Development and validation of two physical exercise programmes to prevent hospital-associated disability in older adults during hospitalisation: Protocol for two Delphi studies.

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Structured exercise interventions preserve functional independence and physical performance in this population substantially better than usual care. Many research articles fail to provide sufficiently detailed descriptions of the exercises and their specific modalities, limiting the feasibility of translating these interventions into clinical practice. Aim We aim to use evidence from an ongoing living systematic review with network meta-analysis to establish consensus on two exercise programmes identified as the most effective for hospitalised older adults. One programme will consist exclusively of resistance training exercises, while the other will adopt a multicomponent approach integrating balance, resistance, and gait training exercises. Each programme will be refined through a separate Delphi study. Methods and analysis We will use a modified Delphi study design to reach consensus among 30 participants, including clinicians, prescribing physical exercises to older adults and researchers in the relevant fields. Each study will consist of three Delphi rounds conducted via electronic surveys. Quantitative responses will be analysed by dichotomising the results of Likert items with a six-point ordinal scale into “in favor” and “not agreeing”, with consensus defined as ≥80% agreement. Qualitative responses will be examined using a modified version of the argument-based qualitative analysis strategy (AQUA). Ethics and dissemination: This study does not collect health-related data. These two studies are part of a broader project designed to enhance the accessibility of up-to-date scientific evidence on preventing hospital-associated disability (HAD) in older adults for both clinicians and patients. The findings will serve as a foundation for developing structured clinical training programmes tailored for geriatric hospitals in Switzerland. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/15-559/v1", "name": "Development and validation of two physical exercise programmes to..." } } ] } Home Browse Development and validation of two physical exercise programmes to... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Wist S, Hilfiker R, Giacomino K et al. Development and validation of two physical exercise programmes to prevent hospital-associated disability in older adults during hospitalisation: Protocol for two Delphi studies. [version 1; peer review: awaiting peer review] . F1000Research 2026, 15 :559 ( https://doi.org/10.12688/f1000research.178951.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Study Protocol Development and validation of two physical exercise programmes to prevent hospital-associated disability in older adults during hospitalisation: Protocol for two Delphi studies. [version 1; peer review: awaiting peer review] Sophie Wist https://orcid.org/0000-0003-3673-4404 1,2 , Roger Hilfiker 3 , Katia Giacomino https://orcid.org/0000-0003-0522-3185 1,2 , David Beckwée 2 , Karl Martin Sattelmayer https://orcid.org/0000-0001-8001-4776 1 Sophie Wist https://orcid.org/0000-0003-3673-4404 1,2 , Roger Hilfiker 3 , [...] Katia Giacomino https://orcid.org/0000-0003-0522-3185 1,2 , David Beckwée 2 , Karl Martin Sattelmayer https://orcid.org/0000-0001-8001-4776 1 PUBLISHED 18 Apr 2026 Author details Author details 1 Institute of Health Sciences, School of Health Sciences, HES-SO Valais Wallis, Leukerbad, Valais, 3954, Switzerland 2 Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Rehabilitation Research (RERE) Research Group, Vrije Universiteit Brussel, Brussel, Brussels, Belgium 3 Independent researcher at Englisch-Gruss-Strasse 32, Haus Euklid, Glis, Valais, 3902, Switzerland Sophie Wist Roles: Conceptualization, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Roger Hilfiker Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Validation, Writing – Review & Editing Katia Giacomino Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing David Beckwée Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Validation, Writing – Review & Editing Karl Martin Sattelmayer Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Supervision, Validation, Writing – Review & Editing OPEN PEER REVIEW REVIEWER STATUS AWAITING PEER REVIEW This article is included in the Health Services gateway. Abstract Introduction Older adults admitted to hospital are particularly vulnerable to rapid functional decline, primarily due to prolonged inactivity, a phenomenon known as hospital-associated disability (HAD). Structured exercise interventions preserve functional independence and physical performance in this population substantially better than usual care. Many research articles fail to provide sufficiently detailed descriptions of the exercises and their specific modalities, limiting the feasibility of translating these interventions into clinical practice. Aim We aim to use evidence from an ongoing living systematic review with network meta-analysis to establish consensus on two exercise programmes identified as the most effective for hospitalised older adults. One programme will consist exclusively of resistance training exercises, while the other will adopt a multicomponent approach integrating balance, resistance, and gait training exercises. Each programme will be refined through a separate Delphi study. Methods and analysis We will use a modified Delphi study design to reach consensus among 30 participants, including clinicians, prescribing physical exercises to older adults and researchers in the relevant fields. Each study will consist of three Delphi rounds conducted via electronic surveys. Quantitative responses will be analysed by dichotomising the results of Likert items with a six-point ordinal scale into “in favor” and “not agreeing”, with consensus defined as ≥80% agreement. Qualitative responses will be examined using a modified version of the argument-based qualitative analysis strategy (AQUA). Ethics and dissemination: This study does not collect health-related data. These two studies are part of a broader project designed to enhance the accessibility of up-to-date scientific evidence on preventing hospital-associated disability (HAD) in older adults for both clinicians and patients. The findings will serve as a foundation for developing structured clinical training programmes tailored for geriatric hospitals in Switzerland. READ ALL READ LESS Keywords Physical exercises programme, hospital-associated disability, older adults, prevention Corresponding Author(s) Sophie Wist ( [email protected] ) Karl Martin Sattelmayer ( [email protected] ) Close Corresponding authors: Sophie Wist, Karl Martin Sattelmayer Competing interests: No competing interests were disclosed. Grant information: This work was supported by the Swiss National Science Foundation grant number 220492. The sponsor is independent from the trial team and has no authority over this protocol or the coming trial. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2026 Wist S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Wist S, Hilfiker R, Giacomino K et al. Development and validation of two physical exercise programmes to prevent hospital-associated disability in older adults during hospitalisation: Protocol for two Delphi studies. [version 1; peer review: awaiting peer review] . F1000Research 2026, 15 :559 ( https://doi.org/10.12688/f1000research.178951.1 ) First published: 18 Apr 2026, 15 :559 ( https://doi.org/10.12688/f1000research.178951.1 ) Latest published: 18 Apr 2026, 15 :559 ( https://doi.org/10.12688/f1000research.178951.1 ) Study protocol 1. Study context Meta-analyses provide summaries of the effects of exercise, yet descriptions of these programmes often lack sufficient detail for effective clinical implementation. The SHADE (Physical intervention S to prevent and rehabilitate H ospital- A ssociated D isability in hospitalised older p E ople) project is driven by the objective of providing adequate and feasible solutions to clinicians, informed by the most current knowledge. This project has been granted financial support from the Swiss National Science Foundation. The initial phase of the project entailed conducting a living systematic review with network meta-analysis (LSR). The primary aim of this LSR is to evaluate the effectiveness of various types of physical exercises in preventing and rehabilitating hospital-associated disability (HAD) among hospitalised older adults, compared with usual care. This phase remains ongoing, and its results have not yet been published. 1 As of October 2025, the LSR included 84 randomised controlled trials (RCTs). The subsequent phase of this project is to formulate a consensus on the two most effective exercise interventions to be implemented in an acute hospital setting, using a Delphi methodology. Consequently, it is necessary to conduct two Delphi studies, one for each of the two most effective physical exercise training programmes. The following protocol will be used to present this part of the project. 2. Background With advancing age, individuals become increasingly susceptible to functional decline, and the risk of disability in activities of daily living (ADL) rises accordingly. 2 Evidence suggests that older people who engage in two hours of moderate physical activity daily, incorporating both aerobic and strength component, demonstrate a substantially reduced risk of developing a disability. 3 According to the World Health Organization (WHO), physical activity is defined as “any bodily movement produced by skeletal muscles that requires energy expenditure,” whereas exercise refers to a planned, structured, and repetitive form of physical activity performed with the objective of improving or maintaining physical fitness. 4 In Switzerland in 2023, people aged over 65 years represented 43.9% of all hospitalisations. 5 This population is characterised by a high burden of comorbidities and chronic conditions, coupled with reduced physiological reserves, making them especially susceptible to adverse health outcomes. 6 A study conducted at the University Hospital of Lausanne, Switzerland, employed a wrist accelerometer to assess physical activity levels in 177 patients. 7 Ninety percent of this cohort engaged in less than 20 minutes of moderate physical activity per day. 7 Older patients were predominantly active around mealtimes, accounting for only 10% of the day. 7 The median duration of activity at any intensity was approximately one hour per day (Tasheva et al., 2020). Furthermore, patients using medical devices such as urinary catheters or nasal cannula oxygen therapy, as well as those who had relied on walking aids two weeks prior to admission, were 70–75% less likely to be active. 7 These findings are consistent with results reported in studies conducted in other countries. Moreover, a systematic review with meta-analysis including seven studies showed that hospitalised patients spend 87–100% of the day sitting or lying in bed. 8 They also concluded that hospitalised patients from different wards monitored over the course of a 24-hour period, walked or stood for between 57 and 83 minutes per day. 8 By contrast, older adults living in the community appear to have substantially higher activity levels. For example, a study including 432 community dwelling older people, with a mean age of 71,69 (SD 5,28) reported that participants were active for around 7.8 hours per day. 9 Approximately one third of older adults experience a functional decline during hospitalisation or acute illness. 10 – 12 This functional decline is not only related to the disease for which they were admitted but also persists after it has been cured. 13 Several factors contributing to functional decline during hospitalisation have been identified and are commonly classified into three categories: pre-existing patient frailty, the severity of the condition necessitating hospitalisation, and factors inherent to the hospitalisation process itself. 6 Factors influencing pre-existing frailty or vulnerability include age, mobility, cognitive function, dependence in activities of daily living (ADL), geriatric syndromes (including conditions such as falls and incontinence), polypharmacy, nutritional status, sensory deficits (e.g., blindness or deafness), social determinants, and depression. 6 , 14 Hospitalisation-related contributors comprise the care environment, restricted mobility, malnutrition, dependence, polypharmacy, and insufficient promotion of independence. 14 HAD is defined as the loss of independence in at least one ADL among individuals who are or have been hospitalised. 14 For example, an older adult may lose the ability to walk independently following a hospital stay. This decline in ADL can lead to longer hospital stays, increased nursing home placement, and increased mortality in such patients. 6 , 15 These outcomes adversely affect patients’ quality of life and impose a substantial economic burden on healthcare systems, as older adults with multiple comorbidities are more likely to be hospitalised, experience extended lengths of stay, and develop HAD. 16 – 18 Insufficient physical exercise among hospitalised older adults is a negative contributor to HAD. 6 , 12 , 14 A reduction in physical activity of healthy older adults due to prolonged bed rest or hospitalisation for approximately 10 days can result in a loss of about 15% of maximal strength and a reduction of 4–10% of lean tissue mass in the legs, accompanied by an increase in truncal fat tissue. 19 , 20 Notably, muscle strength can decline by 6% within the first two days of hospitalisation. 21 Even in healthy adults under 50 years old, a short stay of around five days in an acute ward followed by prolonged bed rest can have a negative impact on muscle strength. 22 The recommendations of the World Health Organization (WHO) to older people are to engage in at least 150 to 300 minutes of moderate-intensity physical activity, or 75 to 150 minutes of vigorous-intensity physical activity per week, and to minimise their sedentary behaviour for overall health benefits. 4 These recommendations also included muscle-resistance exercises twice per week, as well as multi-component training three times per week. 4 Physical exercise programmes, such as those used in rehabilitation, have been shown to exert a greater positive effect on the functional independence and physical performance of older hospitalised patients compared with usual care. 10 , 12 In their systematic review and dose–response network meta-analysis, Gallardo-Gómez et al. (2023) demonstrated that clinically meaningful functional improvements in acutely hospitalised adults aged over 55 years can be achieved with approximately 70 minutes per day of light physical activity or 40 minutes per day of moderate physical activity. The authors also reported a reduction in adverse events within this population. 23 Given the current demographic trends, characterised by a growing geriatric population, the political imperative to contain healthcare and long-term care costs, and the shortage of healthcare personnel, it is increasingly important to translate the scientific evidences of this topic of high importance into clinical practice The available literature is continually evolving, highlighting the need for an efficient and targeted training pathway, grounded in robust scientific evidence, that can be readily implemented in hospital settings. Such a pathway should clearly define the selected exercises, the modalities to be employed, the safety parameters to be observed, and the facilitators required for implementation. To address this gap, the present project aims to apply findings from an LSR 1 to achieve consensus, using a Delphi methodology, on two training programmes designed to prevent or reduce HAD in acutely hospitalised older patients. The LSR and the planned Delphi studies form part of the SHADE project. As of October 2025, the ongoing LSR and its network meta-analysis indicate that resistance training alone, as well as multicomponent programmes combining resistance, balance, and gait training, are the most effective forms of physical exercise for preventing HAD across different endpoints. 2.1 Training programme 1: Resistance training A systematic review has demonstrated that resistance training effectively improves muscle strength in adults over 50 with sarcopenia, a condition closely linked to reduced autonomy in activities of daily living. 24 Furthermore, finding from the ongoing SHADE LSR indicate that, among all types of physical exercise, resistance training is currently one of the most effective interventions for preventing HAD in older adults, consistently yielding positive results across all analyses. 25 Several studies included in the SHADE living systematic review based their resistance training interventions on existing multicomponent exercise programmes, such as the Vivifrail physical exercise programme, 26 High Intensity Functional Exercise (HIFE) Training, 27 and the Otago exercise programme. 26 – 28 These programmes served as a foundation for selecting specific exercises. Researchers then used these selections to develop their own tailored training programmes. 29 – 31 Some studies incorporated power training, also referred to as high-velocity training, which involves performing the concentric phase of resistance exercises at a higher speed. 29 , 31 , 32 This type of training has been shown to be more effective than moderate-velocity resistance exercises in improving the physical function of healthy older adults. 33 – 35 However, there is no evidence that high-velocity training has an impact on ADL for hospitalised older people. In the studies included in the LSR, as of October 2025, patients were typically hospitalised for a short duration, with a mean length of stay of 8.05 days at discharge. Observing meaningful effects of resistance training within such a limited timeframe is challenging, particularly when advanced modalities such as velocity-based training are considered. In addition, the studies did not describe how to instruct patients in these modalities. They also lacked guidance on which patient groups might benefit most from the intervention. To describe resistance training modalities precisely, it has been recommended to report the exercise selection, training frequency and length, intensity, number of repetitions and set endpoint, number of exercises, progression, the fractional and temporal distribution of the contraction modes per repetition, time under tension and its range of motion. 36 , 37 None of the included studies in the LSR contain all these parameters. 2.2 Training programme 2: Multicomponent exercise programme including balance, resistance and gait training Multicomponent exercise programmes are well established in geriatric care. Such programmes have been shown to have a positive influence on strength and balance, thereby reducing fear of falling. This fear is a factor that correlates with both the risk of falls and limitations in ADL. 38 Furthermore, these multicomponent exercise programmes have also been shown to reduce HAD and adverse events associated with hospitalisation. 23 The ongoing SHADE LSR, which included 84 studies in October 2025, highlights that balance, resistance, and gait training are the key components within multicomponent programmes that most effectively prevent hospital-associated disability (HAD) in older adults during acute hospitalisation. 25 The multicomponent exercise programmes included in the SHADE LSR comprised balance, resistance, and gait training, and showed variation in design and implementation. Balance exercises typically included standing balance training on stable or unstable surfaces, as well as seated balance exercises tailored for patients with reduced physical capacity. 30 , 39 , 40 Resistance training was performed as mentioned for resistance training above. Gait training mostly involved walking, either with or without supervision or walking aid, in the hospital corridors. 29 , 40 , 41 Other walking exercises described in the LSR included stepping practice and navigating small obstacles. 32 , 42 The multicomponent exercise programmes reviewed did not specify how the proportion of each component was determined. Nor did they explain how the exercises and their load was adapted for different patient types or which safety measures were implemented. 3. Aim This project aims to develop two evidence- and consensus-based physical exercise programmes to prevent hospital-associated disability in hospitalised older adults: one focused on resistance training and the other on multicomponent training. 4. Objectives The first objective of this study is to reach consensus on the programme content, specifically the exercises designed to prevent HAD in older adults who are currently hospitalised or have been recently discharged. The second objective is to specify the exercise modalities, including the training frequency, duration, volume, load and speed, required to prevent HAD in these populations. The third objective is to identify safety parameters and implementation facilitator and barriers to these programmes. 5. Methods 5.1. Study design For our research, we will use a modified Delphi study design. 43 This project comprises two distinct Delphi studies, each dedicated to one exercise programme: the first focusing on resistance training and the second on a multicomponent exercise programme combining balance, resistance and gait training. This approach aims to achieve consensus on two exercise programmes designed to prevent HAD in patients within an acute hospital setting. This Delphi design is recognised as valuable for evidence-based practice, as it facilitates the incorporation of existing knowledge into practical guidelines. 44 Our methodology is modified from the typical Delphi study in that not all questions in the first round will be open-ended. This will enable the use of the knowledge acquired in the LSR. 1 5.2. Sampling Participants for both Delphi studies (i.e. resistance training only and multicomponent programme with a combination of balance, resistance and gait training) will be recruited using a non-probability purposive sampling strategy. 5.3. Sample size We consider the sample of participants to be homogeneous, since they will all be clinicians or researchers working with older people. A sample size of 10 to 15 participants is considered adequate for a homogeneous group. 45 We plan to include 30 participants per type of training programme (i.e. resistance training and a multicomponent exercise programme combining balance, resistance and gait training). A sample size of approximately 30 participants per group should ensure the generalisability of the results, even with a dropout rate of up to 20%. 43 , 46 5.4. Participant recruitment The participants on the expert panel will be clinicians, mostly, from various regions of Switzerland, including physiotherapists and sports scientists, who actively instruct physical exercise to older people. Snowball recruitment will be conducted. To recruit physiotherapists and sport scientists working in hospitals and rehabilitation centres, we will contact the heads of the medical and therapeutic services at hospitals and geriatric rehabilitation centres in Switzerland, asking them to forward our email to their employees. To recruit physiotherapists in private practice, we will ask the two Swiss physiotherapy associations, Physioswiss and the Swiss Association of Independent Physiotherapists (ASPI), to circulate an email to their members. We will also contact different physiotherapy rehabilitation community of interest, such as plateforme-Reha and Interessengemeinschaft Physiotherapie Rehabilitation Akutspital (IGPTR A) to find potential experts in different fields. We will proceed in the same way with the Swiss Associations of Professionals in Adapted Sports Activities (ASP-APA and Sportwissenschaft.ch). To ensure that we contact a wide range of people working in these fields, we will also contact Swiss associations active in Health Sport and Sports Therapy, such as Rheumaliga, Le Réseau Santé & Sport (LRSS), Allianz Bewegung, Sport und Gesundheit, Pro Senectute, Public Health Schweiz, Swissheart and Swisscardiotherapists. To approach Swiss researchers in this field, we will reach out to alumni and collaborators from universities working in this area and identify researchers through their published articles. Across all categories, we will also leverage our professional network, combining direct personal outreach with targeted promotion on LinkedIn. The recruitment will take place between October and November 2025. 5.5. Inclusion criteria for participant selection These two modified Delphi studies will be open to clinicians who instruct physical exercise to older people (over 65 years old) in facilities such as hospitals, rehabilitation centres, and private practices such as physiotherapists and sports scientists. Participants must have worked with this population for at least five years. 47 Researchers specialising in geriatrics and physical exercise with at least three publications in this field will also be eligible. 47 As the questions will be asked in English, participants should be able to understand basic written English to participate. Participants will be included in the study only after providing written consent immediately before Round 1 survey. They must also agree to the publication of their anonymised responses. 5.6 Establishment of the modified Delphi rounds In each modified Delphi study (i.e. resistance training only and multicomponent exercise programme with a combination of balance, resistance and gait training), we will conduct three rounds, as conducting between two and three rounds is recommended to avoid participant fatigue and ensure the relevance of the results. 43 To minimise attrition, we will keep the interval between the closure of one round and the start of the next as short as possible. 43 Two participation reminders will be sent during each round: one shortly before the initial deadline and another immediately after, granting participants an additional week to respond. The investigator team will use the browser-based research electronic data capture (REDCap) software 48 to develop the questionnaires for the three rounds, focusing on developing questions designed to achieve the objectives of each round. This software will also be used to gather and store the data. The questionnaires will be the same for all participants of one Delphi study. The study will start in November 2025 and should end before July 2026. 5.6.1. Round 1 The primary aim of the first modified Delphi round is to gather participants’ perspectives on the appropriateness of the exercise interventions identified in the ongoing LSR. 1 A secondary objective is to assess the levels of patient functional ability for which these interventions are suitable and to propose progression strategies and safety measures for each level. Additionally, this round will explore alternative exercise options and seek consensus on feasible implementation modalities. Finally, it will identify facilitators and barriers to implementing such training in a hospital setting from both clinician and patient reported perspectives. Participants will first be provided with an overview of the scientific evidence gathered in the LSR regarding physical exercise interventions for preventing hospital-associated disability (HAD) in hospitalised older adults. Following this, their demographic and professional data will be collected. Next, participants will evaluate the exercises identified in the studies included in our LSR for their suitability in a Swiss hospital setting for older adults with varying levels of functional ability. For these exercises, participants will indicate how they would adapt them for patients with different ability levels and specify the safety parameters to be included. They will also be invited to propose additional exercises appropriate for the respective training concept (i.e., resistance or multicomponent programme). Each exercise will be described in terms of its name, starting position, movement pattern, and instructions. During this first round, participants will also define the appropriate load for each ability level in hospitalised patients aged over 65 years. Similarly, expert consensus will be sought on training frequency, duration, exercise volume, contraction timing and proportion, as well as exercise type to determine their appropriateness for different patient profiles. Finally, clinicians and researchers will identify facilitators and barriers to implementing such exercise programmes for the prevention of HAD in older adults within a hospital setting. Due to the wide range of patients’ needs and capacities, we will use a predetermined classification system for patients based on the three-level dependency scale of the commonly used Barthel Index. This scale categorises patients as “severely dependent patient”, “moderately dependent patient” or “slightly dependent or independent patient”. 49 , 50 To facilitate responses, these different ability levels categories will be defined descriptively rather than by specific point thresholds on the Barthel Index: - Severely dependent: patient is unable to perform any or most ADLs without substantial help - Moderately dependent: patient can perform several ADLs independently or with minimal help - Slightly dependent or independent: patient is mostly independent In the first round of the present modified Delphi study, exercises consensus questions will be presented using Likert items with a six-point ordinal scale to minimise questionnaire length and reduce the risk of participants dropping out. Additionally, open-ended questions will be included to clarify sources of disagreement, identify missing exercises and explore possibilities regarding exercise modalities. Based on the results obtained, we will: i) compile a pool of potentially relevant exercises, ii) define a set of modalities for a preliminary exercise programme and iii) compile a pool of potential facilitators and barriers to implementing such exercise programmes for the prevention of HAD in older adults in a hospital setting. 5.6.2. Round 2 The second rounds of the modified Delphi study will aim to collect the participants’ opinion on the developed physical exercise programmes. To this end, we will present the results of the first round to the participants. For the consensus questions, the results will be summarised using the median and interquartile range (IQR) of the participants’ ratings. The key themes and concepts identified through the open-ended responses will be organised systematically and presented in a structured manner. Participants will be asked to indicate their level of agreement with the proposed exercises, their progression and safety measures using Likert items with a six-point ordinal scale. Participants will then be asked to do the same with the modality descriptions and the facilitators and barriers to implementing such exercise programmes for the prevention of HAD in older adults in a hospital setting. In case of disagreement, volunteering clinicians will be invited to suggest modifications or propose alternative approaches. The same question types as in round 1 (i.e. agreement questions using Likert items with a six-point ordinal scale and open text questions will be used to clarify disagreement). 5.6.3. Round 3 The aim of the third modified Delphi study round is to gather participants’ opinions on the revised physical exercise programme, modalities, facilitators and barriers to implementing such exercise programmes for the prevention of HAD in older adults in a hospital setting. The results of the consensus questions from round two will therefore be presented with summary statistics such as medians and IQR to the participants. Any elements that fail to reach consensus will be adapted and re-evaluated using the same procedure as in round two. 5.7 Data collection The electronic data collection system REDCap 48 will be used to collect and manage study’s data. REDCap surveys will first be tested by team members and colleagues not involved in developing the questions. This will provide feedback on completion time and comprehensibility. The surveys will then be adapted and sent to the participants via email. Participants’ identities will be coded, and access to these data will be restricted to the three main investigators and two bachelor students. All participants’ contact information will be permanently deleted upon completion of the study. 5.8 Data analysis The data from the modified Delphi studies will be reported in accordance with the reporting guidelines for Delphi techniques in health sciences, as proposed by Spranger et al. 51 We will use Likert items with a six-point ordinal scale, as this lies between four and seven categories that have been considered as optimal. 43 Given that participants are expected to constitute a homogeneous group with sufficient expertise to address all questions, a neutral “don’t know” response option will not be included. This approach is intended to encourage participants to take a definitive position on each item, thereby supporting the consensus-building process. 52 5.8.1. Quantitative analysis of the modified Delphi study rounds The characteristics of the participants, including their work setting, primary training, years of experience, age, and gender, will be presented in a table using mean values and their standard deviation. The number of participants in each round of the modified Delphi studies will be presented using a participant flow diagram. This diagram will visually represent participant retention and attrition across the different modified Delphi rounds. 5.8.1.1. Level of agreement In this study, consensus will be defined as the level of agreement, which will be measured as follows: Likert items with a six-point ordinal scale will be used to assess participants’ agreement or disagreement with each question in the questionnaire. Participants will be asked to indicate their level of agreement on a scale from 1 to 6 (1 = Very strongly agree, 2 = Strongly agree, 3 = Agree, 4 = Disagree, 5 = Strongly disagree, and 6 = Very strongly disagree). During the analysis phase, the Likert items with a six-point ordinal scale will be dichotomised as suggested by Limotai et al. (2020) as follows: i) responses 1 to 3 will be considered positive ii) responses 4 to 6 will be considered negative Our a priori criterion will be as follows: if more or equal to 80% of participants agree with a statement, we will assume that they are in favour of it, and it will be included in the final version of the training programme. Statements (e.g. type of exercise, duration, frequency, safety measures) will be included if approved by 80% of participants (Likert items: 1–3) and excluded if disapproved (Likert items: 4–6) by 50% or more of participants after each round of the modified Delphi studies. 53 All intermediate values will be included in the next round. We will also describe the distribution by providing the median and IQR for each task. Items for which no agreement was reached by the end of the three rounds will be presented separately, using the results from the third round. 5.8.1.2. Stability of response/internal reliability The stability of responses (i.e. referring to the level of agreement between rounds in the modified Delphi study and serving as a measure of reliability) will be reported using the median and interquartile range (IQR) across rounds. The stability of results will be determined using a Wilcoxon matched-pairs signed-rank test. 43 5.8.2. Qualitative analysis of the different modified Delphi study rounds For the open-ended questions, we will primarily apply an adapted version of the argument-based qualitative analysis strategy (AQUA), complemented by qualitative content analysis for those sections where AQUA cannot be applied due to the nature of the questions. 54 First, all responses will be read thoroughly to ensure familiarity with the content. Next, each response will be segmented into distinct arguments, translated into British English if originally written in German or French, and harmonised for language style. 54 Similar suggestions will then be grouped into categories using both inductive and deductive approaches, as outlined in qualitative content analysis, and ranked by frequency. 55 The arguments within each category will be condensed and summarised to identify core statements and establish links between similar ideas. 54 Two investigators will carry out this step separately and their results will be compared. If there is persistent conflict, a third person will intervene and make the final decision. The research group will then meet to decide which elements to include or exclude in the next round. Dissemination The findings of both Delphi studies will be disseminated through multiple academic and professional channels. Results will be published in open-access format on Zenodo ( https://zenodo.com ), including anonymised datasets, survey instruments, data analysis and final consensus outputs. In addition, both studies will be submitted for publication in a peer-reviewed journal. The authors will also apply for presentations or posters at conferences in the geriatric, rehabilitation and physiotherapy fields. No identifiable participant information will be disclosed in any dissemination activities. Ethics and consent This study was reviewed by the Cantonal Research Ethics Commission of Vaud (CER-VD), Switzerland, following a request for clarification (Req-2025-00928). The Commission confirmed that the project does not fall under the scope of the Swiss Federal Human Research Act (HRA). As such, authorisation from an ethics committee is not required. The study does not involve the collection of health-related data, and all procedures comply with applicable ethical standards for research not subject to the HRA. All participants will provide informed written consent prior to taking part in the study. Consent will be obtained through REDCap questionnaire immediately before the Round 1 survey. Study status The study began recruiting participants in October 2025. All participants provided written informed consent prior to their inclusion in accordance with the procedure described in this manuscript. Data collection for the first round started in November 2025 and concluded in January 2026. The data from the first round were analysed between January and March 2026. If new participants are included in rounds 2 or 3, written consent will be obtained prior to their participation. The study is expected to be completed by July 2026. Data availability No datasets have been generated or analysed for this study. This article describes a study protocol; therefore, no data are associated with this article. Reporting guidelines As no dedicated reporting guidelines exist for protocols of Delphi studies, this protocol has been structured according to the DELPHISTAR checklist, 56 applying the relevant items while acknowledging that not all elements are applicable to a protocol of a Delphi study. Zenodo: DELPHISTAR Checklist for a Delphi study protocol on physical exercise programmes to prevent hospital-associated disability in hospitalised older adults. https://doi.org/10.5281/zenodo.18865036 . 57 Data are available under the terms of the Creative Commons Attribution 4.0 International . Registration The protocol has been registered on Zenodo under the DOI 10.5281/zenodo.17524197 . 58 Extended data The following extended data are associated with this protocol and are available under a CC BY 4.0 licence: - Study information ( https://doi.org/10.5281/zenodo.19069168 ) 59 - Questionnaire for Delphi Round 1: one questionnaire for the resistance training programme and one for the multicomponent programme ( https://doi.org/10.5281/zenodo.18963663 ) 60 - DELPHISTAR checklist for a Delphi study protocol on physical exercise programmes to prevent hospital-associated disability in hospitalised older adults. ( https://doi.org/10.5281/zenodo.18865036 ) 57 The questionnaires for rounds 2 and 3 are not yet available, as they had not been developed at the time of this protocol’s submission. They will be uploaded to Zenodo at the end of each respective round. All uploaded data will be made available under a CC BY 4.0 licence. 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Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 18 Apr 2026 ADD YOUR COMMENT Comment Author details Author details 1 Institute of Health Sciences, School of Health Sciences, HES-SO Valais Wallis, Leukerbad, Valais, 3954, Switzerland 2 Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Rehabilitation Research (RERE) Research Group, Vrije Universiteit Brussel, Brussel, Brussels, Belgium 3 Independent researcher at Englisch-Gruss-Strasse 32, Haus Euklid, Glis, Valais, 3902, Switzerland Sophie Wist Roles: Conceptualization, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Roger Hilfiker Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Validation, Writing – Review & Editing Katia Giacomino Roles: Conceptualization, Funding Acquisition, Methodology, Writing – Review & Editing David Beckwée Roles: Conceptualization, Funding Acquisition, Methodology, Supervision, Validation, Writing – Review & Editing Karl Martin Sattelmayer Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Supervision, Validation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information This work was supported by the Swiss National Science Foundation grant number 220492. The sponsor is independent from the trial team and has no authority over this protocol or the coming trial. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (1) version 1 Published: 18 Apr 2026, 15:559 https://doi.org/10.12688/f1000research.178951.1 Copyright © 2026 Wist S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. 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