The reliability and validity of ultrasound to quantify muscles in older adults: a systematic review

Reliability and validity of ultrasound to estimate muscles: A comparison between different transducers and parameters

BACKGROUND AND AIMS

We aimed to investigate the test-retest reliability and validity of ultrasound for two commonly used types of transducer, using different methods for the estimation of muscle size and echo intensity (EI).

METHODS

Fourteen healthy adults were included in this study. Ultrasound images of the rectus femoris size (thickness in cm and cross-sectional area [CSA] in cm²), obtained at the mid-thigh, were validated against MRI. Both a linear and a curved array transducer were used to assess rectus femoris size and EI (values 0-255, higher scores indicating increased intramuscular fat and interstitial fibrous tissue). To assess test-retest reliability of ultrasound, participants were tested twice, with a one-week interval. Validity and reliability were evaluated using paired sample t-tests, intraclass correlation coefficient (ICC), and Bland-Altman plots.

RESULTS

No significant differences between the repeated evaluations of rectus femoris thickness, CSA and EI were found. Reliability for thickness and CSA evaluations was excellent for both transducers (ICC = 0.87-0.97) and moderate for EI (ICC = 0.42-0.44). Mean difference between MRI and ultrasound for CSA (curved = 0.59 cm², p = 0.086; linear = 2.1 cm², p = 0.002) and thickness (curved = 0.31 cm, p = 0.01; linear = 0.21 cm, p = 0.043) were small but significant, except for CSA using a curved transducer. Agreement between ultrasound and MRI ranged from moderate for thickness (ICC = 0.45) to excellent for CSA (ICC = 0.92).

CONCLUSIONS

Our study demonstrates that the test-retest reliability and validity of muscle size estimation by ultrasound for both curved and linear array transducers seems to be adequate. Future studies should focus on the longitudinal evaluation of muscle size and EI by ultrasound.

Sarcopenia: A Time for Action. An SCWD Position Paper

The term sarcopenia was introduced in 1988. The original definition was a "muscle loss" of the appendicular muscle mass in the older people as measured by dual energy x-ray absorptiometry (DXA). In 2010, the definition was altered to be low muscle mass together with low muscle function and this was agreed upon as reported in a number of consensus papers. The Society of Sarcopenia, Cachexia and Wasting Disorders supports the recommendations of more recent consensus conferences, i.e. that rapid screening, such as with the SARC-F questionnaire, should be utilized with a formal diagnosis being made by measuring grip strength or chair stand together with DXA estimation of appendicular muscle mass (indexed for height2). Assessments of the utility of ultrasound and creatine dilution techniques are ongoing. Use of ultrasound may not be easily reproducible. Primary sarcopenia is aging associated (mediated) loss of muscle mass. Secondary sarcopenia (or disease-related sarcopenia) has predominantly focused on loss of muscle mass without the emphasis on muscle function. Diseases that can cause muscle wasting (i.e. secondary sarcopenia) include malignant cancer, COPD, heart failure, and renal failure and others. Management of sarcopenia should consist of resistance exercise in combination with a protein intake of 1 to 1.5 g/kg/day. There is insufficient evidence that vitamin D and anabolic steroids are beneficial. These recommendations apply to both primary (age-related) sarcopenia and secondary (disease related) sarcopenia. Secondary sarcopenia also needs appropriate treatment of the underlying disease. It is important that primary care health professionals become aware of and make the diagnosis of age-related and disease-related sarcopenia. It is important to address the risk factors for sarcopenia, particularly low physical activity and sedentary behavior in the general population, using a life-long approach. There is a need for more clinical research into the appropriate measurement for muscle mass and the management of sarcopenia. Accordingly, this position statement provides recommendations on the management of sarcopenia and how to progress the knowledge and recognition of sarcopenia.

Physical Exercise in the Oldest Old

Societies are progressively aging, with the oldest old (i.e., those aged >80-85 years) being the most rapidly expanding population segment. However, advanced aging comes at a price, as it is associated with an increased incidence of the so-called age-related conditions, including a greater risk for loss of functional independence. How to combat sarcopenia, frailty, and overall intrinsic capacity decline in the elderly is a major challenge for modern medicine, and exercise appears to be a potential solution. In this article, we first summarize the physiological mechanisms underlying the age-related deterioration in intrinsic capacity, particularly regarding those phenotypes related to functional decline. The main methods available for the physical assessment of the oldest old are then described, and finally the multisystem benefits that exercise (or "exercise mimetics" in those situations in which volitional exercise is not feasible) can provide to this population segment are reviewed. In summary, lifetime physical exercise can help to attenuate the loss of many of the properties affected by aging, especially when the latter is accompanied by an inactive lifestyle and benefits can also be obtained in frail individuals who start exercising at an advanced age. Multicomponent programs combining mainly aerobic and resistance training should be included in the oldest old, particularly during disuse situations such as hospitalization. However, evidence is still needed to support the effectiveness of passive physical strategies including neuromuscular electrical stimulation or vibration for the prevention of disuse-induced negative adaptations in those oldest old people who are unable to do physical exercise. © 2019 American Physiological Society. Compr Physiol 9:1281-1304, 2019.

Enhanced Echo Intensity of Skeletal Muscle Is Associated With Exercise Intolerance in Patients With Heart Failure

BACKGROUND

Skeletal muscle is quantitatively and qualitatively impaired in patients with heart failure (HF), which is closely linked to lowered exercise capacity. Ultrasonography (US) for skeletal muscle has emerged as a useful, noninvasive tool to evaluate muscle quality and quantity. Here we investigated whether muscle quality based on US-derived echo intensity (EI) is associated with exercise capacity in patients with HF.

METHODS AND RESULTS

Fifty-eight patients with HF (61 ± 12 years) and 28 control subjects (58 ± 14 years) were studied. The quadriceps femoris echo intensity (QEI) was significantly higher and the quadriceps femoris muscle thickness (QMT) was significantly lower in the patients with HF than the controls (88.3 ± 13.4 vs 81.1 ± 7.5, P= .010; 5.21 ± 1.10 vs 6.54 ±1.34 cm, P< .001, respectively). By univariate analysis, QEI was significantly correlated with age, peak oxygen uptake (VO₂), and New York Heart Association class in the HF group. A multivariable analysis revealed that the QEI was independently associated with peak VO₂ after adjustment for age, gender, body mass index, and QMT: β-coefficient = -11.80, 95%CI (-20.73, -2.86), P= .011.

CONCLUSION

Enhanced EI in skeletal muscle was independently associated with lowered exercise capacity in HF. The measurement of EI is low-cost, easily accessible, and suitable for assessment of HF-related alterations in skeletal muscle quality.

MRI-Derived Biomarkers Related to Sarcopenia: A Systematic Review

BACKGROUND

MRI allows quantitatively assessing muscle quantity and quality.

PURPOSE

To summarize the role of MRI as a noninvasive technique for the identification of in vivo surrogate biomarker of sarcopenia.

STUDY TYPE

Systematic review.

POPULATION

In April 2019, a systematic literature search (Medline/EMBASE) was performed to identify articles on the topic at issue.

FIELD STRENGTH/SEQUENCE

No field strength or sequence restrictions.

ASSESSMENT

After a literature search, study design, aim, sample size, demographics, magnetic field strength, imaged body region, MRI sequences, and imaging biomarker were extracted.

STATISTICAL TESTS

Data are presented as frequencies and percentages.

RESULTS

From 69 records identified through search query, 18 articles matched the inclusion criteria. All articles were published from 2012 and had a mainly prospective design (14/18, 78%). Sample size ranged from 9 to 284 subjects, for a total of 1706 enrolled subjects. Healthy subjects were enrolled or retrospectively selected in 8/18 (44%) articles, corresponding to 658 (39%) healthy subjects. Magnetic field strength was 1.5 or 3T in 14/18 (78%) studies. The most analyzed body regions were the thigh (7/18, 39%) and the trunk (6/18, 33%). Stratifying studies according to their aim, 13/18 (72%) studies focused on muscle quality and quantity, 3/18 (17%) studies on outcome prediction, and 2/18 articles (11%) addressed both aims. A wide set of MRI biomarkers have been proposed. Muscle cross-sectional area was the most used for muscle quantity estimation, while quantitative biomarkers of muscle fat content or fiber architecture were proposed to assess muscle quality.

DATA CONCLUSION

The proposed biomarkers were assessed using different MRI sequences for different body regions in different subjects/patient cohorts, pointing out a lack of standardization on this topic. Future studies should test and compare the performance of proposed MRI biomarkers for sarcopenia characterization and quantification using a standardized experimental setup.

LEVEL OF EVIDENCE

1 Technical Efficacy Stage: 2 J. Magn. Reson. Imaging 2020;51:1117-1127.

Stiffness and echogenicity: Development of a stiffness-echogenicity matrix for clinical problem solving

The assessment of soft tissue stiffness is important to evaluate many neuromusculoskeletal conditions. Several tools have been proposed for the assessment of stiffness, but ultrasonography appears to be most practical. The reflection of ultrasound waves as it travels through tissue enables assessment of tissue echogenicity, which is influenced by the characteristics of the sound wave as well as the characteristics of the tissue through which it passes, such as the amount of fat and fibrous tissue. However, tissue stiffness is not directly proportional to its echogenicity. Hence evaluation of echogenicity, as a stand-alone technique, is inadequate to describe its mechanical properties. The aim of this manuscript is to present a method of combining echogenicity evaluation by ultrasound and stiffness evaluation by palpation to better describe the mechanical properties of muscle using a stiffness-echogenicity matrix.

Correlation between lower limb isometric strength and muscle structure with normal and challenged gait performance in older adults

BACKGROUND

Muscular parameters have been considered to influence gait of older adults, but it is still unclear which specific lower limb muscular parameters correlate with kinematics of overground and obstacle crossing in older adults.

RESEARCH QUESTION

What lower limb muscular parameters correlate and explain kinematics of overground walking and obstacle crossing ability in the elderly?

METHODS

Muscle structure was evaluated in 15 older individuals (75.4 ± 5 years) through measures of architecture (muscle thickness, fascicle length, and pennation angle) and muscle quality (echo intensity) from lower limb muscles (vastus lateralis, biceps femoris, rectus femoris, tibialis anterior, and gastrocnemius medialis). Muscle function was assessed through isometric strength of hip, knee and ankle joint muscles. Gait kinematics (toe and heel clearances, step length and gait speed) was evaluated during walking with and without obstacle crossing at preferred and maximal gait speeds. Correlation and regression analyses were performed considering a significance level of 0.05.

RESULTS

Isometric strength did not correlate with gait kinematics and gait speed. Tibialis anterior thickness correlated with lead limb toe clearance, and vastus lateralis thickness with gait speed and step length. Vastus lateralis echo intensity correlated with step length and gait speed.

SIGNIFICANCE

Tibialis anterior and vastus lateralis muscles deserve attention in physical training to improve gait of older adults. Specifically, tibialis anterior should receive more attention on exercise programs aiming at improvement of obstacle crossing, and knee extensors when aiming at improving gait speed and step length.

Ultrasound assessment of muscle mass in response to exercise training in chronic kidney disease: a comparison with MRI

BACKGROUND

Chronic kidney disease (CKD) is a catabolic condition associated with muscle wasting and dysfunction, which associates with morbidity and mortality. There is a need for simple techniques capable of monitoring changes in muscle size with disease progression and in response to interventions aiming to increase muscle mass and function. Ultrasound is one such technique; however, it is unknown how well changes in muscle cross-sectional area (CSA) measured using ultrasound relate to changes in whole muscle volume measured using magnetic resonance imaging. We tested whether rectus femoris CSA (RF-CSA) could be used as a valid indication of changes in quadriceps muscle volume as a single measure of muscle size and following a 12 week exercise intervention that resulted in muscle hypertrophy.

METHODS

Secondary analysis of data was collected from the ExTra CKD study (ISRCTN 36489137). Quadriceps muscle size was assessed from 36 patients with non-dialysis CKD before and after 12 weeks of supervised exercise that resulted in muscle hypertrophy.

RESULTS

Strong positive correlations were observed between RF-CSA and quadriceps volume at baseline (r² = 0.815, CI 0.661 to 0.903; P < 0.001) and following 12 week exercise (r² = 0.845, CI 0.700 to 0.923; P < 0.001). A moderate positive association was also observed between changes in RF-CSA and quadriceps following exercise training (rho = 0.441, CI 0.085 to 0.697; P = 0.015). Bland-Altman analysis revealed a small bias (bias 0.6% ± 12.5) between the mean percentage changes in RF-CSA and quadriceps volume but wide limits of agreement from -24 to 25.

CONCLUSIONS

Rectus femoris CSA appears to be a reliable index of total quadriceps volume as a simple measure of muscle size, both as a single observation and in response to exercise training in non-dialysis CKD patients.

The usefulness of muscle architecture assessed with ultrasound to identify hospitalized older adults with physical decline

BACKGROUND

Muscle mass and strength decline are known to be key factors in the development of physical incapacities in later life. These structural and functional declines are even more significant in older people during hospitalizations, increasing risk of falls, fractures, and loss of quality of life. In clinical daily practice, functional and muscular decline are assessed using the validated Short Physical Performance Battery (SPPB). Nevertheless, psychological conditions (pain, demotivation, depression) and temporary physical incapacities (e.g: hip fracture) during hospitalization can be significant barriers to evaluate these patients. Skeletal muscle ultrasound assessment could be an alternative in clinical daily practice since muscle architecture (MA) is related to poor muscle function. However, this potential objective and clinical tool is not yet implemented in geriatric setting during hospitalization. Our study aimed at: 1) comparing MA, muscle mass and strength measurements in hospitalized older adults with different functional levels, 2) evaluating the association between these measurements.

METHODS

Forty-four hospitalized older adults were divided in 2 groups: 21 Pre-Disabled (PDis (SPPB_score: 6-9): 81 ± 7 years old, SPPB_score:7.6 ± 1.1) and 23 Disabled (Dis (SPPB_score:<6): 83 ± 7 years old, SPPB_score:3.6 ± 1.6). SPPB, body mass (BM) and composition (bio-impedance), handgrip strength (HS, dynamometer) and MA (Pennation angle (PA), muscle thickness (MT); ultrasound) were evaluated.

RESULTS

Relative muscle strength (HS/BM: 0.28 ± 0.08 vs 0.34 ± 0.09 kg/kg), PA (10.6 ± 1.8 vs 12.3 ± 1.9°), and MT (16.4 ± 0.4 vs 19.2 0.4 mm) but not lean body mass were significantly different between Dis and PDis, respectively. Significant associations between PA and the SPPB_score (r² = 0.37) or walking speed (r² = 0.38); between SCF and walking speed (r² = -0.36); as well as between MT and SPPB_score (r² = 0.29), walking speed (r² = 0.30), LBM (r² = 0.382) or MMI (r² = 0.361) were observed.

CONCLUSION

Muscle architecture (proxy of muscle quality) and functional capacities/status of hospitalized older adults are related. Thus, ultrasound seems to be a potential useful and objective screening tool for clinicians to assess/prevent physical decline during hospitalization. Larger and/or longitudinal studies are needed to confirm our findings from a pilot pragmatic study.

Evaluation of the use of muscle condition score and ultrasonographic measurements for assessment of muscle mass in dogs

OBJECTIVE

To evaluate repeatability and reproducibility of muscle condition score (MCS) in dogs with various degrees of muscle loss; to compare MCS, muscle ultrasonographic measurements, and quantitative magnetic resonance (QMR) measurements; and to identify cutoff values for ultrasonographic measurements of muscle that can be used to identify dogs with cachexia and sarcopenia.

ANIMALS

40 dogs of various age, body condition score (BCS), and MCS.

PROCEDURES

A prospective cross-sectional study was conducted. Body weight, BCS, QMR measurements, thoracic radiographic measurements, and muscle ultrasonographic measurements were assessed once in each dog. The MCS for each dog was assessed 3 separate times by 4 separate raters.

RESULTS

For the MCS, overall κ for interrater agreement was 0.50 and overall κ for intrarater agreement ranged from 0.59 to 0.77. For both interrater and intrarater agreement, κ coefficients were higher for dogs with normal muscle mass and severe muscle loss and lower for dogs with mild and moderate muscle loss. The MCS was significantly correlated with age (r = -0.62), vertebral epaxial muscle score (VEMS; r = 0.71), forelimb epaxial muscle score (FLEMS; r = 0.58), and BCS (r = 0.73), and VEMS was significantly correlated (r = 0.84) with FLEMS. Cutoff values for identification of mild muscle loss determined by use of VEMS and FLEMS were 1.124 and 1.666, respectively.

CONCLUSIONS AND CLINICAL RELEVANCE

MCS had substantial repeatability and moderate reproducibility for assessment of muscle mass in dogs. Prospective studies of MCS, VEMS, and FLEMS for assessment of muscle mass in dogs are warranted.

Clinical and laboratory findings and survival time associated with cardiac cachexia in dogs with congestive heart failure

BACKGROUND

Cardiac cachexia, loss of muscle mass associated with congestive heart failure (CHF), is associated with increased morbidity and shorter survival times in people, but an association between cardiac cachexia and survival has not been reported in dogs.

OBJECTIVES

To determine the prevalence of cachexia and its associations with clinical, laboratory, and survival data in dogs with CHF.

ANIMALS

Two hundred sixty-nine dogs with CHF.

METHODS

Retrospective cohort study. Cachexia was defined by 1 of 2 definitions: (1) mild, moderate, or severe muscle loss or (2) weight loss of ≥5% in 12 months or less. Variables were compared between dogs with and without cachexia.

RESULTS

One hundred thirty of 269 dogs (48.3%) had cardiac cachexia based on muscle loss, whereas 67 of 159 dogs (42.1%) with pre-evaluation body weights had cachexia based on weight loss. Dogs with cachexia (based on muscle loss) were significantly older (P = .05), more likely to have a cardiac arrhythmia (P = .02), had higher chloride concentrations (P = .04), and had a lower body condition score (P < .001), hematocrit (P = .006), hemoglobin (P = .006), and albumin (P = .004) concentrations. On multivariable analysis, cachexia (P = .05), clinically important tachyarrhythmias (P < .001), azotemia (P < .001), and being under- or overweight (both P = .003) were associated with shorter survival times.

CONCLUSIONS AND CLINICAL IMPORTANCE

Cardiac cachexia in common in dogs with CHF and is associated with significantly shorter survival. This emphasizes the importance of preventing, diagnosing, and treating muscle loss in dogs with CHF.

Association Between Muscle Strength and Modeling Estimates of Muscle Tissue Heterogeneity in Young and Old Adults

OBJECTIVES

Assessing aging muscle through estimates of muscle heterogeneity may overcome some of the limitations of grayscale analyses. The objectives of this study included determining statistical model parameters that characterize muscle echogenicity and are associated with strength in younger and older participants.

METHODS

Thirty-three community-dwelling participants were assigned to younger and older groups. Quantitative B-mode ultrasound scanning of the rectus femoris and isometric grip strength testing were completed. Shape or dispersion parameters from negative binomial distribution, Nakagami, gamma, and gamma mixture models were fitted to the grayscale histograms.

RESULTS

The mean ages ± SDs of the younger and older groups were 24.0 ± 2.3 and 65.1 ± 6.5 years, respectively. Statistical model shape and dispersion parameters for the grayscale histograms significantly differed between the younger and older participants (P = .002-.006). Among all of the statistical models considered, the gamma mixture model showed the best fit with the grayscale histograms (χ² goodness of fit = 62), whereas the Nakagami distribution displayed the poorest fit (χ² goodness of fit = 2595). Grayscale values were significantly associated with peak grip strength force in younger adult participants (R²  = 0.36; P < .008). However, the negative binomial dispersion parameter k (adjusted R²  = 0.70; P < .001) and gamma shape parameter α (adjusted R²  = 0.68; P < .01) showed the highest associations with peak grip strength force in older adult participants.

CONCLUSIONS

The negative binomial dispersion parameter k and the gamma shape parameter α have clinical relevance for the assessment of age-related muscle changes. Statistical models of muscle heterogeneity may characterize the association between muscle tissue composition estimates and strength better than grayscale measures in samples of community-dwelling older adults.

Ultrasound-based detection of glucocorticoid-induced impairments of muscle mass and structure in Cushing's disease

PURPOSE

To investigate the glucocorticoid-induced impairments of muscle mass and structure in patients presenting different stages of steroid myopathy progression.

METHODS

Thirty-three patients (28 women) affected by active (N = 20) and remitted (N = 13) Cushing's disease were recruited and the following variables were assessed: walking speed, handgrip strength, total body and appendicular muscle mass by bioelectrical impedance analysis (BIA), thickness and echo intensity of lower limb muscles by ultrasonography.

RESULTS

The two groups of patients showed comparable values of both handgrip strength [median (interquartile range) values: active disease: 27.4 (7.5) kg vs. remitted disease: 26.4 (9.4) kg; P = 0.58] and walking speed [active disease: 1.0 (0.2) m/s vs. remitted disease: 1.1 (0.3) m/s; P = 0.43]. Also, the thickness of the four muscles and all BIA-derived sarcopenic indices were comparable (P > 0.05 for all comparisons) between the two groups. On the contrary, the echo intensity of vastus lateralis, tibialis anterior (lower portion), and medial gastrocnemius was significantly (P < 0.05 for all comparisons) higher in patients with active disease compared to patients with remitted disease. Finally, significant negative correlations were found in the whole group of patients between muscle echo intensity and muscle function assessments.

CONCLUSIONS

We provided preliminary evidence that the ultrasound-derived measurements of muscle thickness and echo intensity can be useful to detect and track the changes of muscle mass and structure in patients with steroid myopathy and we suggest that the combined assessment of muscle mass, strength, and performance should be systematically applied in the routine examination of steroid myopathy patients.

Ultrasound imaging for sarcopenia, spasticity and painful muscle syndromes

PURPOSE OF REVIEW

On the basis of its various advantages and the relevant awareness of physicians, ultrasound imaging has overwhelmingly taken its place in the scientific arena. This is true both from the side of daily clinical applications and also from the side of research. Yet, ultrasound provides real-time (diagnostic) imaging and (interventional) guidance for a wide spectrum of muscle disorders. In this regard, this review aims to discuss the potential/actual utility of ultrasound imaging in particular muscle disorders, that is, sarcopenia, spasticity and fibromyalgia/myofascial pain syndrome.

RECENT FINDINGS

Due to the aging population worldwide and the importance of functionality in the older population, mounting interest has been given to the diagnosis and management of sarcopenia in the recent literature. Likewise, several articles started to report that ultrasound imaging can be used conveniently and effectively in the early diagnosis and quantification of sarcopenia.For spasticity, aside from ultrasound-guided botulinum toxin injections, intriguing attention has been paid to sonographic evaluation of muscle architecture, echogenicity and elasticity in the follow-up of these chronic conditions.As regards painful muscle syndromes, quantitative ultrasound techniques have been shown to detect statistically significant differences between healthy controls and patients with myofascial pain syndrome.

SUMMARY

Ultrasound imaging seems to be a promising tool that indisputably deserves further research in the management of a wide range of muscle disorders. VIDEO ABSTRACT: http://links.lww.com/COSPC/A17.

The Role of Ultrasound as a Diagnostic Tool for Sarcopenia

Sarcopenia is the progressive loss of skeletal mass and strength, particularly in older adults, with consequent reduction in function and independence. Changing population demographics, have resulted in increased prevalence of sarcopenia and this is associated with a considerable economic burden. Whilst simple, effective, non-intrusive management of this condition exists, no routine diagnosis takes place either in the UK or in many other countries, partly due to an absence of pragmatic clinical diagnostic tools to support the early identification of the syndrome. This position paper aims to provide a short overview proposing the potential case for developing ultrasound as a new and alternative diagnostic tool for identifying sarcopenia.

A preliminary investigation of mechanisms by which short-term resistance training increases strength of partially paralysed muscles in people with spinal cord injury

STUDY DESIGN

Pretest-posttest design.

OBJECTIVES

To investigate mechanisms by which short-term resistance training (6 weeks) increases strength of partially paralysed muscles in people with spinal cord injury (SCI).

SETTING

Community-based setting, Sydney, Australia.

PARTICIPANTS

Ten community-dwelling people with partial paralysis of elbow flexor, elbow extensor, knee flexor or knee extensor muscles following SCI (range 5 months to 14 years since injury).

METHODS

Muscle architecture and strength were assessed before and after participants underwent a six week strength-training program targeting one partially paralysed muscle group. The outcome of primary interest was physiological cross sectional area (PCSA) of the trained muscle group measured using magnetic resonance imaging (MRI) and diffusion tensor imaging (DTI). Other outcomes were changes in mean muscle fascicle length, muscle volume, pennation angle, isometric strength and muscle strength graded on a 13-point scale.

RESULTS

The mean increase in maximal isometric muscle strength was 14% (95% CI, -3 to 30%) and 1.5 points (95% CI, 0.5 to 2.5) on the 13-point manual muscle test. There was no evidence of a change in muscle architecture.

CONCLUSION

This study is the first to examine the mechanisms by which voluntary strength training increases strength of partially paralysed muscles in people with SCI. The data suggest that strength gains produced by six weeks of strength training are not caused by changes in muscle architecture. This suggests short-term strength gains are due to increased neural drive or an increase in specific muscle tension.

Ultrasound measurement of rectus femoris muscle thickness as a quick screening test for sarcopenia assessment

INTRODUCTION

Sarcopenia is a geriatric syndrome related to loss of muscle mass and function, leading to disability, frailty and higher mortality. According to European Working Group on Sarcopenia in Older People (EWGSOP) the diagnosis of sarcopenia requires the assessment of muscle mass, muscle force and function, that is time-consuming and not easily at hand in everyday clinical practice. We propose the B-mode ultrasound measurement of muscle thickness as a quick screening test to assess the presence of sarcopenia.

METHODS

A cross-sectional study was realized, 119 patients (average age 82 years, 50.4% females) from the Department of Internal Medicine of the University Hospital of Siena (Italy) were enrolled. The diagnosis of sarcopenia was assessed according to EWGSOP criteria. Rectus femoris muscle (RFM) thickness (in cm) was measured by ultrasound B-mode scanning. Sensibility and specificity of the test was evaluated and Receiver Operating Analysis (ROC) was performed to assess the accuracy of the test.

RESULTS

Average RFM thickness was 0.78 ± 0.26, significantly lower in sarcopenic patients (0.55 ± 0.2 vs. 0.9 ± 0.3; Mann-Whitney; p < 0.001) and females (0.7 ± 0.3 vs 0.86 ± 0.3; Mann-Whitney; p < 0.001). The cut-off point of 0.7 cm for females and 0.9 cm for males was established as a threshold to assess the presence of sarcopenia by ultrasound. Sensibility of ultrasound measurement of RFM thickness was 100%, specificity 64%, positive predictive value (PPV) 64.3% and negative predictive value (NPV) 100%. ROC analysis was performed in order to quantify how accurately RFM thickness can discriminate between sarcopenia and non-sarcopenia state. AUC for all patients was 0.9 and after a comparative analysis for gender higher values for males (0.94 vs. 0.92) were observed.

CONCLUSION

We suggest a screening test for sarcopenia based on the ultrasound measurement of RFM thickness, as a not invasive and easy to perform method even in elderly patients with functional or cognitive impairment.

Regional and total muscle mass, muscle strength and physical performance: The potential use of ultrasound imaging for sarcopenia

OBJECTIVE

To evaluate the relationship between the regional and total muscle mass, muscle strength and physical performance, and also to investigate the affected muscles, their strength and physical performance with aging.

METHODS

A total of 145 healthy subjects were included for the cross-sectional descriptive study. Demographic data were obtained, and body composition was consecutively assessed by anthropometric methods, bioelectrical impedance analysis and ultrasound (muscle thickness, fascicule length and pennation angle). Functional status was assessed using hand grip strength and gait speed measurements.

RESULTS

Abdominal and thigh muscles were thinner and triceps muscle was thicker in older subjects when compared with younger ones. Age and grip strength were significant predictors for physical performance. Gait speed, grip strength and regional muscle measurements decreased with age at higher rates (26-28%), skeletal muscle mass index was affected at a lower rate (15%).

CONCLUSIONS

Low muscle strength and regional muscle measurements should be used to confirm the diagnosis of sarcopenia.

The added value of ultrasound muscle measurements in patients with COPD: An exploratory study

BACKGROUND AND AIMS

Malnutrition and sarcopenia are common nutrition (-related) disorders in patients with COPD and are associated with negative health outcomes and mortality. This study aims to correlate ultrasound measured rectus femoris size with fat-free mass and muscle function in patients with COPD.

METHODS

Patients with COPD, at the start of a pulmonary rehabilitation program, were asked to participate in this study. Rectus femoris (RF) size (thickness in cm, cross-sectional area [CSA] in cm²) was determined by ultrasound. Fat-free mass index (FFMI in kg/m²) was estimated with bioelectrical impedance analyses, using a disease-specific equation. Handgrip strength (HGS) was measured in kilograms and the five times sit to stand test (in seconds, higher scores indicating decreased strength) was performed to assess leg muscle power. The Incremental Shuttle Walk Test (ISWT, in m) was used to assess maximal exercise capacity.

RESULTS

In total, 44 patients with COPD (mean age 59.8 ± 8.6 years, 43% male, median FEV1%pred 37 [IQR = 23-52]) were included. Greater RF-CSA and thickness were associated with higher FFMI (r = 0.57, p < 0.001; r = 0.53, p = 0.003, respectively) and HGS (CSA r = 0.58, p < 0.001, thickness r = 0.48, p = 0.009). No significant correlations between RF-thickness, CSA, and leg muscle power were found (r = -0.33, p = 0.091; r = -0.35, p = 0.073, respectively). Furthermore, no correlation between RF size and maximal exercise capacity was observed (thickness r = 0.21, p = 0.297, CSA r = 0.22, p = 0.274).

CONCLUSIONS

This exploratory study shows that in patients with COPD, rectus femoris size is moderately correlated with FFMI and HGS. Future studies should focus on the role of ultrasound in evaluating nutritional status.

Low body mass index negatively affects muscle mass and intramuscular fat of chronic stroke survivors

Objective

Relationship between secondary changes in skeletal muscle and body weight in chronic stroke survivors has not yet been carefully examined. The objective of this study was to clarify the relationships between muscle mass, intramuscular fat, and body weight in chronic stroke survivors.

Methods

Seventy-two chronic stroke survivors participated in this study. Transverse ultrasound images were acquired using B-mode ultrasound imaging. Quadriceps muscle mass and intramuscular fat were assessed based on muscle thickness and echo intensity, respectively. We used a stepwise multiple regression analysis to identify the factors that were independently associated with the body mass index. We entered quadriceps thickness and echo intensity of the paretic and non-paretic sides into another stepwise multiple regression model to avoid multicollinearity. Age, sex, type of stroke, time since stroke, thigh length, number of medications, and an updated Charlson comorbidity index were included as the independent variables.

Results

The quadriceps thickness and echo intensity of the paretic and non-paretic sides were significantly independently associated with the body mass index: quadriceps thickness of the paretic side, β = 0.52; quadriceps thickness of the non-paretic side, β = 0.55; quadriceps echo intensity of the paretic side, β = −0.35; quadriceps echo intensity of the non-paretic side, β = −0.27).

Conclusions

Our results suggest that low body mass index is associated with loss of muscle mass and increased intramuscular fat on both the paretic and non-paretic sides of chronic stroke survivors. Further studies examining whether appropriate weight management, along with targeted rehabilitation programs aimed at increasing muscle mass and decreasing intramuscular fat, achieves good outcomes in chronic stroke survivors are warranted.

Effects of quadriceps muscle neuromuscular electrical stimulation in living donor liver transplant recipients: phase-II single-blinded randomized controlled trial

OBJECTIVE

To evaluate the efficacy of neuromuscular electrical stimulation on quadriceps muscle strength and thickness in liver transplantation patients.

DESIGN

Phase-II, randomized, parallel-group, allocation-concealed, assessor-blinded, single-center controlled trial.

SETTING

Inpatient rehabilitation sector.

SUBJECTS

Patients following living donor liver transplantation.

INTERVENTIONS

The quadriceps muscle stimulation and the control groups received bilateral muscle electrical stimulation on the quadriceps and tibialis anterior muscles, respectively. Neuromuscular electrical stimulation sessions in both groups were conducted for 30 minutes per session, once per day for five weekdays over four weeks by a physical therapist.

MAIN MEASURES

Quadriceps muscle strength and quadriceps muscle thickness.

RESULTS

Neuromuscular electrical stimulation was applied to the quadriceps muscles group ( n = 23) or the tibialis anterior muscle in the control group ( n = 22). The decrease in quadriceps muscle thickness differed significantly between both groups on postoperative day 30 (median -3 vs -8, P < 0.01). The changes in predicted quadriceps strength and 6 minutes walking distance were not significantly different between groups (quadriceps strength median -12% vs -5%, P = 0.40; 6 minutes walking distance median -18 vs -21 m, P = 0.74).

CONCLUSION

Neuromuscular electrical stimulation of the quadriceps muscle for liver transplantation recipients was able to maintain the quadriceps muscle thickness after surgery. Future larger scale studies are needed to consider the effectiveness of neuromuscular electrical stimulation and how to incorporate this intervention in the overall strategy of the physical therapy program.

Utility of four sarcopenia criteria for the prediction of falls-related hospitalization in older Australian women

Numerous sarcopenia definitions are not associated with increased falls-related hospitalization risk over 5 years to 9.5 years in older community-dwelling Australian women. Measures of muscle strength and physical function, but not appendicular lean mass (measured by dual-energy X-ray absorptiometry) may help discriminate the risk of falls-related hospitalization.

INTRODUCTION

The aim of this prospective, population-based cohort study of 903 Caucasian-Australian women (mean age 79.9 ± 2.6 years) was to compare the clinical utility of four sarcopenia definitions for the prediction of falls-related hospitalization over 9.5 years.

METHODS

The four definitions were the United States Foundation for the National Institutes of Health (FNIH), the European Working Group on Sarcopenia in Older People (EWGSOP), and modified FNIH (AUS-POP_F) and EWGSOP (AUS-POP_E) definitions using Australian population-specific cut points (< 2 SD below the mean of young healthy Australian women). Components of sarcopenia including muscle strength, physical function, and appendicular lean mass (ALM) were quantified using hand grip strength, timed-up-and-go (TUG), and dual-energy X-ray absorptiometry (DXA), respectively. Incident 9.5-year falls-related hospitalization were captured by linked data.

RESULTS

Baseline prevalence of sarcopenia according to FNIH (9.4%), EWGSOP (24.1%), AUS-POP_F (12.0%), and AUS-POP_E (10.7%) differed substantially. Sarcopenia did not increase the relative hazard ratio (HR) for falls-related hospitalization before or after adjustment for age (aHR): FNIH aHR 1.00 95%CI (0.69-1.47), EWGSOP aHR 1.20 95%CI (0.93-1.54), AUS-POP_F aHR 0.96 95%CI (0.68-1.35), and AUS-POP_E aHR 1.33 95%CI (0.94-1.88). When examining individual components of sarcopenia, only muscle strength and physical function but not ALM (adjusted for height² or BMI) were associated with falls-related hospitalization.

CONCLUSION

Current definitions of sarcopenia were not associated with falls-related hospitalization risk in this cohort of community-dwelling older Australian women. Finally, measures of muscle strength and physical function, but not ALM (measured by DXA) may help discriminate the risk of falls-related hospitalization.

Sarcopenia: revised European consensus on definition and diagnosis

Background

in 2010, the European Working Group on Sarcopenia in Older People (EWGSOP) published a sarcopenia definition that aimed to foster advances in identifying and caring for people with sarcopenia. In early 2018, the Working Group met again (EWGSOP2) to update the original definition in order to reflect scientific and clinical evidence that has built over the last decade. This paper presents our updated findings.

Objectives

to increase consistency of research design, clinical diagnoses and ultimately, care for people with sarcopenia.

Recommendations

sarcopenia is a muscle disease (muscle failure) rooted in adverse muscle changes that accrue across a lifetime; sarcopenia is common among adults of older age but can also occur earlier in life. In this updated consensus paper on sarcopenia, EWGSOP2: (1) focuses on low muscle strength as a key characteristic of sarcopenia, uses detection of low muscle quantity and quality to confirm the sarcopenia diagnosis, and identifies poor physical performance as indicative of severe sarcopenia; (2) updates the clinical algorithm that can be used for sarcopenia case-finding, diagnosis and confirmation, and severity determination and (3) provides clear cut-off points for measurements of variables that identify and characterise sarcopenia.

Conclusions

EWGSOP2's updated recommendations aim to increase awareness of sarcopenia and its risk. With these new recommendations, EWGSOP2 calls for healthcare professionals who treat patients at risk for sarcopenia to take actions that will promote early detection and treatment. We also encourage more research in the field of sarcopenia in order to prevent or delay adverse health outcomes that incur a heavy burden for patients and healthcare systems.

Relationship between endothelial function and skeletal muscle strength in community dwelling elderly women

BACKGROUND

The aim of this study is to determine whether there is correlation between endothelial function and skeletal muscle function measured by hand grip strength in elderly women.

METHODS

This cross-sectional study used data of NAMGARAM-2 cohort. The NAMGARAM-2 cohort consisted of a group of people living in three rural communities. They were enrolled for studies on activity limitation due to age-related musculoskeletal disorders including knee osteoarthritis, osteoporosis, and sarcopenia. They were residents aged 40 years or older. They agreed to participate in this cohort from March 2016 to May 2017. Peripheral endothelial function was assessed by reactive hyperaemia-peripheral arterial tonometry using EndoPAT2000 system. Hand grip strength was measured using a digital hand dynamometer.

RESULTS

Endothelial function index assessed by EndoPAT was worse in the low grip strength group than that in the normal group of elderly women (1.54 ± 0.51 in the low grip strength group vs. 1.77 ± 0.67 in the normal group, P = 0.003). There was a positive correlation between hand grip strength and endothelial function (r = 0.176, P = 0.007). On stepwise multivariate analysis, endothelial dysfunction (reactive hyperaemia-peripheral arterial tonometry index < 1.67) significantly increased the risk of low hand grip strength (odds ratio = 2.019; 95% confidence interval = 1.107-3.682; P = 0.022).

CONCLUSIONS

Endothelial function and skeletal muscle strength had a significant correlation in elderly women, providing additional support for the relevant role of vascular system in sarcopenia.

The evolution of body composition in oncology-epidemiology, clinical trials, and the future of patient care: facts and numbers

There is growing interest from the oncology community to understand how body composition measures can be used to improve the delivery of clinical care for the 18.1 million individuals diagnosed with cancer annually. Methods that distinguish muscle from subcutaneous and visceral adipose tissue, such as computed tomography (CT), may offer new insights of important risk factors and improved prognostication of outcomes over alternative measures such as body mass index. In a meta-analysis of 38 studies, low muscle area assessed from clinically acquired CT was observed in 27.7% of patients with cancer and associated with poorer overall survival [hazard ratio: 1.44, 95% CI: 1.32-1.56]. Therapeutic interventions such as lifestyle and pharmacotherapy that modify all aspects of body composition and reduce the incidence of poor clinical outcomes are needed in patients with cancer. In a meta-analysis of six randomized trials, resistance training exercise increased lean body mass assessed from dual-energy X-ray absorptiometry [mean difference (MD): +1.07 kg, 95% CI: 0.76-1.37; P < 0.001] and walking distance [MD: +143 m, 95% CI: 70-216; P < 0.001] compared with usual care control in patients with non-metastatic cancer. In a meta-analysis of five randomized trials, anamorelin (a ghrelin agonist) significantly increased lean body mass [MD: +1.10 kg, 95% CI: 0.35-1.85; P = 0.004] but did not improve handgrip strength [MD: 0.52 kg, 95% CI: -0.09-1.13; P = 0.09] or overall survival compared with placebo [HR: 0.99, 95% CI: 0.85-1.14; P = 0.84] in patients with advanced or metastatic cancer. Early screening to identify individuals with occult muscle loss, combined with multimodal interventions that include lifestyle therapy with resistance exercise training and dietary supplementation combined with pharmacotherapy, may be necessary to provide a sufficient stimulus to prevent or slow the cascade of tissue wasting. Rapid, cost-efficient, and feasible methods to quantify muscle and adipose tissue distribution are needed if body composition assessment is to be integrated into large-scale clinical workflows. Fully automated analysis of body composition from clinically acquired imaging is one example. The study of body composition is one of the most provocative areas in oncology that offers tremendous promise to help patients with cancer live longer and healthier lives.

Assessing sarcopenia with vastus lateralis muscle ultrasound: an operative protocol

BACKGROUND

Muscle ultrasound (MUS) has so far not been implemented for sarcopenia assessment in clinical geriatric practice due to allegedly low reproducibility of results in the absence of standardization of procedures. However, rigorous and standardized application of this technique yields highly reproducible results. Its application, especially if integrated with clinical evaluation and comprehensive geriatric assessment, proofs very useful for rapidly obtaining information on muscle mass and architecture.

OBJECTIVE

Here, we present a standardized protocol for performing right vastus lateralis (RVL) MUS and measuring parameters of muscle size and architecture.

METHODS

RVL muscle thickness (MT), fascicle length (FL), pennation angle (PA), echo-intensity (EI) and cross-sectional area (CSA) can be assessed with this protocol. A portable instrument equipped with a 5-cm long 3-11 mHz linear probe should be used with both B-mode real-time and extended-field-of-view (EFOV) techniques. Longitudinal B-mode and transverse EFOV images should be acquired during each exam, and analyzed with NIH-ImageJ software.

CONCLUSIONS

This operative protocol represents a good compromise between the feasibility of MUS in clinical settings and the need of obtaining precise measurements of muscle parameters. Future studies should verify the reproducibility of the proposed technique, and its correlation with appendicular lean mass and parameters of muscle function.

Ultrasound measurements of gastrocnemius muscle thickness in older people with sarcopenia

Background

Sarcopenia, defined as low muscle mass and low muscle strength and/or low physical performance, is affecting more and more people. The European Working Group on Sarcopenia in Older People has suggested the routine community screening. However, selecting the most suitable method to evaluate muscle mass to detect sarcopenia in community screening is a challenge. This study sought to analyze the correlation between ultrasound (US) measurements of the gastrocnemius muscle and low muscle mass, as defined by sarcopenia.

Methods

One hundred thirty-five elderly participants were enrolled. US measurements included muscle thickness (MT), fat thickness (FT), MT/body mass index (BMI), and MT/FT. The definition of low muscle mass was based on the proposal from the Asian Working Group for Sarcopenia, in which the cutoff values for low muscle mass were 7.0 kg/m² for men and 5.4 kg/m² for women using dual energy X-ray absorptiometry (DXA). The participants were divided into low and normal muscle mass groups. Participants with low muscle mass were divided into presarcopenia, sarcopenia, and severe sarcopenia groups.

Results

Those in the low muscle mass group were older and had lower weights and BMIs (P<0.05). In addition, MT and MT/BMI were lower in the low muscle mass group (P<0.05). Binary logistic regression analysis revealed that MT was the factor associated with low skeletal muscle mass (OR =0.001, P<0.001). ANOVA revealed that MT was not significantly different between subjects with presarcopenia, sarcopenia, and severe sarcopenia (F=1.69, P=0.192). Receiver operating characteristic curve analyses indicated that the cutoff value of the gastrocnemius MT for low muscle mass was 1.50 cm.

Conclusion

MT measured by US was identified as the factor associated with low skeletal muscle mass. Those with gastrocnemius MT less than 1.5 cm can be considered as low muscle mass.

Rectus femoris muscle mass evaluation by ultrasound: facilitating sarcopenia diagnosis in pre-dialysis chronic kidney disease stages

OBJECTIVES

We evaluated the validity and reliability of ultrasonography measurement of rectus femoris cross-sectional area compared to computed tomography in patients in pre-dialysis chronic kidney disease and analyzed the association between these measurements and the diagnosis of sarcopenia.

METHODS

One hundred patients with nondialysis chronic kidney disease were evaluated. Sarcopenia was defined using the criteria of the Foundation for the National Institutes of Health Sarcopenia Project (FNIH). The rectus femoris cross-sectional area was evaluated using ultrasonography and computed tomography.

RESULTS

The prevalence of sarcopenia was 29% according to the FNIH criteria. The difference in mean rectus femoris cross-sectional area by ultrasonography and computed tomography was 3.97 mm, with a strong correlation between the two methods (p<0.001). Bland-Altman plot analysis showed good agreement between computed tomography and ultrasonography. Rectus femoris cross-sectional area was significantly correlated with muscle strength (r=0.300, p=0.002), lean body mass in the upper limbs (r=0.286, p=0.004), and lean body mass in the lower limbs (r=0.271, p=0.006). The prevalence of sarcopenia was 12% (n=12) based on the definition of low muscle mass according to ultrasonography of the rectus femoris cross-sectional area.

CONCLUSION

Ultrasonography was demonstrated to be a valid and reliable method for evaluating the rectus femoris cross-sectional area in patients in pre-dialysis chronic kidney disease.

Structural and physical-functional deficits in lower limbs with fractures and treated surgically

Abstract Introduction: A fracture is a traumatic bone injury that can occur from a variety of causes. Although the repercussions of fractures on the musculoskeletal system are documented, studies with more comprehensive outcomes and later stages of injury are still scarce. Objective: To evaluate the structural and physical-functional adaptations in individuals who suffered unilateral lower limb fractures treated surgically. Methods: Thirty-two patients of both genders, aged between 18 and 59 years, with a diagnosis of unilateral fracture of the lower limb and hospital discharge of at least one year, participated in the study. The affected lower limb was compared to the healthy lower limb of all participants using the outcome measures: vastus lateral muscle thickness (ultrasonography), knee extension and flexion strength (isokinetic dynamometer), ankle dorsiflexion range of motion of the distance from the foot to the wall) and functional fitness of the lower limb (single and triple horizontal jump test). Results: Statistically significant differences were found between the limbs affected and not affected in the measurements of muscle thickness (p = 0.0001), knee extension force (p = 0.0094), dorsiflexion amplitude (p = 0.0004) and functional performance (p = 0.0094, single jump and = 0.0114, triple jump). In all significant outcomes, the values of the affected limb were smaller than that of the non-affected limb. The peak torque of the knee flexor muscles did not show a statistically significant difference between limbs (p = 0.0624). Conclusion: Individuals who have undergone a surgically treated unilateral fracture of the lower limb present important structural and physical-functional late changes in relation to the non-affected limb.

Muscle mass and intramuscular fat of the quadriceps are related to muscle strength in non-ambulatory chronic stroke survivors: A cross-sectional study

Objective

Improving muscle mass and intramuscular fat in the mid-thigh increases the muscle strength of the paretic and non-paretic limbs in ambulatory chronic stroke survivors. There is a remarkable decrease in muscle mass and muscle strength and an increase in intramuscular fat in the quadriceps of both limbs of non-ambulatory compared with ambulatory survivors. Therefore, given that paretic lower extremity function does not recover sufficiently in the chronic phase, it may be helpful to improve muscle mass and intramuscular fat to increase muscle strength in the quadriceps of non-ambulatory chronic stroke survivors. However, these relationships remain unclear. The purpose of this study was to clarify the relationships between muscle strength, muscle mass, and intramuscular fat of the quadriceps in non-ambulatory chronic stroke survivors.

Methods

Study design: A cross-sectional study.

Participants: Fifty non-ambulatory chronic stroke survivors.

Main outcome measures: Quadriceps muscle strength was measured using a handheld dynamometer. Transverse ultrasound images were acquired using B-mode ultrasound imaging. Muscle mass and intramuscular fat of the quadriceps were assessed based on muscle thickness and echo intensity, respectively.

Data analysis: Stepwise multiple regression analyses were used to identify the factors independently associated with the quadriceps muscle strength of the paretic and non-paretic limbs. To avoid multicollinearity, muscle thickness and echo intensity were entered into separate multiple regression models. Muscle thickness or echo intensity of the paretic or non-paretic limbs and other confounding factors were set as the independent variables.

Results

Muscle thickness was positively related and echo intensity was negatively related to the quadriceps muscle strength of the paretic and non-paretic limbs.

Conclusions

Muscle mass and intramuscular fat of the quadriceps are related to muscle strength in non-ambulatory chronic stroke survivors. Increasing muscle mass and decreasing intramuscular fat of the quadriceps of both limbs may improve muscle strength.

Muscular responses to testosterone replacement vary by administration route: a systematic review and meta-analysis

BACKGROUND

Inconsistent fat-free mass (FFM) and muscle strength responses have been reported in randomized clinical trials (RCTs) administering testosterone replacement therapy (TRT) to middle-aged and older men. Our objective was to conduct a meta-analysis to determine whether TRT improves FFM and muscle strength in middle-aged and older men and whether the muscular responses vary by TRT administration route.

METHODS

Systematic literature searches of MEDLINE/PubMed and the Cochrane Library were conducted from inception through 31 March 2017 to identify double-blind RCTs that compared intramuscular or transdermal TRT vs. placebo and that reported assessments of FFM or upper-extremity or lower-extremity strength. Studies were identified, and data were extracted and validated by three investigators, with disagreement resolved by consensus. Using a random effects model, individual effect sizes (ESs) were determined from 31 RCTs reporting FFM (sample size: n = 1213 TRT, n = 1168 placebo) and 17 reporting upper-extremity or lower-extremity strength (n = 2572 TRT, n = 2523 placebo). Heterogeneity was examined, and sensitivity analyses were performed.

RESULTS

When administration routes were collectively assessed, TRT was associated with increases in FFM [ES = 1.20 ± 0.15 (95% CI: 0.91, 1.49)], total body strength [ES = 0.90 ± 0.12 (0.67, 1.14)], lower-extremity strength [ES = 0.77 ± 0.16 (0.45, 1.08)], and upper-extremity strength [ES = 1.13 ± 0.18 (0.78, 1.47)] (P < 0.001 for all). When administration routes were evaluated separately, the ES magnitudes were larger and the per cent changes were 3-5 times greater for intramuscular TRT than for transdermal formulations vs. respective placebos, for all outcomes evaluated. Specifically, intramuscular TRT was associated with a 5.7% increase in FFM [ES = 1.49 ± 0.18 (1.13, 1.84)] and 10-13% increases in total body strength [ES = 1.39 ± 0.12 (1.15, 1.63)], lower-extremity strength [ES = 1.39 ± 0.17 (1.07, 1.72)], and upper-extremity strength [ES = 1.37 ± 0.17 (1.03, 1.70)] (P < 0.001 for all). In comparison, transdermal TRT was associated with only a 1.7% increase in FFM [ES = 0.98 ± 0.21 (0.58, 1.39)] and only 2-5% increases in total body [ES = 0.55 ± 0.17 (0.22, 0.88)] and upper-extremity strength [ES = 0.97 ± 0.24 (0.50, 1.45)] (P < 0.001). Interestingly, transdermal TRT produced no change in lower-extremity strength vs. placebo [ES = 0.26 ± 0.23 (-0.19, 0.70), P = 0.26]. Subanalyses of RCTs limiting enrolment to men ≥60 years of age produced similar results.

CONCLUSIONS

Intramuscular TRT is more effective than transdermal formulations at increasing LBM and improving muscle strength in middle-aged and older men, particularly in the lower extremities.

Development and validation of a clinically applicable score to classify cachexia stages in advanced cancer patients

BACKGROUND

Cachexia is a multifactorial syndrome that is highly prevalent in advanced cancer patients and leads to progressive functional impairments. The classification of cachexia stages is essential for diagnosing and treating cachexia. However, there is a lack of simple tools with good discrimination for classifying cachexia stages. Therefore, our study aimed to develop a clinically applicable cachexia staging score (CSS) and validate its discrimination of clinical outcomes for different cachexia stages.

METHODS

Advanced cancer patients were enrolled in our study. A CSS comprising the following five components was developed: weight loss, a simple questionnaire of sarcopenia (SARC-F), Eastern Cooperative Oncology Group, appetite loss, and abnormal biochemistry. According to the CSS, patients were classified into non-cachexia, pre-cachexia, cachexia, and refractory cachexia stages, and clinical outcomes were compared among the four groups.

RESULTS

Of the 297 participating patients, data from 259 patients were ultimately included. Based on the CSS, patients were classified into non-cachexia (n = 69), pre-cachexia (n = 68), cachexia (n = 103), and refractory cachexia (n = 19) stages. Patients with more severe cachexia stages had lower skeletal muscle indexes (P = 0.002 and P = 0.004 in male and female patients, respectively), higher prevalence of sarcopenia (P = 0.017 and P = 0.027 in male and female patients, respectively), more severe symptom burden (P < 0.001), poorer quality of life (P < 0.001 for all subscales except social well-being), and shorter survival times (P < 0.001).

CONCLUSIONS

The CSS is a simple and clinically applicable tool with excellent discrimination for classifying cachexia stages. This score is extremely useful for the clinical treatment and prognosis of cachexia and for designing clinical trials.

Preoperative sarcopenia and post-operative accelerated muscle loss negatively impact survival after resection of pancreatic cancer

BACKGROUND

Sarcopenia and post-operative accelerated muscle loss leading to cachexia are commonly observed in patients with pancreatic cancer. This study aimed to assess the influence of body compositions and post-operative muscle change on survival of patients with surgically treated pancreatic cancer.

METHODS

We analysed data of patients diagnosed with pancreatic adenocarcinoma who underwent surgery from 2008 to 2015. Skeletal muscle areas, muscle attenuation, and visceral and subcutaneous adipose tissue areas were measured from two sets of computed tomography images at L3 vertebral levels. In addition, muscle change was calculated from images obtained before and after cancer resection. We set our own cut-off values of various body compositions based on sex-specific tertiles.

RESULTS

A total of 180 patients were analysed. Patients with perioperative sarcopenia (n = 60) showed poorer overall survival than those without perioperative sarcopenia (P = 0.031). Fifty (28.6%) patients with accelerated muscle loss after surgery (>10%/60 days) had poorer survival compared with the others (P = 0.029). Sarcopenia (hazard ratio, 1.79: 95% confidence interval, 1.20-2.65] and post-operative muscle change (%/60 days) (hazard ratio, 0.94: 95% confidence interval, 0.92-0.96) were identified as significant predictors of survival on multivariable analyses.

CONCLUSIONS

Preoperative sarcopenia identified on CT scan was associated with poor overall survival in patients with pancreatic cancer following surgery. Accelerated muscle loss after surgery also negatively impacted survival in pancreatic cancer patients.

DXA-Rectified Appendicular Lean Mass: Development of Ultrasound Prediction Models in Older Adults

OBJECTIVE

Dual-energy X-ray absorptiometry (DXA)-derived appendicular lean soft tissue mass (aLM) is used to diagnose sarcopenia. However, DXA-derived aLM includes non-skeletal muscle components, such as fat-free component of adipose tissue fat cell. These components, if not accounted for, could falsely inflate the aLM in individuals with a high amount of adipose tissue mass. B-mode ultrasound accurately measures muscle size in older adults. We sought to develop regression-based prediction equations for estimating DXA-rectified appendicular lean tissue mass (i.e. DXA-derived aLM minus appendicular fat-free adipose tissue (aFFAT); abbreviated as aLM minus aFFAT) using B-mode ultrasound.

DESIGN

Cross-sectional study.

MEASUREMENTS

Three hundred and eighty-nine Japanese older adults (aged 60 to 79 years) volunteered in the study. aLM was measured using a DXA, and muscle thickness (MT) was measured using ultrasound at nine sites. An ordinary least-squares multiple linear regression model was used to predict aLM minus aFFAT from sex, age and varying muscle thicknesses multiplied by height. Based on previous studies, we chose to use 4 MT sites at the upper and lower extremities (4-site MT model) and a single site (1-site MT model) at the upper extremity to develop prediction models.

RESULTS

The linear prediction models (4 site MT model; R2 = 0.902, adjusted R2 = 0.899, and 1-site MT model; R2 = 0.868, adjusted R2 = 0.866) were found to be stable and accurate for estimating aLM minus aFFAT. Bootstrapping (n=1000) resulted in optimism values of 0.0062 (4-site MT model) and 0.0036 (1-site MT model).

CONCLUSION

The results indicated that ultrasound MT combined with height, age and sex can be used to accurately estimate aLM minus aFFAT in older Japanese adults. Newly developed ultrasound prediction equations to estimate aLM minus aFFAT may be a valuable tool in population-based studies to assess age-related rectified lean tissue mass loss.

The reliability and validity of ultrasound to quantify muscles in older adults: a systematic review

This review evaluates the reliability and validity of ultrasound to quantify muscles in older adults. The databases PubMed, Cochrane, and Cumulative Index to Nursing and Allied Health Literature were systematically searched for studies. In 17 studies, the reliability (n = 13) and validity (n = 8) of ultrasound to quantify muscles in community-dwelling older adults (≥60 years) or a clinical population were evaluated. Four out of 13 reliability studies investigated both intra-rater and inter-rater reliability. Intraclass correlation coefficient (ICC) scores for reliability ranged from -0.26 to 1.00. The highest ICC scores were found for the vastus lateralis, rectus femoris, upper arm anterior, and the trunk (ICC = 0.72 to 1.000). All included validity studies found ICC scores ranging from 0.92 to 0.999. Two studies describing the validity of ultrasound to predict lean body mass showed good validity as compared with dual-energy X-ray absorptiometry (r²  = 0.92 to 0.96). This systematic review shows that ultrasound is a reliable and valid tool for the assessment of muscle size in older adults. More high-quality research is required to confirm these findings in both clinical and healthy populations. Furthermore, ultrasound assessment of small muscles needs further evaluation. Ultrasound to predict lean body mass is feasible; however, future research is required to validate prediction equations in older adults with varying function and health.