: 0 missing). 5 new references added to bibliography (Yardley 2005, Kempen 2008, Dias 2006 German validation, Delbaere 2010 cut-points, Hauer 2011 cognitive impairment validation); Montero-Odasso 2022 already in bibliography from v8.19 session, no duplicate added. License clarity: ProFaNE/FES-I is "free of charge for clinical and research use providing they are appropriately referenced" — not as unconditional as STEADI's US federal public-domain status, but adequate for FrailtyTrack with proper attribution. Roadmap continues: v9.2.2 (Berg Balance Scale — Scherfer 2006), v9.2.3 (Mini-BESTest — Schädler 2014, possible Lehre advantage like DGG-CFS), v9.2.4 (Tinetti POMA — verify DACH source first), v9.2.5 (STOPPFall medication review tool), each with its own focused verification pass.

v9.2 — Fall Risk Assessment construct (CDC STEADI): First substantive content release after the v9.1 bilingualisation series. Scope: A new construct section "Fall Risk Assessment" (10th construct on the Test Protocols landing) containing 4 cards based on the CDC STEADI workflow: F0 STEADI Algorithm Overview (3-step Screen→Assess→Intervene workflow with cross-references to existing FrailtyTrack tests), F1 Stay Independent 12-Question Self-Assessment (all 12 questions verbatim with point values; ≥4 = at risk), F2 Three Key Questions Rapid Screen (3-question CDC verbatim), F3 4-Stage Balance Test (4 progressively challenging static balance positions, 10-second cut-offs, CDC verbatim instruction script). Live-fetch verification (project Rule 1): Three CDC sources verified in this session. (1) STEADI Algorithm at https://www.cdc.gov/steadi/media/pdfs/STEADI-Algorithm-508.pdf — live-fetched, full 3-step algorithm read. License: US federal government work product, public domain, freely usable. (2) Stay Independent brochure (2023 version) at https://www.cdc.gov/steadi/pdf/STEADI-Brochure-StayIndependent-508.pdf — live-fetched, all 12 questions captured verbatim with their point values (Q1, Q2 = 2 points each; Q3-Q12 = 1 point each; total ≥4 = at risk). Underlying instrument: Rubenstein et al. 2011 (J Safety Res 42(6):493-499); validation in 1,440 community-dwelling older adults; sensitivity 81% / specificity 35% at the ≥4 threshold. (3) 4-Stage Balance Test at https://www.cdc.gov/steadi/media/pdfs/STEADI-Assessment-4Stage-508.pdf — live-fetched, all 4 positions and the verbatim patient instruction script captured ("I'm going to show you four positions. Try to stand in each position for 10 seconds…"). Underlying validation: Rossiter-Fornoff et al. 1995 (FICSIT). Public-domain implications: Unlike the v9.1.4 ADS (Hogrefe), v9.1.4 CFS (DGG), v9.1.6 DZHK 6MWT, v9.1.6 Mini-Cog (Borson), and v9.1.6 MoCA (Nasreddine) situations, STEADI has no copyright restrictions whatsoever — CDC materials as US federal government work product are unconditionally in the public domain. The Stay Independent brochure even says "Adapted with permission of the authors" referring to the underlying Rubenstein 2011 instrument; the CDC adaptation is itself freely reproducible. Translation policy for v9.2: No officially validated DACH-region German STEADI translation exists. The German wording in this tool is therefore a FrailtyTrack-internal Roger-prose Schweizer-ss translation of the CDC English source, explicitly flagged as "FrailtyTrack-Übersetzung — nicht validierter Wortlaut" in the F1 card's translation note (analogous to the v9.1.4 ADS / v9.1.6 MoCA copyright transparency notes). Bilingual from day one (DE + EN simultaneously) per the v9.2 scope decision. F0 (STEADI Algorithm): 30 keys covering 3 workflow steps (Screen/Assess/Intervene) with 6 li each, a "Integration with FrailtyTrack tests" cross-reference section showing how existing test results from the v9.1 series feed into STEADI Step 2 (TUG ≥13.5s, OLS-FAIL, FSST ≥15s, 5×STS ≥12s, 30s CST below-norm, gait speed <0.8 m/s), and a follow-up alert (30-90 days). F1 (Stay Independent): 41 keys including 12 question/why-it-matters pairs, a 4-line scoring section, a 4-line clinical use note, and full attribution. F2 (Three Key Questions): 20 keys including 3 questions/follow-up pairs, a 3-line interpretation section, a 3-line clinical use context, and attribution. F3 (4-Stage Balance): 32 keys covering 8-line protocol with verbatim CDC instruction script, 6-line interpretation, a 4-row decision-points table with stage/position/cut-off/meaning columns, and attribution. Result: 126 new data-i18n keys; total 537 → 663. New cross-references added without new external dependencies: the F0 card cross-references existing v9.1 cards (TUG, 30s CST, OLS, FSST, 5×STS, 4MGS) by their card identifiers (B1, etc.) and existing Bohannon 2006/Shumway-Cook 2000/Araujo 2022/Rikli & Jones 2002/Makizako 2017/Simpkins 2022 references — these references were already verified and bibliographied in earlier releases (v8.x and v9.1.x); zero new memory-based references introduced in this release. Architecture changes: 1 new construct landing card on the Test Protocols overview (becomes 10th of 10 cards), 1 new protocol-section id="ps-fall_risk" with 4 cards. Generic showConstruct('fall_risk') JS routing works without any JS changes (the v9.1.0 architecture handled this case). Zero references added; zero references modified; zero DOIs changed; zero memory-based references retained; no entries flagged [UNVERIFIED]. With v9.2 shipped, the Fall Risk pillar has its STEADI workflow anchor; future v9.2.x releases can add additional fall-risk assessments (BBS-Scherfer, FES-I-Dias/Kempen, Mini-BESTest-Schädler, Tinetti POMA) as cards within this same section, each with its own focused live-fetch verification pass.

v9.1.6 — Aerobic + Cognitive test-card bilingualisation (4 cards): Seventh sub-release of v9.1 bilingual implementation. Scope: Test Protocols tab — the final four test cards: Aerobic Endurance (6MWT, 2MST) and Cognitive Assessment (Mini-Cog, MoCA). With v9.1.6 shipped, the entire Test Protocols tab is now fully bilingual. Live-fetch verification (project Rule 1): Three sources verified in this session. (1) DZHK-SOP-K-04 v1.4 at https://dzhk.de/fileadmin/Downloads/TORCH-Dokumente/DZHK-SOP-K-04_6-Minuten-Gehtest__6MWT_.pdf — live-fetched, full 15-page SOP read. Authors: Marcus Dörr, Kristin Lehnert (Greifswald), reviewed by Rolf Wachter (Göttingen), gültig ab 16.04.2014. License: Public DZHK research SOP based on ATS 2002 guidelines and the Kompetenznetz Asthma und COPD SOP; reproduced unmodified for educational purposes (similar attribution-only stance as KCGeriatrie). The verbatim patient instruction script ("Sie sollen bei diesem Test innerhalb von sechs Minuten so weit wie möglich gehen…"), encouragement phrases ("Sehr gut, Sie haben noch ... Minuten" / "Weiter so, Sie haben noch ... Minuten"), and 15-second-warning phrase ("In Kürze werde ich Sie auffordern stehen zu bleiben. Ich komme dann zu Ihnen.") have been reproduced verbatim. The 6MWT card protocol was expanded from 8 to 10 li items to incorporate these DZHK-verified phrases. Two pre-existing source bugs were corrected in passing: SpO&lt;sub>2&lt;/sub> double-encoded HTML entities → SpO<sub>2</sub>; DZHK version cited as v1.0 → corrected to v1.4. (2) Mini-Cog official Standardized German form at https://mini-cog.com/wp-content/uploads/2022/09/GERMAN-Standardized-MiniCog-Form-in-German.pdf — live-fetched, all 6 official word-list versions captured (v1 Banane/Sonnenaufgang/Stuhl through v6 Tochter/Himmel/Berg), full instruction wording read. License: "Mini-Cog © S. Borson. All rights reserved. Reprinted with permission of the author solely for clinical and educational purposes. May not be modified or used for commercial, marketing, or research purposes without permission of the author (soob@uw.edu)." FrailtyTrack qualifies as educational use. The Mini-Cog protocol was expanded from 3 to 4 li items (added the 6 word-list versions enumeration) and scoring expanded from 8 to 9 li items (added the <3 / <4 cut-off detail from the German form). Attribution footer added. (3) MoCA copyright situation (Nasreddine 2005, © MoCA Test Inc.): verified that mandatory training and certification ($125 per user, lifetime) has been required since 1 September 2019, and that publishing the test or its instructions is explicitly prohibited. Verbatim MoCA test items (specific word lists, the cube to be copied, trail-making sequence, etc.) are therefore NOT reproduced inside FrailtyTrack. The Naming domain item "(lion, camel, rhinoceros)" was REMOVED from the source as that constitutes verbatim test items. The intro "Freely available with registration" was corrected to "Available with mandatory training and certification" (post-2019 reality). The "5-word recall — 5 pts" Memory domain entry was corrected to "5-word registration (no immediate points awarded)" since registration is for later delayed-recall. A new transparency note (similar to the Hogrefe ADS note in v9.1.4) directs users to obtain the official certified MoCA from mocatest.org. 6MWT card: 30 new data-i18n keys including 10-line protocol, 7-line thresholds, 5 column headers, 2 narrative blocks (Morbach 2024 STAAB note retained from v8.23, now translated; new DZHK attribution footer). 2MST card: 19 new keys covering the full Rikli & Jones 1999 protocol and 2002 normative values (Roger-prose Schweizer-ss). Mini-Cog card: 18 new keys including the 4-line protocol with all 6 word-list versions, 9-line scoring algorithm, and Borson attribution footer (German wording verbatim from mini-cog.com). MoCA card: 35 new keys covering 9 domain rows, 8 interpretation rows, 4-row cognitive frailty table, and the new copyright transparency note. Result: 102 new data-i18n keys added to both DE and EN tables. Total i18n keys grew 435 → 537. Two new content elements added in this release: the DZHK attribution footer in the 6MWT card and the MoCA copyright note. One pre-existing content correction: removal of MoCA verbatim Naming items per copyright policy. Zero references added; zero references modified; zero DOIs changed; zero memory-based references retained; no entries flagged [UNVERIFIED]. v9.1 series complete: with v9.1.6 the bilingual implementation reaches all originally scoped content; v9.2 will turn to the Fall-Risk pillar (BBS-Scherfer, FES-I, Tinetti POMA, Mini-BESTest, STEADI logic) as a separate substantive feature release.

v9.1.5 — Strength / Power / Balance test-card bilingualisation (8 cards): Sixth sub-release of v9.1 bilingual implementation. Scope: Test Protocols tab — eight test cards across four constructs: Muscle Strength (HGS, KES), Functional Power (30s CST, 5×STS, 1minSTS), and Balance & Stepping (OLS-10s, FSST, DT-TUG). Source policy: All 8 cards are Roger-authored Schweizer-ss German prose. No validated DACH-region clinical translations were available for these specific procedural protocols (HGS Roberts 2011 SOP, KES make-test, Rikli & Jones 30s CST, 5×STS Guralnik 1994, Strassmann 1minSTS, Araujo 2022 OLS, Dite & Temple 2002 FSST, Montero-Odasso DT-TUG), so no live-fetch verification was required for this release — references already verified in prior sessions and present in the bibliography are preserved unchanged. Schweizer-ss orthography applied throughout: 'regelmässig' (not 'regelmäßig'), 'Sekunden' (with ss), 'Stoppuhr', 'Standschwankung', 'gemäss', 'Füsse', 'fest' (intensifier kept since it has no ß equivalent), 'müssen', 'schlüssel'. The unique Schweizer-ss thousands separator apostrophe (n=49'964 instead of n=49,964) is used in normative data references. HGS card: 24 keys covering protocol (6 li), cut-points (4 li), Dodds 2014 + Bohannon 2019 norm tables (column headers + row data unchanged). KES card: 54 keys — the densest card, including 9-line protocol, 10-line norms list, Bohannon 2017 reference table with 5 column headers, and the 'Why KES?' comparison table (7 row labels × 3 columns × 2 cells = 21 cell keys). 30s CST card: 25 keys, Rikli & Jones 2002 norms with 5 column headers and Garcia-Aguirre 2025 power formula. 5×STS card: 32 keys covering full protocol, interpretation list, Bohannon 2006 + Grgic 2026 norm tables (each with own column headers). Note: Bohannon 2006 'Comment' cells use a single shared key since all three rows have identical text. 1minSTS card: 24 keys covering Strassmann/Puhan 2013 protocol; 12-row Swiss population norm table data unchanged (data values are language-neutral; only column headers and footnote translated). OLS-10s card: 22 keys; the rowspan-5 Mortality-risk cell uses a single shared key (HR 1.84 explanation). FSST card: 18 keys covering Dite & Temple 2002 step-sequence protocol and color-coded fall-risk thresholds (color spans preserved in keys). DT-TUG card: 30 keys including 8-line protocol, 7-line DTC interpretation, and the 4-column DTC interpretation table with 3 rows. Result: 229 new data-i18n keys added to both DE and EN tables. Total i18n keys grew 206 → 435. Zero references added; zero references modified; zero DOIs changed; zero memory-based references retained; no entries flagged [UNVERIFIED]. Out of v9.1.5 scope: 6MWT (DZHK live-fetch needed), 2-Min Step, Mini-Cog, MoCA — deferred to v9.1.6 with the verification budget appropriate to MoCA's copyright situation (similar to ADS in v9.1.4). With v9.1.5 shipped, all non-cognitive Test Protocols cards are now fully bilingual; v9.1.6 will close the loop on aerobic + cognitive constructs.

v9.1.4 — Frailty-construct test cards bilingualisation (Fried PFP, CFS): Fifth sub-release of v9.1 bilingual implementation. Scope: Test Protocols tab — the two test cards inside the Global Frailty Status construct (Fried Frailty Phenotype and Clinical Frailty Scale). Live-fetch verification (project Rule 1): Two sources verified in this session. (1) DGG official German CFS poster at https://www.dggeriatrie.de/images/Bilder/PosterDownload/200331_DGG_Plakat_A4_Clinical_Frailty_Scale_CFS.pdf — live-fetched, all 9 stage descriptions read verbatim. License explicitly states "Vervielfältigung für nicht-profitorientierte Zwecke im Sinne der Patientenversorgung sowie Forschung und Lehre gestattet" (reproduction permitted for non-profit purposes including patient care, research and teaching). FrailtyTrack qualifies under "Lehre". Authors: Singler K., Gosch M., Antwerpen L. © 2020. The DGG version is the de facto standard in DACH practice (recommended by both DGG and DIVI for COVID-19 ICU triage; cited by the German Bundestag). (2) Dalhousie watermarked CFS v2.0 German PDF at https://cdn.dal.ca/.../CFS_V2_ge_WM.pdf — attempted live-fetch failed because the PDF is image-based (no machine-readable text). The DGG-Singler version was used as the authoritative source instead. CFS version note: The DGG poster is "modified after Version 1.2_EN" (Rockwood 2005–2009 era), NOT v2.0 (Rockwood & Theou 2020 revision). The current FrailtyTrack tool uses v1.x English labels (e.g. "Very Mild Frailty" not the v2.0 "Living with Very Mild Frailty"), so the DGG German maps cleanly to existing English wording — both languages now consistently at the v1.x level. A future release may update both languages to v2.0 if desired. (3) Hautzinger & Bailer 2012 ADS (Allgemeine Depressionsskala, German validated CES-D translation, 2nd edition, Hogrefe Verlag): copyright held by Hogrefe; verbatim ADS items therefore NOT reproduced inside FrailtyTrack. Instead, an explicit transparency note in both Fried PFP card and audit log directs users to obtain the validated ADS-L manual from Hogrefe / Testzentrale for clinical use. The English Fried 2001 wording (paraphrased from CES-D items 7 and 20: "everything an effort" / "could not get going") is preserved unchanged in the English version of the card. Fried PFP: 26 new data-i18n keys covering heading, intro, equipment list, criterion thresholds, gait speed cut-off table headers, handgrip cut-off table headers, and the new exhaustion-note alert added in this release. German wording is Roger-authored Schweizer-ss prose. CFS: 31 new data-i18n keys covering heading, intro, table column headers, 9 stage labels (cat) and 9 stage descriptions (desc) reproduced verbatim from the DGG Singler 2020 poster, frailty-status labels (Robust/Pre-frail/Frail/Terminal), the threshold alert, the Swiss validation evidence box (Kaeppeli 2020 / Rueegg 2022 retained from v8.23, now translated), and a new DGG attribution footer. Result: 57 new data-i18n keys added to both DE and EN tables. Total i18n keys grew 149 → 206. One new content element added in this release: a new "Hinweis zum Erschöpfungs-Kriterium" alert inside the Fried PFP card (protocols.fried.exhaustion_note) that did not exist in v9.1.3 — its purpose is the transparent disclosure of why the verbatim ADS wording is not reproduced. Zero references added; zero references modified; zero DOIs changed; zero memory-based references retained; no entries flagged [UNVERIFIED]. Out of v9.1.4 scope: HGS / KES / 5×STS / 30s CST / 1min STS / OLS / FSST / 2-Min Step / Mini-Cog / MoCA / DT-TUG (deferred to v9.1.5).

v9.1.3 — Gait/Mobility test cards bilingualisation (4MGS, TUG, SPPB): Fourth sub-release of v9.1 bilingual implementation. Scope: Test Protocols tab — three test cards inside two construct sections: 4MGS and TUG inside Gait Speed & Mobility, plus SPPB inside Physical Performance Battery. Live-fetch verification (project Rule 1): KCGeriatrie SPPB scoring sheet PDF (https://www.kcgeriatrie.de/fileadmin/Kcgeriatrie/Assessments/sppb.pdf) and KCGeriatrie TUG form PDF (https://www.kcgeriatrie.de/fileadmin/Kcgeriatrie/Assessments/tug.pdf) were live-fetched in this session. Both forms confirm the explicit copyright notice "Es besteht kein Copyright" / "Dem Kompetenz-Centrum Geriatrie liegen keine Hinweise über ein eventuell bestehendes Copyright vor". SPPB: The KCGeriatrie SPPB form is a scoring sheet only, not a verbatim instruction script. Sub-test labels (1. Balance-Test with 'geschlossener Stand' / 'Semitandenstand' / 'Tandemstand', 2. 4-Meter-Gehtest, 3. Stuhl-Aufsteh-Test) and time cut-offs (e.g. <4.82 / 4.82–6.20 / 6.21–8.7 / >8.7 s for the gait sub-test) reproduced verbatim. The "Semitandenstand" spelling on the official form is preserved verbatim (note: the form uses 'Semitanden' rather than the more usual 'Semitandem' — KCGeriatrie's spelling is reproduced as-is). The procedural prose surrounding the verbatim labels is Roger-authored Schweizer-ss German, NOT claimed as a "validated translation". TUG: The KCGeriatrie TUG form contains a verbatim patient-instruction script which has been reproduced word-for-word in protocols.tug.protocol.li1–li6 ("Der Proband sitzt auf einem Stuhl mit Armlehne (Sitzhöhe ca. 46 cm) ..."). The German-Germany "ß" orthography on the published form is preserved as-is per project policy on validated clinical translations. 4MGS: Per Roger's v9.1.3 decision ("we should be transparent and mention both"), the 4MGS card has been restructured to present BOTH standard variants explicitly: Variant A = SPPB-internal (Guralnik 1994, start standing, time full 4 m, used inside SPPB and EWGSOP2 practice) and Variant B = standalone (Studenski 2011, walk longer 6–8 m path, time only the middle 4 m at steady state, used in survival-prediction literature). Cut-offs are largely interchangeable but protocol detail differs; this transparent presentation lets clinicians match the variant to their referring source. Result: 89 new data-i18n keys added to both DE and EN tables (4MGS: 26 keys including dual-variant structure; TUG: 22 keys; SPPB: 41 keys covering subtests/classification/scoring table/Alcazar power formula/normative tables). Total i18n keys grew 60 → 149. Zero references added; zero references modified; zero DOIs changed; zero memory-based references retained; no entries flagged [UNVERIFIED]. Out of v9.1.3 scope: Fried PFP and CFS cards inside the Frailty construct (deferred to v9.1.4 with their own live-fetch verification pass against Dalhousie official German CFS PDF and Hautzinger & Bailer 2012 ADS for Fried exhaustion items). Remaining tests (HGS, KES, 5×STS, 30s CST, 1min STS, OLS, FSST, 2-Min Step, Mini-Cog, MoCA, DT-TUG) deferred to v9.1.5.

v9.1.2 — Test Protocols landing page bilingualisation: Third sub-release of the v9.1 bilingual implementation. Scope: Test Protocols tab landing view — the construct-card grid that lists the nine assessment domains visible when the tab opens. Translation policy applied (per Roger's v9.1.2 decision): "Frailty" is preserved as English clinical term throughout the German UI (never "Gebrechlichkeit"), because (a) DACH research literature uses Frailty, (b) "Gebrechlichkeit" carries defeatist connotations and obscures the dynamic/reversible nature of the construct, (c) Pre-frail/Frail/Robust as status labels stay English for consistency. "Screening" kept as established German loanword. "Sarcopenia" → "Sarkopenie" (etablierter deutscher Fachbegriff, used by Drey 2020 et al.). All other clinical-domain terminology fully translated to German with Schweizer ss-Orthografie. Translation policy block now formalised in de.json under _translation_policy. Tagged elements: Test Protocols landing header (title + subtitle); 9 construct cards (title + tagline each); 9 protocol-section headers visible when a card is opened (title + subtitle); 9 "Back to overview" buttons (single shared key). For 8 of the 9 constructs, the protocol-section subtitle differs slightly from the card tagline (different separator characters or punctuation) — these get a tagline_section variant key alongside the card-level tagline; the Frailty section subtitle happens to match its card tagline exactly, so both share a single frailty.tagline key. Result: 19 new data-i18n keys added to both DE and EN tables (1 landing.title + 1 landing.subtitle + 1 back_to_overview + 2 view_tests/view_test + 9 construct titles + 9 card taglines + 8 section-subtitle variants — less de-duplication of the shared frailty.tagline key). Total i18n keys grew 41 → 60. Zero references added; zero references modified; zero DOIs changed; zero memory-based references retained; no entries flagged [UNVERIFIED]. This is a Roger-authored UI prose release — no validated clinical translations were modified, so no live-fetch verification was required (per project Rule 1, live-fetch is required only for content drawn from external publications). The validated questionnaire content from v9.1.1 (Braun 2018 PRISMA-7/FRAIL/GFI, Drey 2020 SARC-F) is preserved unchanged. Out of v9.1.2 scope: Individual test cards within each construct (SPPB protocol text, TUG instructions, 6MWT instructions, CFS evidence box, Fried exhaustion items, KES, HGS, etc.) — these contain validated clinical translations and will be addressed in v9.1.3–v9.1.5, each with its own live-fetch verification pass against the published validated source (Drey 2020, KCGeriatrie, DZHK SOP-K-04, Dalhousie CFS PDF, Hautzinger & Bailer 2012 ADS).

v9.1.1 — Validated-questionnaire bilingualisation (PRISMA-7, FRAIL, GFI, SARC-F): Second sub-release of v9.1 bilingual implementation. Architecture changes: (1) i18n.js extended with an observer pattern (FrailtyTrackI18n.subscribe(callback), broadcast at the end of applyLang(), plus getCurrentLang() for synchronous reads); (2) the per-section setQLang('en'/'de') toggle in the Questionnaires section (two buttons "English" / "Deutsch") was removed — questionnaire language now follows the global topbar [DE] [EN] control via the observer. The previous local Q_LANG state remains, but its setter now subscribes to the topbar; users see one unified language control. (3) Three calc-function status labels in app.js (Possible Frailty/Unlikely Frail in calcPRISMA7; Frail/Pre-frail/Robust in calcFRAIL; Frail/Not Frail in calcGFI) are now resolved through a small qT() helper that reads from the i18n table at render time, with safe English fallback. Translation policy applied: validated PRISMA-7/FRAIL/GFI question items remain unchanged in app.js (Braun 2018 verbatim, German-Germany spelling preserved). Roger-authored questionnaire-section intro prose written in Swiss orthography (ss). SARC-F German item wording verified verbatim against Drey 2020 Supplementary Table 1 (paper PDF live-checked in this session: J Am Med Dir Assoc 2020;21(6):747-751.e1, doi:10.1016/j.jamda.2019.12.011, PMID 31980396). The five domain labels (Kraft, Gehen, Aufstehen, Treppensteigen, Stürze), full item phrasing ("Wie schwer fällt es Ihnen, …"), response options (nicht schwer / etwas schwer / sehr schwer), and the two validated footnotes (water-box example for 5 kg; "Entspricht den letzten 12 Monaten" for past-year falls) are reproduced verbatim. Initial provisional wording from session memory was caught and corrected during live-fetch verification — all five items required correction (e.g. "Wie viel Schwierigkeiten haben Sie damit, durch ein Zimmer zu gehen?" was replaced with the published "Wie schwer fällt es Ihnen, auf Zimmerebene umher zu gehen?"). This is exactly the failure mode that project Rule 1 (no memory-based references; live-fetch verification mandatory) is designed to prevent. Result: 21 new data-i18n keys added to both DE and EN tables (questionnaire section title/intro/clinical-use, PRISMA-7/FRAIL/GFI status labels, SARC-F item heading and 5 items). Total i18n keys grew from 20 → 41. Zero references added; zero references modified; zero DOIs changed; zero memory-based references retained; no entries flagged [UNVERIFIED].

v9.1.0 — Bilingual UI infrastructure (chrome scope, non-content release): First sub-release of the v9.1 bilingual implementation. Adds a [DE] [EN] segmented language toggle to the topbar, a small i18n.js runtime module (~110 lines, vanilla JS) that loads two translation tables (i18n/de.json, i18n/en.json) inlined into the build at build time, and a data-i18n="key.path" tagging convention for translatable elements. Build script (build.py) extended with deterministic JSON inlining: i18n tables are loaded, top-level _comment / _status keys stripped, serialised with sort_keys=True for stable byte output, and substituted into i18n.js at the build-time markers. Persistence is via URL hash (#lang=de / #lang=en) — no cookies, no localStorage, preserving the privacy story unchanged. Default language: German. On first load with no #lang in the URL, the navigator locale is honoured only if it begins with en; otherwise the tool defaults to DE. v9.1.0 scope (intentionally narrow): topbar tagline + 5 operational badges; nav-tab labels (7); educational disclaimer banner (title + body); About-tab section header (title + subtitle + build note); About-tab disclaimer block (title + body — replacing the previous parallel-bilingual block with a single i18n-driven block). Out of v9.1.0 scope: Test Protocols tab, Background tab, Demo Cases tab, Practice Case Entry tab, Learning Results tab, Longitudinal Comparison tab, STS-compare tab, About-tab bibliography content (these remain English-only and will be tagged in v9.1.1 / v9.1.2). Validated clinical translations preserve published spelling — e.g., the existing inline PRISMA-7/FRAIL/GFI toggle (Braun 2018) and the SARC-F German wording (Drey 2020) remain in their published German-Germany orthography. Roger's own UI prose uses Swiss orthography (ss, no ß) per the project policy. Zero references added; zero references modified; zero DOIs changed; zero memory-based references retained; no entries flagged [UNVERIFIED]. Build determinism confirmed via two consecutive rebuilds producing matching SHA-256 hashes.

v9.0 — Modular source split (non-content release): v9.0 is a structural refactor of the v8.23 single-file source into a modular source tree (src/_head.html, src/styles.css, src/_body_open.html, eight tab partials in src/partials/, src/js/app.js, src/_main_close.html, src/_body_close.html) with a deterministic Python build script (build.py, ~70 lines, standard library only) that concatenates the modular source back into a single distributable HTML file. Byte-equivalence test: PASSED. The first-pass build of v9.0.0-test (with no version bumps applied) produced an output byte-identical to the v8.23 source — confirmed by diff -q and matching SHA-256 hashes (343cb444f8b6eb015953564e6550bf0cddf1e590e8a5e0f9557a321cd84396d9). This proves the split is lossless before any content edits are applied. Zero references added; zero references modified; zero DOIs changed; zero memory-based references retained; no entries flagged [UNVERIFIED]. The v8.23-content carry-forward is exact; the only changes between v8.23 and v9.0 in the rendered output are the five operational version markers (browser title, topbar badge, German disclaimer prose, English disclaimer prose, page footer) and one stray "Version 8.22" subtitle in the About-tab section header that was missed in the v8.23 edit pass and is now corrected to "Version 9.0". The bilingual UI (German default, English toggle, validated translations from the v8.23 verification foundation) is staged for v9.1, where it can be implemented cleanly in the modular architecture against the verified Kaeppeli 2020, Rueegg 2022, Morbach 2024 STAAB, and Hautzinger & Bailer 2012 ADS sources. The fall-risk pillar (BBS, FES-I, Tinetti POMA, Mini-BESTest, STEADI logic) is staged for v9.2 with its own dedicated verification pass.

v8.23 — Swiss/German validation references for clinical instruments (foundation for v9.0 bilingual UI): Four new references entered the bibliography — Kaeppeli et al. 2020 (Swiss validation of CFS in the Basel ED; n=2,393; AUC 0.81 for 30-day mortality; doi:10.1016/j.annemergmed.2020.03.028, PMID 32336486), Rueegg et al. 2022 (extended Swiss CFS validation for 1-year mortality; n=2,191; AUC 0.767 outperforming the Emergency Severity Index; doi:10.1111/acem.14460, PMID 35138670), Morbach et al. 2024 STAAB (first German-population age- and height-specific reference percentiles for 6MWD; n=2,762 Würzburg; 15-m hallway protocol; doi:10.1007/s00392-023-02373-3, PMID 38236418), and Hautzinger & Bailer 2012 ADS (validated German version of CES-D; canonical wording for the two items used in Fried's exhaustion criterion; ISBN 978-3-8409-2393-5; book, no DOI). Five additional references already present in the bibliography were re-fetched and confirmed in this session: Guralnik 1994 SPPB, Podsiadlo & Richardson 1991 TUG, Radloff 1977 CES-D original, ATS 2002 6MWT, Rockwood 2005 CFS. All five fields (authors, title, journal, volume/issue/pages, DOI/ISBN) confirmed for each. Standard-wording sources without peer-reviewed validation papers were also identified for the planned v9.0 German UI: Dalhousie official German CFS v2.0 PDF, KCGeriatrie SPPB and TUG administration forms (de facto DACH standard), and DZHK-SOP-K-04 6MWT German clinical SOP. Zero errors detected; zero memory-based references retained; no entries flagged [UNVERIFIED]. New CFS card evidence box added to the Test Protocols tab citing Kaeppeli 2020 + Rueegg 2022. New 6MWT card evidence box added to the Test Protocols tab citing Morbach 2024 STAAB and noting DZHK SOP-K-04 as German clinical SOP. New "Swiss/German Validation References for Clinical Instruments" bibliography block added to the About tab containing the 4 new entries with full author lists, PMIDs, and DOI links. "Still not re-fetched" block unchanged in count (~20 entries); per Rule 4, no blanket "all DOIs verified" claim is made.

v8.22 — new live-fetch and verification pass for the SARC-CalF Optional Extension: Three new references entered the bibliography — Yang 2018 (largest community-based replication, n=4,361, doi:10.1016/j.jamda.2017.12.016, PMID 29477774), Krzymińska-Siemaszko 2020 (Polish/European replication, n=260, doi:10.2147/CIA.S250508, PMID 32425513), and Lim 2019 (cut-off methodology letter, doi:10.1007/s12603-019-1177-y, PMID 30932140). Four references already present in the v8.21 bibliography were re-fetched and confirmed: Barbosa-Silva 2016 (SARC-CalF development); Bahat 2018 (Turkish replication); Chen 2020 / AWGS 2019; Voelker 2021 (systematic review). All seven have all five fields (authors, title, journal, volume/issue/pages, DOI/PMID) confirmed against PubMed and the publisher's record. Zero errors detected; zero memory-based references retained; no entries flagged [UNVERIFIED].

v8.21 — new live-fetch and verification pass for the SARC-F Background tab: Malmstrom 2013 (original editorial), Malmstrom 2016 (primary validation; moved out of the unverified list), Cruz-Jentoft 2019 / EWGSOP2 (cross-referenced from v8.18 block), Woo 2014 (community validation), Ida 2018 (meta-analysis), Barbosa-Silva 2016 (SARC-CalF), Chen 2020 / AWGS 2019, Bahat 2018 (SARC-F vs SARC-CalF), Voelker 2021 (systematic review), Drey 2020 (German validation), Lu 2021 (diagnostic meta-analysis), Bauer 2019 (SCWD position paper), Dent 2018 (ICFSR guidelines). All thirteen have all five fields (authors, title, journal, volume/issue/pages, DOI/PMID) confirmed against PubMed and the publisher's record. Zero errors detected during the fetch pass; zero memory-based references retained.

v8.20 — moved out of unverified list (now live-fetched and confirmed): Demo case RCT sources (Merchant 2021, Tan 2022, Pandey 2019, Tarazona-Santabalbina 2016, Yoon 2018) and questionnaire references (Hébert 2003, Raîche 2008, Morley 2012 [FRAIL], Morley 2013 [Frailty consensus], Schuurmans 2004 [GFI], Bielderman 2013 [GFI multidimensional], Clegg 2015 [DTA review]). All twelve have all five fields (authors, title, journal, volume/issue/pages, DOI/PMID) confirmed against PubMed and the original publisher records.

v8.19 — moved out of unverified list (now live-fetched and confirmed): Huemer/NAKO 2023, Bergland & Strand 2019, Perera 2006, Bohannon 2006 (5×STS meta-analysis), Baltasar-Fernandez 2021, Montero-Odasso 2022 (Age Ageing). All six have all five fields (authors, title, journal, volume/issue/pages, DOI) confirmed against PubMed and the original publisher records.

Per project protocol, references not verified by live fetch in the current session are listed as unverified for this session. They were verified in prior sessions and the DOIs are considered reliable. Independent clinical verification is always recommended before citing.

Cumulative audit summary: v8.12 — 15 references live-fetched · 1 DOI corrected (Svinøy 2021 TUG: CIA.S279895 → CIA.S294512, 9 locations) · security hardening (CSP, rel=noopener, htmlEscape())  |  v8.13 — 0 new live-fetches · 0 DOI changes · security hardening (innerHTML → DOM API for all user-derived values, legend rebuilt with createElement(), age/sex coerced at parse time)  |  v8.14 — 3 live-fetches · 3 first-author errors corrected (Abizanda→Tarazona-Santabalbina; Krishnaswami→Pandey; Tan→Merchant) · 1 DOI corrected (jamda.2016.01.074→.019, 3 locations) · 1 citation year corrected (Krishnaswami 2020→Pandey 2019) · 1 reference flagged [UNVERIFIED]: Langlois doi:10.1016/j.eurger.2023.05.003  |  v8.17 — Regulatory reframe: Teaching & Reference Tool (non-medical-device). Disclaimer banner, learning mode, educational framing throughout. No DOI changes.  |  v8.16 — 2 DOI errors corrected (Rikli & Jones 2002 fabricated DOI removed; Alcazar 2018 DOI suffix corrected .07.013→.08.006) • Questionnaire tab integrated into Protocols tab as 10th construct section • Tab count reduced 7→6  |  v8.15 — 1 additional live-fetch (Yoon 2018 PubMed, PMID:30272098) · 1 reference fully re-identified: "Langlois F et al. Eur Geriatr Med 2023" corrected to Yoon DH, Lee J-Y, Song W. J Nutr Health Aging. 2018;22(8):944–951. doi:10.1007/s12603-018-1090-9 — author, journal, year, and DOI all wrong; corrected per Roger's confirmation · 5 locations updated.  |  v8.18 — EWGSOP2 paper integration · 7 references live-fetched this session (Cruz-Jentoft 2019 / EWGSOP2; Studenski 2014 / FNIH; Cesari 2009 / Health ABC; Pavasini 2016 / SPPB; Bischoff 2003 / TUG; Abellan van Kan 2009 / IANA gait speed; Ishii 2014 / screening test) · 1 PMID error corrected for the EWGSOP2 paper (was 30312414 in pre-v8.18 versions; correct PMID per live PubMed fetch is 30312372; PMCID PMC6322506; erratum afz046 PMID:31081853) · 6 new bibliography entries added in a new "EWGSOP2 Cut-off Source References" block · New EWGSOP2 Operational Framework card (S0) added to the Sarcopenia Screening section, covering Table 1 operational definition, F-A-C-S algorithm, full Table 3 cut-offs, primary/secondary classification, acute/chronic classification, and frailty↔sarcopenia overlap · ~28 references carried forward from prior sessions remain unverified in v8.18 and were not re-fetched this session — per Rule 4, no blanket "all DOIs verified" claim is made.  |  v8.19 — Targeted re-verification pass on high-priority references driving displayed cut-offs and percentile charts · 6 references live-fetched this session (Huemer/NAKO 2023; Bergland & Strand 2019; Perera 2006; Bohannon 2006 / 5×STS meta-analysis; Baltasar-Fernandez 2021; Montero-Odasso 2022 / falls guidelines) · All five fields (authors, title, journal, volume/issue/pages, DOI) confirmed for each · PMIDs added where previously missing (36702514, 31395008, 16696738, PMC8484545, PMC9523684) · Full author lists expanded for Huemer/NAKO 2023 (was "et al.") and Perera 2006 (was "et al.") · 1 published-title typo finding for Baltasar-Fernandez 2021: the original Sci Rep title reads "negatives outcomes" (anomalous plural, confirmed across Nature.com, PMC, Springer Nature and independent citing literature); FrailtyTrack pre-v8.19 silently corrected to "negative outcomes"; v8.19 restores the original wording with [sic] annotation per scientific citation best practice · "Not re-fetched" block trimmed from ~28 to ~22 entries; six entries moved into the verified pool. ~22 references still carried forward from prior sessions remain unverified in v8.19; per Rule 4, no blanket "all DOIs verified" claim is made.  |  v8.20 — Targeted re-verification pass on demo case RCT sources and questionnaire references · 12 references live-fetched this session: Demo RCT sources (Merchant 2021 [HAPPY]; Tan 2022 [SAIF]; Pandey 2019 [JACC HF]; Tarazona-Santabalbina 2016 [JAMDA]; Yoon 2018 [JNHA]) and questionnaire references (Hébert 2003 [PRISMA model]; Raîche 2008 [PRISMA-7 cut-off]; Morley 2012 [FRAIL]; Morley 2013 [Frailty consensus]; Schuurmans 2004 [GFI]; Bielderman 2013 [GFI multidimensional]; Clegg 2015 [DTA review]) · All five fields (authors, title, journal, volume/issue/pages, DOI/PMID) confirmed for each · 2 PMID errors corrected this session: (a) Merchant 2021 PMID was 33953631; correct PMID per live PubMed fetch is 33937294 (PMCID PMC8086796) — corrected in 2 locations (bibliography + audit log); (b) Hébert 2003 PMID was 14526871; correct PMID per live PubMed fetch is 12943358 — corrected in 2 locations (bibliography + Questionnaires tab inline). PMCIDs added where previously missing (PMC8086796 for Merchant 2021, PMC9713022 for Tan 2022, PMC8067953 for Pandey 2019, PMC4515112 for Morley 2012, PMC4084863 for Morley 2013, PMC3766248 for Bielderman 2013) · Full author lists expanded for Tan 2022 (was "et al."), Morley 2013 (was "et al."), and Bielderman 2013 (was "et al.") · Tan 2022 corrigendum noted (Front Med 2022;9:1105448, doi:10.3389/fmed.2022.1105448, PMID 36619615) · "Still not re-fetched" block trimmed from ~22 to ~21 entries; 12 entries moved into the verified pool (3 prior demo RCT entries had been verified in earlier sessions and 9 are newly added). ~21 references still carried forward from prior sessions remain unverified in v8.20; per Rule 4, no blanket "all DOIs verified" claim is made.  |  v8.21 — Dedicated SARC-F scientific evaluation tab (Background: Sarcopenia) · 13 references live-fetched this session: Malmstrom 2013 (original editorial); Malmstrom 2016 (primary validation; moved out of unverified list); Cruz-Jentoft 2019 / EWGSOP2 (cross-referenced); Woo 2014 (Hong Kong community validation); Ida 2018 (first SARC-F meta-analysis); Barbosa-Silva 2016 (SARC-CalF development); Chen 2020 / AWGS 2019; Bahat 2018 (Turkish SARC-F vs SARC-CalF replication); Voelker 2021 (largest systematic review of SARC-F psychometrics); Drey 2020 (definitive German SARC-F validation); Lu 2021 (updated SARC-F diagnostic meta-analysis); Bauer 2019 (SCWD position paper); Dent 2018 (ICFSR clinical practice guidelines) · All five fields (authors, title, journal, volume/issue/pages, DOI/PMID) confirmed for each · Zero errors detected; zero memory-based references retained; no entries flagged [UNVERIFIED] · New top-level navigation tab "📚 Background: Sarcopenia" added between Test Protocols and Demo Cases (tab count 6→7), containing 8 thematic sections: (1) Origin & construct, (2) Initial validation, (3) Diagnostic accuracy across reference standards with pooled meta-analysis table, (4) Why sensitivity is structurally low, (5) Position in EWGSOP2 / AWGS 2019 / SCWD / ICFSR consensus frameworks, (6) Drey 2020 German version with adaptation details, (7) Practical implications and recommended clinical workflow, (8) Verified reference block · S1 SARC-F card enhanced in the existing Sarcopenia Screening section with an evidence-summary box (pooled diagnostic accuracy from Ida 2018, Lu 2021, Voelker 2021), a German-version note (Drey 2020), and a cross-reference link to the new Background tab · New "SARC-F Scientific Evaluation References" bibliography block added to the About tab, containing all 13 entries with full author lists, PMIDs, and DOI links · "Still not re-fetched" block trimmed from ~21 to ~20 entries; Malmstrom 2016 moved into the verified pool. ~20 references still carried forward from prior sessions remain unverified in v8.21; per Rule 4, no blanket "all DOIs verified" claim is made.  |  v8.22 — SARC-CalF Optional Extension added to the S1 SARC-F card and to Section 4 of the Background tab · 7 references live-fetched and verified this session: Barbosa-Silva 2016 (re-confirmed; SARC-CalF development); Yang 2018 (NEW; community-based replication, n=4,361 China, AWGS 2014 reference; SARC-CalF Se 60.7% / Sp 94.7% vs SARC-F Se 29.5% / Sp 98.1%; AUC 0.92 vs 0.89, p = 0.003); Bahat 2018 (re-confirmed; Turkish replication, mixed result); Chen 2020 / AWGS 2019 (re-confirmed; explicit SARC-CalF endorsement at the case-finding step); Krzymińska-Siemaszko 2020 (NEW; Polish community-dwelling cohort, n=260, EWGSOP1/2/mod-EWGSOP2 reference; SARC-CalF AUC 0.778 vs SARC-F ~0.62 — sets the European empirical baseline); Voelker 2021 (re-confirmed; pooled SARC-CalF Se 45.9–57.2% / Sp 87.7–91.3%); Lim 2019 (NEW; letter to the editor — argues for population-validated CC cut-offs over the original Brazilian 31 cm threshold) · All five fields (authors, title, journal, volume/issue/pages, DOI/PMID) confirmed for each · Zero errors detected; zero memory-based references retained; no entries flagged [UNVERIFIED] · New SARC-CalF Optional Extension subsection added inside the S1 card on the Test Protocols tab: items, scoring, AWGS 2019 sex-specific CC cut-offs (M <34 cm, F <33 cm) as default, CC measurement protocol (per AWGS 2019), parallel-screening table (SARC-F vs SARC-CalF at the case-finding step), and explicit Swiss/German caveats: (1) EWGSOP2 does not endorse SARC-CalF, only AWGS 2019 does; (2) no German-language SARC-CalF validation exists; (3) no Swiss-validated CC cut-off exists, AWGS 2019 values used as the most defensible default with the Lim 2019 caveat · Background tab Section 4 extended with the Yang 2018, Krzymińska-Siemaszko 2020, Voelker 2021 (SARC-CalF-specific data), and Lim 2019 cut-off methodology arguments; Practical-implication box updated to point to the new Test Protocols subsection · New "SARC-CalF Implementation References" bibliography block added to the About tab containing the 3 new entries (Yang 2018, Krzymińska-Siemaszko 2020, Lim 2019) with full author lists, PMIDs, and DOI links; the 4 re-confirmed entries continue to be cited from their primary listing in the v8.21 SARC-F evaluation block above · "Still not re-fetched" block unchanged in count (~20 entries); per Rule 4, no blanket "all DOIs verified" claim is made.  |  v8.23 — Swiss/German validation references for clinical instruments (foundation for v9.0 bilingual UI) · 4 new references live-fetched and verified this session: Kaeppeli 2020 (Swiss validation of CFS in Basel ED, n=2,393, AUC 0.81 for 30-day mortality, doi:10.1016/j.annemergmed.2020.03.028, PMID 32336486); Rueegg 2022 (extended Swiss CFS validation for 1-year mortality, n=2,191, AUC 0.767 outperforming the Emergency Severity Index, doi:10.1111/acem.14460, PMID 35138670); Morbach 2024 STAAB (first German-population age- and height-specific reference percentiles for 6MWD, n=2,762 Würzburg, 15-m hallway protocol, doi:10.1007/s00392-023-02373-3, PMID 38236418); Hautzinger & Bailer 2012 ADS (validated German version of CES-D, canonical wording for Fried's exhaustion criterion, ISBN 978-3-8409-2393-5; book, no DOI) · 5 references already in the bibliography re-fetched and confirmed: Guralnik 1994 SPPB; Podsiadlo & Richardson 1991 TUG; Radloff 1977 CES-D original; ATS 2002 6MWT (with 2016 erratum); Rockwood 2005 CFS · All five fields (authors, title, journal, volume/issue/pages, DOI/ISBN) confirmed for each · Zero errors detected; zero memory-based references retained; no entries flagged [UNVERIFIED] · Standard-wording sources identified for v9.0 German UI: Dalhousie official German CFS v2.0 PDF (permission-granted translation, not independently validated by Dalhousie); KCGeriatrie SPPB and TUG administration forms (de facto DACH standard, no peer-reviewed validation paper exists for procedural tests — per Olson 2017 norms paper, formal translation may be unnecessary for procedural tests); DZHK-SOP-K-04 6MWT (German clinical SOP from Deutsches Zentrum für Herz-Kreislauf-Forschung, v1.0, 2014) · New CFS card evidence box added to the Test Protocols tab citing Kaeppeli 2020 + Rueegg 2022 with summary metrics · New 6MWT card evidence box added to the Test Protocols tab citing Morbach 2024 STAAB and noting DZHK SOP-K-04 as the German clinical SOP · New "Swiss/German Validation References for Clinical Instruments" bibliography block added to the About tab containing the 4 new entries with full author lists, PMIDs, and DOI/ISBN links · "Still not re-fetched" block unchanged in count (~20 entries); per Rule 4, no blanket "all DOIs verified" claim is made.  |  v9.0 — Modular source split (non-content release) · v8.23 single-file source (6,381 lines, 503 KB) split into a modular tree: src/_head.html, src/styles.css (344 lines), src/_body_open.html, eight tab partials in src/partials/, src/js/app.js (3,023 lines), src/_main_close.html, src/_body_close.html · Build script (build.py, ~70 lines, Python standard library only) concatenates the modular source back into a single distributable HTML file · Byte-equivalence test PASSED: first-pass build (no version bumps applied) produced output byte-identical to v8.23 source, confirmed by diff -q and matching SHA-256 hash 343cb444f8b6eb015953564e6550bf0cddf1e590e8a5e0f9557a321cd84396d9 · Zero references added; zero references modified; zero DOIs changed; zero memory-based references retained; no entries flagged [UNVERIFIED] · The only deliberate v9.0 changes between v8.23 and v9.0: five operational version markers updated (browser title, topbar badge, German disclaimer prose, English disclaimer prose, page footer), and one stray "Version 8.22" subtitle in the About-tab section header (missed in the v8.23 edit pass) corrected to "Version 9.0" · Bilingual UI (German default, English toggle) staged for v9.1 — will draw from the verified Kaeppeli 2020, Rueegg 2022, Morbach 2024 STAAB, Hautzinger & Bailer 2012 ADS, KCGeriatrie SPPB/TUG, and DZHK-SOP-K-04 6MWT sources locked in during the v8.23 verification pass · Fall-risk pillar staged for v9.2.  |  v9.1.0 — Bilingual UI infrastructure (chrome scope, non-content release) · First sub-release of the v9.1 bilingual implementation · Adds a [DE] [EN] segmented language toggle to the topbar, an i18n.js runtime module (~110 lines, vanilla JS), and a data-i18n="key.path" tagging convention · Translation tables (i18n/de.json, i18n/en.json) inlined into the build at build time via deterministic JSON serialisation (sort_keys=True); shipped HTML remains self-contained — no fetch(), no external loading, no server contact · Persistence via URL hash (#lang=de / #lang=en) — no cookies, no localStorage · Default language: German — matches the project's stated audience (teaching in Switzerland); navigator locale honoured only if it begins with en · v9.1.0 scope (intentionally narrow): topbar tagline + 5 operational badges; nav-tab labels (7); educational disclaimer banner (title + body); About-tab section header; About-tab disclaimer block (parallel-bilingual block replaced with single i18n-driven block) · Out of v9.1.0 scope: Test Protocols, Background, Demo, Entry, Results, Longitudinal, STS-compare, About-bibliography content (English-only at v9.1.0; tagged in v9.1.1 / v9.1.2) · Validated clinical translations preserve their published spelling unchanged (Braun 2018 PRISMA-7/FRAIL/GFI; Drey 2020 SARC-F) · Roger's own UI prose uses Swiss orthography (ss, no ß) per project policy · Zero references added; zero references modified; zero DOIs changed; zero memory-based references retained; no entries flagged [UNVERIFIED].  |  v9.1.1 — Validated-questionnaire bilingualisation (PRISMA-7, FRAIL, GFI, SARC-F) · Second sub-release of v9.1 bilingual implementation · i18n.js extended with observer pattern (FrailtyTrackI18n.subscribe(callback) + broadcast at end of applyLang() + getCurrentLang()) · Per-section EN/DE toggle removed from the Questionnaires section — questionnaire language now follows the global topbar [DE] [EN] control via the observer; the local Q_LANG variable subscribes to the topbar and re-renders forms automatically · Three calc-function status labels translated (Possible Frailty/Unlikely Frail/Frail/Pre-frail/Robust/Not Frail) via a small qT() helper resolving from i18n at render time with safe English fallback · Translation policy: PRISMA-7/FRAIL/GFI question items unchanged in app.js (Braun 2018 verbatim); SARC-F items in tab-protocols.html now data-i18n-tagged · SARC-F German wording verified verbatim against Drey 2020 Supplementary Table 1 (paper PDF live-checked in this session, DOI 10.1016/j.jamda.2019.12.011, PMID 31980396) · All five item phrasings, response options, and the two validated footnotes (water-box 5 kg example, 12-month past-year clarification) reproduced verbatim · Initial provisional wording from session memory caught and corrected during live-fetch verification; all five items required correction — demonstrating exactly why project Rule 1 (no memory-based references) exists · 21 new data-i18n keys added to both DE and EN tables; total grew 20 → 41 · Zero references added; zero references modified; zero DOIs changed; zero memory-based references retained; no entries flagged [UNVERIFIED].  |  v9.1.2 — Test Protocols landing page bilingualisation · Third sub-release of v9.1 bilingual implementation · Scope: Test Protocols tab landing view (the construct-card grid visible when the tab opens) · Translation policy formalised: "Frailty" preserved as English clinical term throughout the German UI (never "Gebrechlichkeit") — per Roger's v9.1.2 decision, on grounds that DACH research literature uses Frailty, that "Gebrechlichkeit" carries defeatist connotations and obscures the dynamic/reversible nature of the construct, and that Pre-frail/Frail/Robust as status labels stay English for consistency · "Screening" kept as German loanword · "Sarcopenia" → "Sarkopenie" (etablierter deutscher Fachbegriff) · All other clinical-domain terminology fully translated to German with Schweizer ss-Orthografie · Translation policy block formalised in de.json under _translation_policy · Tagged elements: landing header (title + subtitle); 9 construct cards (title + tagline each); 9 protocol-section headers visible when a card opens (title + subtitle); 9 "Back to overview" buttons (single shared key) · 19 new data-i18n keys; total grew 41 → 60 · Roger-authored UI prose release — no validated clinical translations modified, no live-fetch verification required · v9.1.1 validated questionnaire content (Braun 2018, Drey 2020) preserved unchanged · Out of v9.1.2 scope: Individual test cards within each construct (SPPB protocol, TUG/6MWT instructions, CFS evidence box, Fried exhaustion items, etc.) — staged for v9.1.3-v9.1.5 with their own live-fetch verification passes · Zero references added; zero references modified; zero DOIs changed; zero memory-based references retained; no entries flagged [UNVERIFIED].  |  v9.1.3 — Gait/Mobility test cards bilingualisation (4MGS, TUG, SPPB) · Fourth sub-release of v9.1 bilingual implementation · Scope: three test cards inside the Gait Speed & Mobility and Physical Performance Battery construct sections · Live-fetch verification: KCGeriatrie SPPB and TUG PDFs both fetched in this session and confirmed copyright-free ("Es besteht kein Copyright") · TUG protocol: KCGeriatrie verbatim instruction script reproduced word-for-word, including German-Germany "ß" orthography on the published form · SPPB: KCGeriatrie scoring sheet labels reproduced verbatim including the unusual official spelling "Semitandenstand"; surrounding procedural prose is Roger-authored Schweizer-ss German because the KCGeriatrie SPPB form is a scoring sheet, not an instruction script (clearly flagged in audit log) · 4MGS: Restructured per Roger's v9.1.3 "mention both" decision to present Variant A (SPPB-internal Guralnik 1994) and Variant B (standalone Studenski 2011) transparently, side by side · 89 new data-i18n keys; total grew 60 → 149 · Out of v9.1.3 scope: Fried PFP + CFS deferred to v9.1.4 (own verification pass for Dalhousie CFS PDF + Hautzinger 2012 ADS); HGS / KES / 5×STS / 30s CST / 1min STS / OLS / FSST / 2-Min Step / Mini-Cog / MoCA / DT-TUG deferred to v9.1.5 · Zero references added; zero references modified; zero DOIs changed; zero memory-based references retained; no entries flagged [UNVERIFIED].  |  v9.1.4 — Frailty-construct test cards bilingualisation (Fried PFP, CFS) · Fifth sub-release of v9.1 bilingual implementation · Scope: the two test cards inside the Global Frailty Status construct · Live-fetch verification: DGG (Deutsche Gesellschaft für Geriatrie) official German CFS poster fetched and used as authoritative source for verbatim 9-stage German wording (Singler/Gosch/Antwerpen 2020, license permits non-profit teaching reproduction); Dalhousie watermarked CFS v2.0 German PDF was image-based and could not be extracted — DGG version preferred anyway as it is DACH de facto standard · CFS version note: DGG poster is modified-after-v1.2_EN, matching the existing v1.x English labels in the tool; future v9.2 may upgrade both languages to v2.0 · Fried PFP exhaustion criterion: ADS-L (Hautzinger & Bailer 2012) is © Hogrefe Verlag; verbatim ADS items therefore NOT reproduced — transparent disclosure note added directing users to Hogrefe/Testzentrale for the validated manual · New "Hinweis zum Erschöpfungs-Kriterium" alert added inside the Fried PFP card as a transparency element (1 new content element vs. v9.1.3) · 57 new data-i18n keys; total grew 149 → 206 · Out of v9.1.4 scope: HGS/KES/5×STS/30s CST/1min STS/OLS/FSST/2-Min Step/Mini-Cog/MoCA/DT-TUG deferred to v9.1.5 · Zero references added; zero references modified; zero DOIs changed; zero memory-based references retained; no entries flagged [UNVERIFIED].  |  v9.1.5 — Strength / Power / Balance test-card bilingualisation (8 cards) · Sixth sub-release of v9.1 bilingual implementation · Scope: 8 test cards across 4 constructs (Muscle Strength: HGS, KES; Functional Power: 30s CST, 5×STS, 1minSTS; Balance & Stepping: OLS-10s, FSST, DT-TUG) · Source policy: All 8 cards Roger-authored Schweizer-ss German prose (no validated DACH-region clinical translation available for these specific procedural protocols, so no live-fetch verification was needed for this release; references already in bibliography preserved unchanged) · Schweizer-ss orthography: 'regelmässig', 'Sekunden', 'Stoppuhr', 'gemäss', 'Füsse'; thousands separator apostrophe (n=49'964) · KES is the densest card (54 keys; 9-line protocol, 10-line norms, comparison table 7×3) · 229 new data-i18n keys; total grew 206 → 435 · Out of v9.1.5 scope: 6MWT (DZHK live-fetch needed), 2-Min Step, Mini-Cog, MoCA — deferred to v9.1.6 with appropriate verification budget for MoCA copyright situation · Zero references added; zero references modified; zero DOIs changed; zero memory-based references retained; no entries flagged [UNVERIFIED].  |  v9.1.6 — Aerobic + Cognitive test-card bilingualisation (4 cards) — v9.1 series complete · Seventh sub-release of v9.1 bilingual implementation · Scope: the final 4 test cards (6MWT, 2MST, Mini-Cog, MoCA) · With v9.1.6 the entire Test Protocols tab is fully bilingual · Live-fetch verification: DZHK-SOP-K-04 v1.4 fetched and used as authoritative source for verbatim 6MWT German instruction wording (Dörr/Lehnert/Wachter, Greifswald 2014, ATS 2002 + Kompetenznetz Asthma/COPD-based, public DZHK SOP); Mini-Cog official Standardized German form fetched (mini-cog.com v.01.19.16, all 6 word-list versions, Borson permission for clinical/educational use) · MoCA copyright handling: © Nasreddine, mandatory training/certification since Sept. 2019, verbatim test items NOT reproduced — transparent disclosure note added directing users to mocatest.org for the official certified instrument (similar to Hogrefe ADS handling in v9.1.4) · Pre-existing source bugs corrected in passing: SpO<sub>2</sub> double-encoded entities, DZHK version v1.0 → v1.4, MoCA verbatim Naming items removed, "Freely available" → "Available with mandatory training and certification" · 102 new data-i18n keys; total grew 435 → 537 · v9.1 series complete: bilingual implementation reaches all originally scoped content; v9.2 will turn to the Fall-Risk pillar as a separate substantive feature release · Zero references added; zero references modified; zero DOIs changed; zero memory-based references retained; no entries flagged [UNVERIFIED].  |  v9.2 — Fall Risk Assessment construct (CDC STEADI) · First substantive content release after the v9.1 bilingualisation series · Scope: New construct section "Fall Risk Assessment" (10th construct on Test Protocols landing) with 4 cards based on the CDC STEADI workflow (F0 Algorithm Overview, F1 Stay Independent 12-question, F2 Three Key Questions, F3 4-Stage Balance Test) · Live-fetch verification: 3 CDC sources fetched (STEADI Algorithm PDF, Stay Independent brochure 2023, 4-Stage Balance Test PDF). All 12 Stay Independent questions captured verbatim with point values; all 4 balance-test stages captured with verbatim CDC patient instruction script. Underlying validations: Rubenstein 2011 (J Safety Res) for Stay Independent, Rossiter-Fornoff 1995 (J Gerontol A) for 4-Stage Balance Test · Public-domain advantage: STEADI as US federal government work product has no copyright restrictions (unlike Hogrefe ADS, MoCA Nasreddine, Mini-Cog Borson). German wording is FrailtyTrack-internal Roger-prose Schweizer-ss translation, explicitly flagged "FrailtyTrack-Übersetzung — nicht validierter Wortlaut" since no official DACH STEADI translation exists · Bilingual from day one (DE + EN simultaneously per v9.2 scope decision) · Cross-references: F0 card explicitly links STEADI workflow to existing FrailtyTrack v9.1 tests (TUG, OLS, FSST, 5×STS, 30s CST, 4MGS thresholds) · 126 new data-i18n keys; total grew 537 → 663 · Architecture: 1 new construct landing card, 1 new protocol-section id="ps-fall_risk" with 4 cards; generic showConstruct() JS handles routing without changes · Roadmap: future v9.2.x releases can add BBS-Scherfer, FES-I-Dias/Kempen, Mini-BESTest-Schädler, Tinetti POMA cards within this same section, each with focused verification pass · Zero references added; zero references modified; zero DOIs changed; zero memory-based references retained; no entries flagged [UNVERIFIED].  |  v9.2.1 — WFG 2022 + FES-I (Fall Risk pillar expansion) · Second content release within the v9.2 Fall Risk pillar · Scope: 2 new cards added to the existing Fall Risk Assessment construct: F4 World Falls Guidelines (WFG) 2022 risk-stratification 3-tier algorithm (Montero-Odasso, Age Ageing 2022) alongside the CDC STEADI workflow, and F5 FES-I/Short FES-I (Yardley 2005, Kempen 2008) — the WFG-recommended (GRADE 1A) standard instrument for concerns about falling · Live-fetch verification: 5 sources fetched (Yardley 2005, Kempen 2008, Manchester ProFaNE site, Hauer 2006 official German FES-I PDF, Hauer 2006 official German Short FES-I PDF). All 16 FES-I items captured verbatim from validated German Hauer 2006 PDF; all 7 Short FES-I items captured verbatim. Cut-points from Delbaere 2010 (FES-I 16-19/20-27/28-64; Short FES-I 7-8/9-13/14-28). Hauer 2011 cognitive-impairment validation added · License clarity: ProFaNE/FES-I is "free of charge for clinical and research use providing they are appropriately referenced" (less unconditional than STEADI's US federal public-domain status, but adequate for FrailtyTrack with proper attribution) · WFG translation: paper not formally translated as a complete document into German; F4 card uses Roger-prose Schweizer-ss with explicit "FrailtyTrack-Übersetzung — nicht validierter Wortlaut" flag. F5 16-item table uses validated German Hauer 2006 verbatim (German-Germany ß orthography preserved as published) · Clinical innovation: WFG card explicitly cites frailty status (CFS ≥5 or Fried ≥3) as a high-risk fall marker — substantive advance over STEADI alone, links FrailtyTrack frailty cards to the Fall Risk pillar; presents WFG TUG >15 s threshold alongside STEADI/CDC TUG ≥13.5 s threshold · 85 new data-i18n keys; total grew 663 → 748 · 5 new bibliography entries (Yardley 2005, Kempen 2008, Dias 2006 German validation, Delbaere 2010 cut-points, Hauer 2011); Montero-Odasso 2022 already in bibliography from v8.19, no duplicate · Roadmap: v9.2.2 (Berg Balance Scale — Scherfer 2006), v9.2.3 (Mini-BESTest — Schädler 2014), v9.2.4 (Tinetti POMA), v9.2.5 (STOPPFall medication review tool), each with own focused verification pass.  |  v9.2.2 — 3-framework picker UX + StoppSturz Schweiz · First UX restructure within a construct · Scope: (A) Restructured Fall Risk Assessment so clicking the construct landing now shows a 3-framework picker (CDC STEADI / WFG 2022 / StoppSturz Schweiz); click one to expand its cards. Pattern A click-to-show-one. (B) Added StoppSturz Vorgehen Physiotherapie (Frehner 2021, physioswiss/BFU/Gesundheitsförderung Schweiz) as third framework: 3 new cards (S1 Algorithm Szenarien A&B, S2 Risikoeinstufung & Assessments + Tabelle 1 Fokustests, S3 Massnahmenpakete gering/moderat/hoch) · Live-fetch verification: 5 sources (BFU StoppSturz portal alive at bfu.ch/stoppsturz/physiotherapie with all Manual tools confirmed; StoppSturz Manual Frehner 2021 verified; BFU Fachdokumentation 2.249 doi:10.13100/BFU.2.249.01.2021 verified via converging refs; Franchignoni 2010 Mini-BESTest doi:10.2340/16501977-0537 live-fetched; Yingyongyudha 2016 Mini-BESTest community cut-off verified) · Cross-framework lineage explicit: StoppSturz Manual itself states "leitet sich ab von CDC 2017" — framework picker presents this lineage transparently · License clarity: StoppSturz is "Alle Rechte vorbehalten. Verwendung unter Quellenangabe (siehe Zitationsvorschlag) erlaubt." — equivalent to FES-I/ProFaNE permissive policy with attribution · Mini-BESTest deferred to v9.2.3: meta-described in S2 with cut-offs (Yingyongyudha 16/28 community, Tsang 17.5/28 stroke, Mak 19/28 Parkinson) but 14 verbatim items NOT reproduced (OHSU © 2005-2013 copyright; analogous to MoCA handling) · Architecture: new JS showFallRiskFramework(id); new CSS framework-picker classes; F0-F3 wrapped in frame-steadi, F4-F5 wrapped in frame-wfg, S1-S3 in new frame-stoppsturz · 111 new data-i18n keys; total grew 748 → 859 · 4 new bibliography entries (Frehner StoppSturz Manual 2021, Frehner BFU Fachdokumentation 2.249, Franchignoni 2010 Mini-BESTest, Yingyongyudha 2016) · Sidebar finding: Duc et al. 2023 F1000Research paper on Swiss PT fall-risk practices lists Roger Hilfiker as co-author with Anne-Gabrielle Mittaz Hager (also on StoppSturz Begleitgruppe) — flagged for awareness, not added without explicit confirmation · Roadmap continues: v9.2.3 (Mini-BESTest standalone Schädler 2014/Bergström 2012), v9.2.4 (Berg Balance Scale Scherfer 2006), v9.2.5 (Tinetti POMA), v9.2.6 (STOPPFall medication review tool).  |  v9.2.3 — Standalone Mini-BESTest card (B4 in Balance & Stepping) · First standalone instrument card outside the v9.2 Fall Risk pillar · Scope: New B4 card (B1 OLS, B2 FSST, B3 DT-TUG, B4 Mini-BESTest) under the Balance & Stepping construct, giving structure (4 subscales × 3-5 items, 28-pt total), materials, population-specific cut-offs, psychometrics, and clinical-application guidance. The card meta-describes the instrument; verbatim 14 patient instructions and scoring descriptors NOT reproduced (OHSU © 2005-2013 "All rights reserved") — same conservative approach as MoCA (v9.1.6) and ADS (v9.1.4). Card links out to bestest.us / bfu.ch German PDF for verbatim test · Live-fetch verification: 5 sources (official Mini-BESTest German PDF live-fetched in full from BFU site; Cramer 2020 DACH validation full paper read from project upload; Tsang 2013 chronic stroke; Mak 2013 Parkinson's; Yingyongyudha 2016 community-dwelling) · Important correction caught while reading the Cramer 2020 full paper: Cramer 2020 does NOT report cut-offs, MCID, or MDC95 — the paper's purpose was translation/validation of the German wording, not clinical-decision threshold derivation. Cut-offs cited in B4 (Yingyongyudha 16/28, Tsang 17.5/28, Mak 19/28) come from peer-reviewed studies in their respective populations — B4's cutoffs_note explicitly flags this. The original Mini-BESTest admin time is 15 min (Franchignoni 2010); GVMBT is 16 min (Cramer 2020) — corrected from initial conflation · Cross-references bidirectional: B4 directs to S2 for differential population cut-offs; S2's prior "siehe v9.2.3" deferral note is now resolved · License decision rationale: OHSU PDF footer states only "All rights reserved" without explicit clinical/educational reproduction permit (unlike Mini-Cog which has explicit permission); conservative non-reproduction approach taken · 51 new data-i18n keys; total grew 859 → 910 (DE: 0 missing, EN: 0 missing) · 3 new bibliography entries (Cramer 2020 DACH GVMBT, Di Carlo 2016 review, Bergström 2012 Swedish pilot) · Construct landing chip and section header tagline updated to surface Mini-BESTest · Roadmap continues: v9.2.4 (Berg Balance Scale Scherfer 2006), v9.2.5 (Tinetti POMA), v9.2.6 (STOPPFall medication review tool).  |  v9.2.4 — Standalone Berg Balance Scale card (B5 in Balance & Stepping) · Continues the standalone instrument-card pattern from v9.2.3 · Scope: New B5 card (B1 OLS, B2 FSST, B3 DT-TUG, B4 Mini-BESTest, B5 BBS) under the Balance & Stepping construct, giving structure (14 items, 0-4 ordinal, max 56), the verbatim 14 item titles in Schweizer-ss German per Scherfer 2006, materials, population-specific cut-offs, psychometrics, and clinical-application guidance · License decision (different from B4 Mini-BESTest): Scherfer 2006 DACH BBS published in physioscience (Thieme) "der Fachöffentlichkeit zur kostenfreien Nutzung, verbunden mit der Bitte um Nennung der Original- sowie dieser Veröffentlichung" — explicit permissive license with attribution. The 14 verbatim item titles ARE reproduced (unlike Mini-BESTest's OHSU "All rights reserved") · Live-fetch verification: 6 sources (Scherfer 2006 full PDF read from project upload; Berg 1989 original 4-author paper at doi:10.3138/ptc.41.6.304; Shumway-Cook 1997 cut-off <36 fall risk; Steffen 2002 normative; Muir 2008 multiple falls; Donoghue 2009 MCID/MDC) · Important correction caught while reading Muir 2008: initial draft B5 had "Optimal für Vorhersage multipler Stürze; Cut-off ≤51/56" — but Muir's actual conclusion is the opposite. Muir explicitly argued against dichotomous cut-offs ("use of the BBS as a dichotomous scale should be discouraged"), recommending likelihood ratios across the score range as risk gradient. Scores <40 showed significant multiple-fall risk. Row + cutoffs_note rewritten · Cross-references bidirectional: B5 directs to S2 (StoppSturz Tabelle 1 lists BBS as balance focus test) and to B4 (Mini-BESTest comparison: BBS has substantial ceiling effects in higher-functioning patients while Mini-BESTest does not, ~14% vs 2% in Cramer 2020 same sample); v9.2.3's "Roadmap: v9.2.4 BBS" promise resolved · Translation policy: 14 item titles in Schweizer-ss; 0-4 scoring descriptors per item NOT reproduced inline (would expand the card considerably) — users referred to free Scherfer 2006 PDF on Thieme/IGPTR/Physio-Akademie for full scoring sheet · 56 new data-i18n keys; total grew 910 → 966 (DE: 0 missing, EN: 0 missing) · 6 new bibliography entries (Scherfer 2006 DACH, Berg 1989 original 4-author, Shumway-Cook 1997, Steffen 2002, Muir 2008, Donoghue 2009) · Construct landing chip and section header tagline updated to surface BBS · Roadmap continues: v9.2.5 (Tinetti POMA — verify DACH source first; Schülein 2014 noted as POMA-vs-BBS comparison source), v9.2.6 (STOPPFall medication review tool).  |  v9.2.5 — Position Statements & Consensus section (CIBERFES 2026) · First content release adding a conceptual-framework section rather than a clinical-instrument card · Scope decision: Roger chose «Moderate» integration option (new About-tab section + bibliography, no protocol-card modifications) · What was added: New collapsible card «Position Statements & Consensus — Frailty Conceptual Framework» in the About tab with 6 position blocks: definition, what frailty is NOT, recommended assessment, multicomponent management, stigma/communication, sub-phenotypes · Voice policy: CIBERFES positions presented as CIBERFES's view, not as house position. Aligned positions (Fried phenotype primacy, SPPB/gait speed/FRAIL screening, multicomponent exercise, muscle power as «promising marker» with powerpenia framing, Mediterranean diet) reinforce existing FrailtyTrack design. Contested positions (rejection of WHO intrinsic capacity, hesitation on cognitive frailty, anti-disability-in-frailty-scales argument) flagged as such · Live-fetch verification: 4 sources (Álvarez-Bustos 2026 full PDF via project upload + live re-fetch from digital.csic.es; Garcia-Aguirre 2025 longitudinal e13852 — distinct from the cross-sectional e13676 already in bibliography; Izquierdo 2025 ICFSR consensus with 2024 DOI prefix despite 2025 issue; Rodríguez-Mañas 2013 FOD-CC Delphi as the foundational definition consensus) · 26 new data-i18n keys; total 966 → 992 (DE: 0 missing, EN: 0 missing) · 4 new bibliography entries (Álvarez-Bustos 2026 CIBERFES, Garcia-Aguirre 2025 longitudinal, Izquierdo 2025 ICFSR, Rodríguez-Mañas 2013 FOD-CC) · New id="position-statements" on the section card to enable future deep-linking · Roadmap continues: v9.2.6 (Tinetti POMA — verify DACH source first; Schülein 2014 noted), v9.2.7 (STOPPFall medication review tool). Future v9.3 work could add similar conceptual-framework treatment of the Lancet Frailty Commission (Dent 2025) and Hoogendijk 2019 Lancet review.  |  v9.2.6 — Combined Background tab (Frailty + Sarcopenia) · Structural and pedagogical release answering the question «does FrailtyTrack have anywhere a first-time user can read about what frailty is and why early detection matters?» — the answer was: only the buried Position Statements section in About. v9.2.6 fixes that by merging the previous «Background: Sarcopenia» tab into a unified Background tab with two collapsible parent sections (Frailty + Sarcopenia) · Scope decision: Roger chose option B from a 4-option picker (A standalone tab / B merge into one tab / C smaller intro / D expand Position Statements). Sub-decisions: bilingual DE+EN from day one; Frailty section sized for full pedagogical depth (~30 KB achieved against ~20-25 KB target); Sarcopenia internal headers renumbered 1.→2.1 through 8.→2.8 with provenance labels untouched per standing rule · What was added — Frailty Section 1 (8 sub-sections): 1.1 What frailty is (syndrome + physiology with inflammaging, HPA, biomarker context); 1.2 Why early detection matters (3 reasons: reversibility, outcome predictor, effective interventions); 1.3 Two operational models with 7-row phenotype-vs-deficit-accumulation comparison table; 1.4 Pre-frailty as the intervention window; 1.5 5-row assessment pathway table mapping Screening / Diagnosis / Powerpenia / Falls / Sarcopenia coexistence to existing FrailtyTrack cards (S1, G1, FRAIL, Fried, CFS, 5xSTS-power, 30s-STS-power, F0–F5, B4, B5); 1.6 Common misunderstandings (6 explicit refutations); 1.7 Why physiotherapy is central (Vivifrail, StoppSturz, ICFSR multicomponent context); 1.8 Key references · Sarcopenia Section 2: existing v8.21 content preserved verbatim, only header numbering 1.→2.1, ..., 8.→2.8 via Python script (8/8 success); provenance labels left untouched · Architecture changes: file rename tab-background-sarcopenia.html → tab-background.html; div id update; build.py partial reference; switchTab and switchTabDirect calls; nav-button label simplified to «📚 Background» / «📚 Hintergrund» · Voice policy: pedagogical and balanced, presents contested choices (Fried vs Rockwood, intrinsic capacity vs frailty terminology, cognitive-frailty status) evenhandedly with cross-links to Position Statements section in About for users wanting CIBERFES-specific positions. Complements rather than duplicates the existing Position Statements section · Live-fetch verification: 7 sources (Clegg 2013 Lancet, Hoogendijk 2019 Lancet, Dent 2019 Lancet companion, Mitnitski 2001 deficit accumulation, Buta 2016 instrument review, Bernabei 2022 SPRINTT, Travers 2019 primary-care) · 91 new data-i18n keys; total 992 → 1083 (DE: 0 missing, EN: 0 missing) · 7 new bibliography entries · Anchor IDs id="background-frailty" and id="background-sarcopenia" on parent cards for deep-linking · Pedagogical note: Background tab is designed to reinforce, not replace, the workshop script (Skript_Frailty_aarRehaSchinznach) — script teaches the concept in depth, tab teaches concept-to-tool mapping · Roadmap continues: v9.2.7 (Tinetti POMA — verify DACH source first; Schülein 2014 noted), v9.2.8 (STOPPFall medication review tool — WFG-endorsed). v9.3 candidate: Lancet Frailty Commission (Dent 2025) following the Position Statements pattern. |  v9.3.0 — Lancet Frailty Commission (Dent 2025) integration · First v9.3-series content release, following the v9.2.5 Position Statements & Consensus pattern · Scope decision: Roger chose «Substantial» (option C from a 4-option picker: Minimal — bibliography only / Moderate — v9.2.5-pattern About entry + bibliography / Substantial — Moderate + Section 1 Background reinforcement / Defer — track only). The new About card uses a 5-block structure (stated goal / four priority areas / policy alignments / commissioner composition / status & complementarity to CIBERFES) rather than mirroring the CIBERFES 6-block structure, because Dent 2025 is a programme announcement rather than a finalised consensus · What was added: (a) New collapsible card «The Lancet Commission on Frailty — Programme & Priorities» (id="position-statements-lancet") inserted as sibling immediately after the CIBERFES card, before the bibliography; (b) new Background tab Section 1.9 «Frailty as a public-health priority — the Lancet Commission's reframing» (3 framing paragraphs: prevalence/equity, four priority areas, policy alignments) appended after the existing Section 1.8 references; (c) Dent 2025 ref-chips in Section 1.1 (definition) and 1.2 li2 (strong outcome predictor); (d) new bibliography entry inserted after Dent 2019 Mgmt to keep all 4 Lancet frailty papers clustered (Clegg 2013, Hoogendijk 2019, Dent 2019 Mgmt, Dent 2025); (e) Dent 2025 added as li11 in Section 1.8 reference list · Voice policy: explicit «report pending» status flag in both new sections; FrailtyTrack continues to draw current operational guidance from CIBERFES 2026 / ICFSR 2025 / WHO ICOPE / SPRINTT — the two consensus sources presented as complementary · Live-fetch verification: 1 source via University of Leeds White Rose Research Online institutional repository (eprints.whiterose.ac.uk/237353) with full Dublin Core / EPrints metadata record (authors, title, journal, volume 405, issue 10497, pages 2265–2266, DOI 10.1016/s0140-6736(25)01101-8, ISSN 0140-6736, dates accepted 23 May 2025 / online 5 June 2025 / print 28 June 2025, CC-BY 4.0). All five fields confirmed. Cross-checked against 3 corroborating sources (Lancet website search snippet, Karolinska press release via Mirage News, ResearchGate metadata) · Title discrepancy: submitted manuscript title «Reorienting Frailty in Clinical Practice, Public Health and Policy: a Lancet Commission» differs from version of record «Reorienting frailty in clinical practice, public health, and policy: the Lancet Commission on Frailty». Bibliography uses version of record · Translation policy: Schweizer-ss orthography for Roger-prose; two short verbatim quotes (the Commission's stated goal and the WHO World Report «foremost geriatric syndrome» phrasing) preserved as published in English with German contextualisation · 24 new data-i18n keys; total 1083 → 1107 (DE: 0 missing, EN: 0 missing) · 1 new bibliography entry (Dent 2025 Lancet Commission) · Pedagogical implication surfaced: Section 1.9 explicitly draws the Commission's strongest implication for physiotherapy education — frailty assessment is no longer specialist-only knowledge and belongs in every adult-orthopaedic, neurological, surgical, and oncological rehabilitation curriculum, not only the geriatric one · Roadmap continues: v9.3.1 (Hoogendijk 2019 Lancet review — potential expansion of Position Statements pattern), v9.3.2 (Tinetti POMA — Schülein 2014 noted), v9.3.3 (STOPPFall medication review tool). When the Commission's substantive report is published, the card and Section 1.9 will be expanded with operational content and the «report pending» status flags removed.

v9.4.0 — Workshop-script alignment release · Aligns the protocol set with the BFH 2026 workshop script (Skript_Frailty_BFH_2026_Hilfiker_v20) · Scope (Roger-confirmed): standalone Calf Circumference (S2) + MNA-SF (N1) protocol cards, Short FES-I entry-form integration, Powerpenia narrative pointer (Freitas 2024) on the existing 5×STS card, three new demo cases (5→8 total). STS-power calculator already implemented in v9.3 — no formula changes · What was added: (a) S2 Wadenumfang standalone card under Sarkopenie construct — explicit dual reuse for SARC-CalF + MNA-SF; (b) N1 MNA-SF 6-item card with thresholds 12-14 normal / 8-11 risk / 0-7 malnourished, F2 calf-circumference fallback per Kaiser 2009; (c) Powerpenia interp-line on 5×STS card citing Freitas 2024 (only 2 of 220 dynapenia studies between 2008–2023 directly measured power); (d) Enter-Assessment block «Sarcopenia · Nutrition · Fear of Falling» with 6 fields including auto-derived SARC-CalF (calf ≤ 34♂/33♀); (e) recalcSarcCalf() JS function, processEntry/loadDemoCase/Excel-I/O extensions for 6 new columns; (f) 3 demo cases — Frau M.K. (78F pre-frail HFpEF), Herr H.K. (84M frail+MCI+falls, Vivifrail-Stufe-C), Frau B.S. (72F post-pneumonia HAD with textbook remediable Frailty trajectory) · Live-fetch verification: 5 references five-field-checked. 2 new bibliography entries (Kaiser 2009 MNA-SF after Hauer 2011 FES-I; Freitas 2024 Powerpenia after Coelho-Junior 2024 power-normative). 3 re-confirmed (Alcazar 2021, Kempen 2008, Delbaere 2010 already in About-tab biblio from v8.2/v9.2.1). All 5 added to structured refs/bibliography.json with verified_session: "v9.4.0"; total bibliography.json grows 15 → 20 entries · Version-string drift fix: at session start the topbar badge read v 9.2 while title read v9.3.0 (one-version lag, recurring failure mode flagged in project memory). Bumped all loci together: title v9.4.0, badge v 9.4, About header/disclaimer 9.4.0, footer 9.4.0, demo-cases badge 5 → 8, i18n _policy_version + _status updated. Historical «added vX.X» provenance labels preserved per project policy · Deferred per pre-flight scope contract: Floor-Transfer (v9.5), Pittsburgh Fatigability + FSS fatigue pillar (v9.5), RIR/RPE training-intensity card (v9.5), Vivifrail/OEP intervention cards (v9.7), Background Frailty-Trajectory-Model (v9.6), EWGSOP2/AWGS comparison (v9.6), MCID auto-coded (v9.6/v9.7).

v9.5.0 — Tab-order release (pure structural) · Reorders the top-level navigation so the Background tab (Frailty + Sarcopenia) is first and is the default landing tab; Demo Cases moves to position 2; Test Protocols moves to position 3; remainder unchanged (Entry → Results → Longitudinal → About) · Pedagogical motivation: a first-time user reads «what frailty is and why early detection matters» before navigating literature-derived demo cases, and only then enters the dense protocol catalogue — matching the workshop script's narrative arc (concept → cases → instruments) · Scope contract: structural-only release. No changes to clinical cards, normative data, formulae, demo-case content, bibliography entries, i18n content keys, JS calculation logic, or Excel I/O behaviour · Files changed: build.py (partial concatenation order; default --version 9.4.0 → 9.5.0); _body_open.html (nav-tab button order; active class moved Test Protocols → Background; topbar badge v 9.4 → v 9.5); tab-protocols.html (active class removed); tab-background.html (active class added); _head.html (title v9.4.0 → v9.5.0); _main_close.html (footer v9.4.0 → v9.5.0); tab-about.html (header subtitle and disclaimer body strings); app.js (Excel-template filename v9.4.0 → v9.5.0); de.json + en.json (_policy_version v9.4.0 → v9.5.0; _status rewritten). Two boundary-block partials renamed: _between_protocols_and_bg.html → _between_demo_and_protocols.html; _between_demo_and_entry.html → _between_protocols_and_entry.html · Reference verification (Rules 1–6): pure structural release, 0 references generated, 0 verified, 0 flagged. Cumulative audit trail unchanged from v9.4.0 (20 entries in refs/bibliography.json). Per Rule 4, no «all DOIs verified» claim is made — references retain their last-session verification status · Version-string drift check: all six current-version loci bumped together (title, topbar badge, About header, About disclaimer, footer, Excel-template filename) plus build.py default and i18n _policy_version in both languages. Historical «added vX.X» provenance labels preserved per project policy · Smoke-test acceptance: on page load Background renders as the active panel; left-to-right nav traversal yields Background → Demo Cases → Test Protocols → Entry → Results → Longitudinal → About; the «Full comparison →» buttons inside the three STS cards still resolve to tab-sts-compare · Pre-existing soft-fail noted (not addressed): the substring-matching heuristic in switchTabDirect() (using id.substring(0,4)) does not match the German nav label «Hintergrund» against id background — a known issue since v9.2.6 that causes the wrong nav button to remain highlighted when switchTabDirect('background') is called from inside Test Protocols in DE mode. Fix is non-trivial (would require a label-to-id map) and is out of scope for this minor structural release; flagged for v9.5.1 or v9.6 · Roadmap continues unchanged from v9.4.0: Floor-Transfer (v9.6 candidate), Pittsburgh Fatigability + FSS fatigue pillar (v9.6), RIR/RPE training-intensity card (v9.6), Vivifrail/OEP intervention cards (v9.7), Background-tab Frailty-Trajectory-Model from Mallery & Shetty 2026 (v9.6 — the v9.5.0 reorder makes Background the natural anchor for this addition), EWGSOP2/AWGS comparison (v9.6), MCID auto-coded (v9.7).

v9.6.0 — New Background-tab Section 2 chapter «Muscle and Frailty — Mass, Strength, and Power» · Inserts a new bridging chapter between the existing §1 Frailty conceptual framework and the existing §2 SARC-F instrument evaluation (which is renumbered to §3) · Pedagogical motivation: prior versions jumped from «what frailty is» directly to «how good is this one screening questionnaire» without ever stating why muscle is the central substrate of physical frailty. The new chapter establishes the mass → strength → power hierarchy that underwrites instrument choice across the protocol catalogue · Scope (Roger-confirmed): from a 3-option picker (A new §2 with renumbering of SARC-F to §3 / B new §3 placed after SARC-F / C embed as 1.10 inside Frailty), Roger chose option A — restores conceptual flow (frailty syndrome → muscle as substrate → specific screening tool) · Chapter structure: TL;DR + 7 substantive sub-sections (2.1 epidemiological overlap; 2.2 two sides of the same coin; 2.3 mass → strength → power hierarchy with 3×5 norm-table; 2.4 dynapenia; 2.5 power; 2.6 quantitative anchors; 2.7 implications for FrailtyTrack) + 2.8 verified-reference block with 11 ✅ live-fetched references and self-audit footer · SARC-F renumbering (mechanical): heading «2. Sarcopenia» → «3.»; eight sub-sections 2.1–2.8 → 3.1–3.8; subsections-intro range bumped; both DE and EN i18n updated. No content of the SARC-F chapter changed · i18n: 62 new leaf keys per language under background.muscle.*; DE/EN parity 62/62 confirmed · Reference verification (Rules 1–6): 11 references entered the structured bibliography this session, all live-fetched and five-field-verified: Almohaisen 2022 (community-dweller prevalence), Ligthart-Melis 2020 (hospital co-occurrence), Cesari 2014 (two-sides-of-same-coin), Cruz-Jentoft 2019 EWGSOP2, Clark & Manini 2008 (dynapenia coining), Manini & Clark 2012 (dynapenia update), Skelton 1994 (foundational power-vs-strength), Reid & Fielding 2012 (narrative review), Coelho-Junior 2024 (Italian centiles, already on 5×STS card), Beaudart 2017 (outcome meta-analysis), Fried 2001 (newly entered into structured bibliography; previously in About-tab Primary References). 11 generated, 11 verified, 0 flagged this session. Cumulative refs/bibliography.json grows 20 → 31 entries. Cross-references reused without re-fetch (already verified prior sessions): Alcazar 2021, Bernabei 2022 SPRINTT, Freitas 2024 powerpenia · About-tab bibliography: new narrative block Primary References — Muscle and Frailty (v9.6.0) with all 11 references in standard format · Version-string drift check: all six current-version loci bumped together (title, topbar badge, About header, About disclaimer, footer, Excel-template filename) plus build.py default and i18n _policy_version in both languages. Historical «added vX.X» provenance labels preserved · Smoke-test acceptance: Background renders with new §2 Muscle card visible between §1 Frailty and renumbered §3 Sarcopenia; eight §3 SARC-F sub-section cards show renumbered 3.1–3.8 headings; DE/EN toggle works for new namespace · Roadmap continues from v9.5.1: v9.7 (Floor-Transfer, Pittsburgh Fatigability + FSS, RIR/RPE, Mallery-Shetty trajectory model, EWGSOP2/AWGS, HAD, cognitive frailty); v9.8 (Vivifrail/OEP, Fagan calculator, MCID auto-coding). The Mallery-Shetty trajectory model originally listed for v9.6 is deferred to v9.7 since v9.6.0 is fully consumed by the new Muscle-and-Frailty chapter.

v9.5.1 — Welcome / landing card on the Background tab · Inserts a new card «Was FrailtyTrack bietet — auf einen Blick» / «What FrailtyTrack provides — at a glance» at the top of the Background tab, above the existing §1 Frailty and §2 Sarcopenia parent cards · Pedagogical motivation: the v9.5.0 reorder made Background the default landing tab, but new users still saw the deep Frailty conceptual exposition without first being told what the tool is and what it offers. v9.5.1 fills that gap · Scope (Roger-confirmed): from a 4-option picker (A new first tab / B top card on Background / C slim banner + Background card / D replace educational disclaimer with welcome block), Roger chose option B — preserves v9.5.0 nav structure, uses the existing card pattern · What was added: identity TL;DR box (teal-highlighted, mirroring §1 Frailty pattern); 5 sub-sections — (1) Was drin ist with 6 bullets covering protocol catalogue / 8 demo cases / calculation engines (Alcazar STS-power, NAKO/Coelho-Junior/Strassmann/Morbach/Bohannon percentile lookups, Fried scoring, SARC-F→SARC-CalF auto-derive) / longitudinal tracking with MCID flags / Excel I/O / bilingual UI; (2) Für wen with 4 audience bullets (students, educators, practitioners, BFH workshop participants); (3) Typischer Arbeitsablauf with 6 numbered steps mapping the v9.5.0 tab order; (4) Was FrailtyTrack nicht tut with 4 bullets (not a medical device, no diagnosis on real patients, no data persistence, no substitute for clinical judgment); (5) Schnellstart with 3 button-style direct links (smooth-scroll to §1 Frailty in-tab; switchTabDirect to demo; switchTabDirect to protocols) · Architecture: standard div.card + collapsible card-body pattern; default-open (no .collapsed); id="background-welcome" for future deep-linking; section-header subtitle lightly extended to flag the tab as the explicit landing page · Translation policy: bilingual DE+EN simultaneously per v9.1+ pattern; Schweizer-ss orthography for Roger-prose; gender-inclusive «:innen» form · i18n: 34 new leaf keys per language under background.welcome.* (heading, abbrev, identity_label, identity_body, plus inside.* / audience.* / workflow.* / notdoes.* / next.* sub-namespaces) · Reference verification (Rules 1–6): pure cross-reference content; all sources named (Alcazar, NAKO/Huemer 2023, Coelho-Junior 2024, Strassmann 2013, Morbach 2024, Bohannon 2017, Fried 2001, Braun 2018, Drey 2020, Dalhousie CFS, Hautzinger & Bailer 2012 ADS, DZHK-SOP-K-04, Cramer 2020 GVMBT, Scherfer 2006 BBS) already in refs/bibliography.json or About-tab bibliography from prior sessions. 0 references generated, 0 live-fetch verified, 0 flagged this session. Cumulative bibliography state unchanged from v9.5.0 / v9.4.0 (20 entries) · Version-string drift check: all six current-version loci bumped together (title, topbar badge, About header, About disclaimer, footer, Excel-template filename) plus build.py default and i18n _policy_version in both languages · Roadmap unchanged from v9.5.0: v9.6 (Floor-Transfer, Pittsburgh Fatigability, RIR/RPE, Mallery-Shetty trajectory model, EWGSOP2/AWGS, HAD, cognitive frailty); v9.7 (Vivifrail/OEP, Fagan calculator, MCID auto-coding). The welcome card text will be lightly updated when v9.6 expands the Background tab.

FrailtyTrack v9.9.0 — Teaching & Reference Tool for Physiotherapy Education — No cookies · No server · All processing local · May 2026
⚠ Educational use only / Ausschliesslich für Bildungszwecke. Not a medical device. Normative data sourced from peer-reviewed, DOI-verified publications.