The ultrasonographic measurement of muscle thickness in sarcopenia. A prediction study

Skeletal muscle as a pro- and anti-inflammatory tissue: insights from children to adults and ultrasound findings

Previously regarded as a movement and posture control agent, the skeletal muscle is now recognized as an endocrine organ that may affect systemic inflammation and metabolic health. The discovery of myokines such as IL-6, released from skeletal muscle in response to physical exercise, is now one of the most recent insights. Myokines are the mediators of the balance between the pro-inflammatory and anti-inflammatory responses. This underscores the muscle function as a determinant of good health and prevention of diseases. Advances in ultrasound technology improved evaluation of muscle thickness, composition, and determining fat distribution. Combining imaging with molecular biology, researchers discovered the complicated interplay between muscle function, cytokine production and general health effects.The production of myokines with exercise showcasing the adaptability of muscles to high-stress conditions and contributing to metabolism and inflammation regulation. These findings have significant implications in order to provide improvement in metabolic and inflammatory diseases.

Evaluation of the Anatomical Cross-Sectional Area of Psoas Major Muscle Using an Ultrasound Imaging System Combined With an Inertial Measurement Unit: Improved Reliability in the US Using IMU-Based Positioning Techniques

Introduction: Recently, ultrasound (US) imaging has been used to estimate the cross-sectional area of skeletal muscle, but the reliability is uncertain. To improve the reliability of the US, we investigated skeletal muscle thickness measurement using an inertial measurement unit (IMU) to determine the direction of US beam incidence based on posture angle information. In addition, we examined whether the anatomical cross-sectional area (ACSA) of muscle can be estimated from the muscle thickness measured using the US with the IMU. Methods: In Experiment 1, two examiners measured the right psoas major at the fourth lumbar vertebra level in 10 university students using the US with and without an IMU. The intraclass correlation coefficient (ICC) was used to examine intra- and inter-rater variability. In Experiment 2, the two examiners measured the muscle thickness of the right psoas major in 31 male subjects using the US with an IMU. In addition, the ACSA of this muscle was measured using MRI. Pearson's correlation coefficient was used to examine the relationship between muscle thickness and ACSA, and a single regression analysis was performed. Results: Both intrarater reliability ICC (1, 2) and inter-rater reliability ICC (2, 2) were higher when US was used with IMU compared to without IMU (Experiment 1). A significant positive correlation (r = 0.84, p < 0.01) was observed between muscle thickness and ACSA (Experiment 2). The regression equation was significant at R 2 = 0.71 (p < 0.01). Conclusion: Using an IMU during US measurement of the psoas major improves intra- and interexaminer reliability and can be used to estimate the ACSA of the muscle.

Evaluation of quadriceps muscle cross-sectional area using an ultrasonic diagnostic equipment with a wide field of view

Skeletal muscle index measurement via dual-energy X-ray absorptiometry or bioelectrical impedance analysis is used to evaluate muscle mass when diagnosing sarcopenia. However, inherent challenges exist with these methods. We previously focused on muscle mass evaluation in the quadriceps femoris by using computed tomography (CT). In this observational study, we utilized a new ultrasound device with a wide field of view that can obtain CT-like images and investigated its usefulness. Reproducibility was investigated by calculating the intra- and inter-examiner intraclass correlation coefficient (ICC) by using three examiners and performing five measurements in 12 participants. In 123 participants (48 men, 75 women, mean age 78.2 ± 8.1 years), we investigated the correlation between the quadriceps cross-sectional area measured with supine ultrasound and CT images as well as between supine and sitting ultrasound images. Unadjusted, age-adjusted, and age-sex-adjusted correlations were calculated. Reproducibility was excellent (intra-examiner ICC[1,1]: 0.978, 0.987, and 0.994; inter-examiner ICC[2,1]: 0.993). The unadjusted, age-adjusted, and age-sex-adjusted correlations between the quadriceps cross-sectional area measured using supine ultrasound and CT were 0.949, 0.940, and 0.894, respectively. For sitting ultrasound, the corresponding values were 0.958, 0.953, and 0.912, respectively. Correlations between the supine and sitting ultrasound measurements were also good, with corresponding values of 0.952, 0.945, and 0.904, respectively. The tested ultrasound device showed excellent measurement reproducibility and had good correlations with CT images. Further studies with an increased numbers of clinical cases and additional evaluations should allow the device to become a screening tool for diagnosing sarcopenia.

Ultrasound for body composition assessment: a narrative review

Ultrasound has become an increasingly valuable tool for the assessment of body composition, offering several applications and indications in clinical practice. Ultrasound allows bedside evaluation of muscle mass, fat compartments, and extravascular water, providing a cost-effective, portable, and accessible alternative to traditional methods, such as Dual-energy X-ray Absorptiometry (DEXA), Bioelectrical Impedance Analysis (BIA), Computed Tomography (CT), and Magnetic Resonance Imaging (MRI). It is particularly useful in evaluating conditions, such as malnutrition, sarcopenia, and sarcopenic obesity, which require poor muscle mass to establish a diagnosis. The potential uses of ultrasound in body composition assessment include measurement of muscle thickness, cross-sectional area, pennation angle, and echo-intensity, which are indicative of muscle health. Additionally, ultrasound can be used to evaluate various fat compartments, including visceral, subcutaneous, and ectopic fat, which are important for understanding metabolic health and cardiovascular risk. However, the widespread adoption of ultrasound is challenged by the lack of standardized measurements and the absence of ultrasound measures in the validated diagnostic criteria. This article reviews the current applications of ultrasound in body composition assessment, highlighting the recent advancements and the correlation between ultrasound parameters and clinical outcomes. It discusses the advantages of ultrasound while also addressing its limitations, such as the need for standardized protocols and cut-off points. By providing a comprehensive update based on recent publications, this article aims to enhance the clinical utility of ultrasound in assessing and monitoring body composition and pave the way for future research in this field.

Ultrasound Cut-Off Values for Rectus Femoris for Detecting Sarcopenia in Patients with Nutritional Risk

BACKGROUND

A nationwide, prospective, multicenter, cohort study (the Disease-Related caloric-protein malnutrition EChOgraphy (DRECO) study) was designed to assess the usefulness of ultrasound of the rectus femoris for detecting sarcopenia in hospitalized patients at risk of malnutrition and to define cut-off values of ultrasound measures.

METHODS

Patients at risk of malnutrition according to the Malnutrition Universal Screening Tool (MUST) underwent handgrip dynamometry, bioelectrical impedance analysis (BIA), a Timed Up and Go (TUG) test, and rectus femoris ultrasound studies. European Working Group on Sarcopenia in Older People (EWGSOP2) criteria were used to define categories of sarcopenia (at risk, probable, confirmed, severe). Receiver operating characteristic (ROC) and area under the curve (AUC) analyses were used to determine the optimal diagnostic sensitivity, specificity, and predictive values of cut-off points of the ultrasound measures for the detection of risk of sarcopenia and probable, confirmed, and severe sarcopenia.

RESULTS

A total of 1000 subjects were included and 991 of them (58.9% men, mean age 58.5 years) were evaluated. Risk of sarcopenia was detected in 9.6% patients, probable sarcopenia in 14%, confirmed sarcopenia in 9.7%, and severe sarcopenia in 3.9%, with significant differences in the distribution of groups between men and women (p < 0.0001). The cross-sectional area (CSA) of the rectus femoris showed a significantly positive correlation with body cell mass of BIA and handgrip strength, and a significant negative correlation with TUG. Cut-off values were similar within each category of sarcopenia, ranging between 2.40 cm2 and 3.66 cm2 for CSA, 32.57 mm and 40.21 mm for the X-axis, and 7.85 mm and 10.4 mm for the Y-axis. In general, these cut-off values showed high sensitivities, particularly for the categories of confirmed and severe sarcopenia, with male patients also showing better sensitivities than women.

CONCLUSIONS

Sarcopenia in hospitalized patients at risk of malnutrition was high. Cut-off values for the better sensitivities and specificities of ultrasound measures of the rectus femoris are established. The use of ultrasound of the rectus femoris could be used for the prediction of sarcopenia and be useful to integrate nutritional study into real clinical practice.

Correlation of ultrasound measurement of limb muscle thickness and echo intensity with frailty assessment in elderly patients undergoing malignancies surgery

Introduction

It remains controversial which frailty score correlates with adverse outcomes. Instead of these subjective and time consuming scores, we studied whether ultrasound guided lower extremity thickness measurements more closely are associated with adverse outcomes.

Method

Patients undergoing gastrointestinal malignancy surgery were included as study subjects. Frailty was identified using the FRAIL scale assessment. Ultrasound measured the muscle thickness and echo intensity of the patient's upper and lower limbs. ANOVA was used to analyze the relationship between muscle data and frailty assessment. Significant indicators from the one-way analysis were included in the multivariate logistic regression equation.

Results

A total of 160 study subjects were included, 52 in the normal group, 78 in the prefrailty group, and 30 in the frailty group. The ANOVA showed that there were significant differences in age, hemoglobin, albumin, history of hypertension, history of coronary artery disease, the history of cerebrovascular disease, rate of postoperative complications, rate of transferring to intensive care unit, time out of bed, length of hospitalization, thickness and echo intensity of quadriceps femoris the vastus lateralis and the tibialis anterior, echo intensity of the medial gastrocnemius among the three groups (P < 0.05). Pearson's correlation analysis showed FRAIL score was correlated with muscle thickness and echo intensity of the lower limbs. Multifactor logistic regression analysis showed that the prefrailty group was positively correlated with age（β = 0.146, P = 0.004）, echo intensity of the medial gastrocnemius (β = 0.055, P = 0.031), and rate of postoperative complications（β = 1.439, P = 0.021）, also negatively correlated with muscle thickness of the tibialis anterior（β = -2.124, P = 0.007）. The frailty group was positively correlated with age（β = 0.22, P = 0.005）, tibialis anterior echo intensity (β = 0.082, P = 0.015), medial gastrocnemius echo intensity (β = 0.089, P = 0.026), cerebrovascular disease history (β = 2.311, P = 0.04), and postoperative complication rate (β = 2.684, P = 0.003). It was negatively correlated with albumin (β = -0.26, P = 0.017), quadriceps muscle thickness (β = -2.257, P = 0.017), and tibialis anterior muscle thickness (β = -5.408, P = 0.001).

Conclusion

Ultrasound measurement of lower (not upper) extremity muscle thickness and echo intensity was significantly associated with discriminating severity of frailty and postoperative outcomes than frailty scores in elderly patients.

The value of ultrasound measurement of muscle thickness at different sites and shear wave elastography in Parkinson's disease with sarcopenia: a pilot study

Background

Patients with Parkinson's disease (PD) and sarcopenia often exhibit resilience, frailty, disability, and depression, highlighting the complex and interrelated nature of these conditions.

Objective

Despite the presence of clinical manifestations of muscle atrophy in both PD and sarcopenia, accurately discerning the coexistence of sarcopenia in PD patients remains a challenging task with significant implications for treatment strategies and prognostic assessments. This study aims to elucidate the specific ultrasonic diagnostic parameters associated with PD accompanied by sarcopenia through a comparative analysis of muscle ultrasound parameters in patients with PD, thereby presenting a novel approach for rapid identification of this condition.

Methods

A total of 110 participants were enrolled in this study, including patients with PD and control subjects. Demographic data, clinical characteristics, physical performance tests, appendicular skeletal muscle mass index (ASMI), bioelectrical impedance analysis and muscle ultrasound measurements were collected from all participants. The muscle ultrasound measurements encompassed assessments of muscle thickness, pennation angle and shear wave elastography at various anatomical sites.

Results

Parkinson's disease patients exhibited decreased muscle strength and physical performance, and increased shear wave elastography value. In PD patients with sarcopenia, body circumference, including calf circumference, mid-arm circumference, Waist-to-Hip Ratio and body mass index (BMI) were all significantly decreased. Biceps brachii muscle thickness (MT) and gastrocnemius MT decreased in PD patients with sarcopenia and low ASMI. Binary logistic regression analysis revealed that male PD patients, BMI and gastrocnemius MT were predictive factors for ASMI in PD patients.

Conclusion

Biceps brachii MT and gastrocnemius MT are important indicators for distinguishing whether PD patients have sarcopenia. Male patients, low BMI and gastrocnemius MT were identified as valid predictors of low ASMI in PD patients. The findings of this study provide important insights into the use of muscle ultrasound in the diagnosis of PD with sarcopenia.

Suitable ultrasound screening method for older adults with disability to identify low muscle mass

Objective

This study aimed to investigate the accuracy and consistency of different ultrasound protocols for the measurement of gastrocnemius muscle (GM) thickness and to identify a suitable ultrasound scheme that can be used to detect the low muscle mass in older with disability.

Materials and methods

In this cross-sectional study, each participant underwent three different ultrasound protocols for the measurement of the GM thickness, and each measurement was repeated three times. The three measurement schemes were as follows: method A, lying on the examination bed in a prone position with legs stretched and relaxed and feet hanging outside the examination bed; method B, lateral right side lying position with legs separated (left leg flexed and right leg in a relaxed state); and method C, right side lying position with legs together and lower limb muscles in a relaxed state. The low muscle mass was determined by averaging two or three measurements of the GM thickness determined using different sonographic protocols.

Results

The study included 489 participants. The difference in the prevalence of low muscle mass identified between two and three replicates of the same measurement protocol ranged from 0 to 1.3%. Considering the three repeated measurements of the method A as the reference, the area under the curve (AUC) in different measurement schemes were 0.977-1 and 0.973-1 in males and females, respectively. Furthermore, male and female Kappa values from low to high were 0.773, 0.801, 0.829, 0.839, and 0.967 and 0.786, 0.794, 0.804, 0.819, and 0.984, respectively.

Conclusion

Different ultrasound measurement protocols showed high accuracy and consistency in identifying low muscle mass. Repeating the measurements two or three times was found to be feasible.

Value of conventional ultrasound and shear wave elastography in the assessment of muscle mass and function in elderly people with type 2 diabetes

OBJECTIVES

We assessed muscle mass and function using ultrasound (US) and shear wave elastography (SWE) for sarcopenia in elderly patients with type 2 diabetes.

METHODS

There were 84 patients with type 2 diabetes enrolled in this study; of these, 30 had sarcopenia and 54 did not. We measured appendicular skeletal muscle mass index (ASMI), handgrip strength, calf circumference, 6-m walking speed, and 5-time chair stand test. All patients were in the supine position with their knees in straight and bent poses in turn. The US-derived thickness (Tstraight, Tbent), cross-sectional area (CSAstraight, CSAbent), and SWE (SWEstraight, SWEbent) of the rectus femoris muscle (RFM) were measured and the differences (ΔT, ΔCSA, ΔSWE) were calculated. We assessed the correlations of clinical indicators with US and SWE features. We then compared the clinical indicators and US and SWE features between patients with and without sarcopenia to determine independent predictors. Diagnostic models were established based on these independent predictors.

RESULTS

The ASMI was correlated with Tbent (r = 0.57, p < 0.001) and CSAbent (r = 0.50, p < 0.001). Handgrip strength was correlated with Tbent (r = 0.53, p < 0.001) and CSAbent (r = 0.51, p < 0.001). Between patients with and without sarcopenia, the indicators of age, ΔCSA, and ΔSWE were statically different (all p ≤ 0.001). Based on these results, a diagnostic model for sarcopenia was established with 83.3% sensitivity, 83.3% specificity, and 83.3% accuracy.

CONCLUSIONS

In elderly people with type 2 diabetes, sarcopenia patients had smaller muscle CSA and less stiffness than non-sarcopenia patients. US and SWE might be useful to screen them.

KEY POINTS

• Sarcopenia is common in elderly people with type 2 diabetes. • Ultrasound and shear wave elastography might be useful methods for quantitatively assessing muscle mass and strength. • Ultrasound and shear wave elastography might be useful methods for screening sarcopenia in elderly patients with type 2 diabetes.

Preliminary Study: Short-term Beneficial Effects of Thai Tok Sen Massage on Pain, Pressure Pain Threshold, and Upper Trapezius Muscle Thickness Among People with Shoulder Pain

Background

Shoulder muscle pain and spasm is the most common problem in people after prolonged working, similar to that resulting from office syndrome. Various medicinal treatments with analgesic drugs, hot packs, therapeutic ultrasound, or deep friction techniques can be clinically applied. Alternatively, traditional Thai massage (TM) with deep compression gentle technique also can help to release that problem. In addition, an traditional Thai treatment with Tok Sen (TS) massage has been generally performed in the Northern part of Thailand without any scientific evidence support. Thus, the aim of this preliminary study was to reveal the scientific value of Tok Sen massage on shoulder muscle pain and upper trapezius muscle thickness among people with shoulder pain.

Materials & Methods

Twenty participants (6 males and 14 females) who suffered from shoulder pain were randomized into TS (n =10, aged 34.2 ± 7.34 yrs) or TM (n=10, aged 32.8 ± 7.24 yrs). Each group received two times 5-10 minutes of treatment, one week apart. At the baseline and after completing two times of each intervention, pain score, pain pressure threshold (PPT), and specific trapezius muscle thickness were evaluated.

Results

Before both TM and TS interventions, pain score, PPT, and muscle thickness were not statistically different between groups. After two times of intervention, pain scores significantly reduced in TM (3.1 ± 0.56; p = .02, 2.3 ± 0.48; p < .001), as same as in TS (2.3 ± 0.67; p = .01, 1.3 ± 0.45; p < .001) when compared to baseline. This was the same as the results of PPT in TM (4.02 ± 0.34; p = .012, 4.55 ± 0.42; p = .001) and TS (5.67 ± 0.56; p = .001, 6.8 ± 0.72; p < .001). However, the trapezius muscle thickness reduced significantly after two interventions by TS (10.42 ± 1.04; p = 0.002 & 9.73 ± 0.94 mm, p < .001), but did not change in TM (p > .05). Moreover, when compared between intereventions at the first and second periods, TS showed a significant difference in pain score (p = .01 & p <.001), muscle thickness (p = .008 & p = .001) as well as PPT (p < .001 & p < .001) when compared to TM.

Conclusion

Tok Sen massage improves upper trapezius thickness from muscle spasms and reduces pain perception and increases the pressure threshold pain among participants who suffer from shoulder pain similar to that of office syndrome.

Diagnostic test accuracy of ultrasound for sarcopenia diagnosis: A systematic review and meta-analysis

Muscle ultrasound is an emerging tool for diagnosing sarcopenia. This review aims to summarize the current knowledge on the diagnostic test accuracy of ultrasound for the diagnosis of sarcopenia. We collected data from Ovid Medline, Embase and the Cochrane Central Register of Controlled Trials. Diagnostic test accuracy studies using muscle ultrasound to detect sarcopenia were included. Bivariate random-effects models based on sensitivity and specificity pairs were used to calculate the pooled estimates of sensitivity, specificity and the area under the curves (AUCs) of summary receiver operating characteristic (SROC), if possible. We screened 7332 publications and included 17 studies with 2143 participants (mean age range: 52.6-82.8 years). All included studies had a high risk of bias. The study populations, reference standards and ultrasound measurement methods varied across the studies. Lower extremity muscles were commonly studied, whereas muscle thickness (MT) was the most widely measured parameter, followed by the cross-sectional area (CSA). The MTs of the gastrocnemius, rectus femoris, tibialis anterior, soleus, rectus abdominis and geniohyoid muscles showed a moderate diagnostic accuracy for sarcopenia (SROC-AUC 0.83, 8 studies; SROC-AUC 0.78, 5 studies; AUC 0.82, 1 study; AUC 0.76-0.78, 2 studies; AUC 0.76, 1 study; and AUC 0.79, 1 study, respectively), whereas the MTs of vastus intermedius, quadriceps femoris and transversus abdominis muscles showed a low diagnostic accuracy (AUC 0.67-0.71, 3 studies; SROC-AUC 0.64, 4 studies; and AUC 0.68, 1 study, respectively). The CSA of rectus femoris, biceps brachii muscles and gastrocnemius fascicle length also showed a moderate diagnostic accuracy (AUC 0.70-0.90, 3 studies; 0.81, 1 study; and 0.78-0.80, 1 study, respectively), whereas the echo intensity (EI) of rectus femoris, vastus intermedius, quadriceps femoris and biceps brachii muscles showed a low diagnostic accuracy (AUC 0.52-0.67, 2 studies; 0.48-0.50, 1 study; 0.43-0.49, 1 study; and 0.69, 1 study, respectively). The combination of CSA and EI of biceps brachii or rectus femoris muscles was better than either CSA or EI alone for diagnosing sarcopenia. Muscle ultrasound shows a low-to-moderate diagnostic test accuracy for sarcopenia diagnosis depending on different ultrasound parameters, measured muscles, reference standards and study populations. The combination of muscle quality indicators (e.g., EI) and muscle quantity indicators (e.g., MT) might provide better diagnostic test accuracy.

Muscle Cross-Sectional Area Segmentation in Transverse Ultrasound Images Using Vision Transformers

Automatically measuring a muscle’s cross-sectional area is an important application in clinical practice that has been studied extensively in recent years for its ability to assess muscle architecture. Additionally, an adequately segmented cross-sectional area can be used to estimate the echogenicity of the muscle, another valuable parameter correlated with muscle quality. This study assesses state-of-the-art convolutional neural networks and vision transformers for automating this task in a new, large, and diverse database. This database consists of 2005 transverse ultrasound images from four informative muscles for neuromuscular disorders, recorded from 210 subjects of different ages, pathological conditions, and sexes. Regarding the reported results, all of the evaluated deep learning models have achieved near-to-human-level performance. In particular, the manual vs. the automatic measurements of the cross-sectional area exhibit an average discrepancy of less than 38.15 mm2, a significant result demonstrating the feasibility of automating this task. Moreover, the difference in muscle echogenicity estimated from these two readings is only 0.88, another indicator of the proposed method’s success. Furthermore, Bland−Altman analysis of the measurements exhibits no systematic errors since most differences fall between the 95% limits of agreements and the two readings have a 0.97 Pearson’s correlation coefficient (p < 0.001, validation set) with ICC (2, 1) surpassing 0.97, showing the reliability of this approach. Finally, as a supplementary analysis, the texture of the muscle’s visible cross-sectional area was examined using deep learning to investigate whether a classification between healthy subjects and patients with pathological conditions solely from the muscle texture is possible. Our preliminary results indicate that such a task is feasible, but further and more extensive studies are required for more conclusive results.

Musculoskeletal Ultrasound Shows Muscle Mass Changes during Post-Acute Care Hospitalization in Older Men: A Prospective Cohort Study

This study aimed to prospectively assess changes in muscle thickness (MT) and the cross-sectional area (CSA) of the rectus femoris (RF) muscle in a cohort of older adults, using musculoskeletal ultrasound at admission and at a 2-week follow-up during hospitalization in a post-acute care unit. Differences in frailty status and correlations of MT-RF and CSA-RF with current sarcopenia diagnostic criteria were also studied. Forty adults aged 79.5 (SD 9.5) years (57.5% women) participated, including 14 with frailty and 26 with pre-frailty. In the first week follow-up, men had a significant increase in MT (0.9 mm [95%CI 0.3 to 1.4], p = 0.003) and CSA (0.4 cm2 [95%CI 0.1 to 0.6], p = 0.007). During the second week, men continued to have a significant increase in MT (0.7 mm [95%CI 0.0 to 1.4], p = 0.036) and CSA (0.6 cm2 [95%CI 0.01 to 1.2], p = 0.048). Patients with frailty had lower values of MT-RF and CSA-RF at admission and during the hospitalization period. A moderate-to-good correlation of MT-RF and CSA with handgrip strength, fat-free mass and gait speed was observed. Musculoskeletal ultrasound was able to detect MT-RF and CSA-RF changes in older adults admitted to a post-acute care unit.

Current practice and barriers in the implementation of ultrasound-based assessment of muscle mass in Japan: A nationwide, web-based cross-sectional study

Muscle mass is an important factor for surviving an illness. Ultrasound has gained increased attention as a muscle mass assessment method because of its noninvasiveness and portability. However, data on the frequency of ultrasound-based muscle mass assessment are limited, and there are some barriers to its implementation. Hence, a web-based cross-sectional survey was conducted on healthcare providers in Japan, which comprised four parts: 1) participant characteristics; 2) general muscle mass assessment; 3) ultrasound-based muscle mass assessment; and 4) the necessity of, interest in, and barriers to its implementation. Necessity and interest were assessed using an 11-point Likert scale, whereas barriers were assessed using a 5-point Likert scale, in which “Strongly agree” and “Agree” were counted for the analysis. Of the 1,058 responders, 1,026 participants, comprising 282 physicians, 489 physical therapists, 84 occupational therapists, 120 nurses, and 51 dieticians, were included in the analysis. In total, 93% of the participants were familiar with general muscle mass assessment, and 64% had conducted it. Ultrasound-based muscle mass assessment was performed by 21% of the participants. Necessity and interest scored 7 (6–8) and 8 (7–10), respectively for ultrasound-based muscle mass assessment. The barriers to its implementation included lack of relevant education (84%), limited staff (61%), and absence of fixed protocol (61%). Regardless of the necessity of and interest in ultrasound-based muscle mass assessment, it was only conducted by one-fifth of the healthcare providers, and the most important barrier to its implementation was lack of education.

The Diagnostic Value of Ultrasound of the Rectus Femoris for the diagnosis of Sarcopenia in adults: A systematic review

BACKGROUND & AIM

Sarcopenia is defined as a loss of muscle mass and function, which can be caused by normal ageing or factors such as physical inactivity. Severe health consequences caused by sarcopenia highlight the need for early identification. Computed Tomography (CT) imaging, often mentioned as the gold standard due to its accuracy, is costly and not routinely performed in daily clinical care. Ultrasound of the rectus femoris, however, is low in costs and easily accessible. The aim is to present the current and most recent literature regarding the diagnostic value of ultrasound measurements of the rectus femoris for the diagnosis of sarcopenia in adults.

METHODS

The databases PubMed and Web of Science were used to search for studies comparing ultrasound of the rectus femoris with a reference test to diagnose sarcopenia in adults. The quality of the final eligible studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies, version 2, tool (QUADAS-2).

RESULTS

Six studies were included in this systematic review. The muscle thickness and cross-sectional area of the rectus femoris were assessed and compared with the reference tests CT, Dual-Energy X-ray Absorptiometry (DXA), and Bioelectrical Impedance Analysis (BIA). Half of the studies had a low risk of bias on all QUADAS-2 domains. Three studies reported statistical significant outcomes and diagnostic values ranging from 60 to 81% sensitivity and 51 to 94% specificity.

CONCLUSIONS

Ultrasound of the rectus femoris muscle to diagnose sarcopenia has been shown to be a promising method in multiple clinical populations. However, there were some limitations such as a high methodological heterogeneity. Future research should develop standardized protocols and determine clear cut-off values to allow for a better implementation of ultrasound in clinical practice.

Inter- and Intra-Rater Reliability of Ultrasound Measurements of Superficial and Deep Fasciae Thickness in Upper Limb

Ultrasound (US) imaging is increasingly the most used tool to measure the thickness of superficial and deep fasciae, but there are still some doubts about its reliability in this type of measurement. The current study sets out to assess the inter-rater and intra-rater reliability of US measurements of superficial and deep fasciae thicknesses in the arm and forearm. The study involved two raters: the first (R1) is an expert in skeletal–muscle US imaging and, in particular, the US assessment of fasciae; the second (R2) is a radiologist resident with 1 year’s experience in skeletal–muscle US imaging. R2, not having specific competence in the US imaging of fasciae, was trained by R1. R1 took US images following the protocol by Pirri et al. 2021, and the US-recorded images were analyzed separately by the two raters in different sessions. Each rater measured both types of fasciae at different regions and levels of the arm and forearm. Intra- and inter-rater reliability was excellent for the deep fascia and good and excellent for the superficial fascia according to the different regions/levels (for example for the anterior region of the arm: deep fascia: Ant 1: ICC_2,2 = 0.95; 95% CI = 0.81–0.98; superficial fascia: Ant 1: ICC_2,2 = 0.85, 95% CI = 0.79–0.88). These findings confirm that US imaging is a reliable and cost-effective tool for evaluating both fasciae, superficial and deep.

Resistance training with or without nutritional supplementation showed no influence on muscle thickness in old-institutionalized adults: a secondary analysis of the Vienna Active Ageing Study

BACKGROUND

Resistance training and protein supplementation are recommended strategies to combat sarcopenia.

AIM

Quantification of muscle thickness (MT) by musculoskeletal ultrasound is a promising method to follow changes in skeletal muscles. The aim of this study was to investigate the effect of six months of resistance training with or without nutritional supplementation on MT of M. quadriceps in institutionalized old adults.

DESIGN

This is a prospective, randomized, multi-arm parallel and controlled intervention study.

SETTING

This study was conducted in five different retirement care facilities.

POPULATION

Institutionalized individuals (mean age 82.6±6.2 years) were randomly assigned to an elastic band resistance training (N.=41), training with nutritional supplementation (N.=36) or control group (N.=40).

METHODS

Health status and handgrip strength were investigated at baseline. MT of all parts of M. quadriceps of the left leg was assessed using musculoskeletal ultrasound at baseline and after six months. Linear regression models adjusted for age, BMI and sex were calculated to investigate the influence of baseline characteristics on MT. Multivariable regression analyses were performed for investigation of study intervention on MT. Follow-up examinations were performed after 12 and 18 months.

RESULTS

Handgrip strength of both hands was significantly correlated with MT of M. vastus lateralis. Moreover, the sum of regularly taken medication was significantly correlated to MT of all parts of quadriceps. Six months of training or nutritional supplementation was not able to alter MT. However, participants with lower baseline MT values or a higher number of diseases and medications at baseline showed significant higher increases in MT after intervention.

CONCLUSIONS

Resistance training using elastic bands with or without nutritional supplementation did not alter MT of M. quadriceps of old institutionalized individuals. However, baseline values and health status had a significant influence on the training effect.

CLINICAL REHABILITATION IMPACT

As old individuals are very heterogenic according to their health and muscle status; further studies might focus on individualizing training regimes with particular emphasize on accompanied diseases and medications of this population.

Automatic Extraction of Muscle Parameters with Attention UNet in Ultrasonography

Automatically delineating the deep and superficial aponeurosis of the skeletal muscles from ultrasound images is important in many aspects of the clinical routine. In particular, finding muscle parameters, such as thickness, fascicle length or pennation angle, is a time-consuming clinical task requiring both human labour and specialised knowledge. In this study, a multi-step solution for automating these tasks is presented. A process to effortlessly extract the aponeurosis for automatically measuring the muscle thickness has been introduced as a first step. This process consists mainly of three parts. In the first part, the Attention UNet has been incorporated to automatically delineate the boundaries of the studied muscles. Afterwards, a specialised post-processing algorithm was utilised to improve (and correct) the segmentation results. Lastly, the calculation of the muscle thickness was performed. The proposed method has achieved similar to a human-level performance. In particular, the overall discrepancy between the automatic and the manual muscle thickness measurements was equal to 0.4 mm, a significant result that demonstrates the feasibility of automating this task. In the second step of the proposed methodology, the fascicle’s length and pennation angle are extracted through an unsupervised pipeline. Initially, filtering is applied to the ultrasound images to further distinguish the tissues from the other muscle structures. Later, the well-known K-Means algorithm is used to isolate them successfully. As the last step, the dominant angle of the segmented muscle tissues is reported and compared with manual measurements. The proposed pipeline is showing very promising results in the evaluated dataset. Specifically, in the calculation of the pennation angle, the overall discrepancy between the automatic and the manual measurements was less than 2.22° (degrees), once more comparable with the human-level performance. Finally, regarding the fascicle length measurements, the results were divided based on the muscle properties. In the muscles where a large portion (or all) of the fascicles are located between the upper and lower aponeuroses, the proposed pipeline exhibits superb performance; otherwise, overall accuracy deteriorates due to errors caused by the trigonometric approximations needed for the length calculation.

Reliability and validity of ultrasound to measure of muscle mass following allogeneic hematopoietic stem cell transplantation

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients frequently show physical dysfunction due to loss of muscle mass. This study aimed to clarify the reliability and validity of ultrasound in evaluating muscle mass and to analyze the patterns of change in muscle mass before and after allo-HSCT. We conducted a prospective observational study using data from 68 patients who had undergone their first allo-HSCT. We evaluated the thickness of the quadriceps, biceps, and suprahyoid muscle. Three individual evaluators underwent this examination for each muscle before transplantation and on days 30, 90, and 180 after allo-HSCT. Inter-rater reliability was calculated using the interclass correlation (ICC), and the level of correlation between muscle mass measured by ultrasound and psoas muscle mass assessed using computed tomography (CT) was assessed using Pearson correlation. ICC values ranged from 0.897 to 0.977 in the measurement. The correlation scores were 0.730, 0.546 and 0.579 between psoas muscle and the biceps, quadriceps, and suprahyoid muscle. The thickness of the biceps and quadriceps muscle were both significantly decreased after allo-HSCT from baseline. These results showed that the ultrasound technique was a reliable tool for evaluating muscle mass and detecting changes in muscle mass following allo-HSCT.

Sarcopenia Diagnosis: Reliability of the Ultrasound Assessment of the Tibialis Anterior Muscle as an Alternative Evaluation Tool

Sarcopenia is a skeletal muscle disorder characterized by reduced muscle mass, strength, and performance. Muscle ultrasound can be helpful in assessing muscle mass, quality, and architecture, and thus possibly useful for diagnosing or screening sarcopenia. The objective of this study was to evaluate the reliability of ultrasound assessment of tibialis anterior muscle in sarcopenia diagnosis. We included subjects undergoing total or partial hip replacement, comparing measures with a healthy control group. We measured the following parameters: tibialis anterior muscle thickness, echogenicity, architecture, stiffness, skeletal muscle index (SMI), hand grip strength, and sarcopenia related quality of life evaluated through the SarQoL questionnaire. We included 33 participants with a mean age of 54.97 ± 23.91 years. In the study group we found reduced tibialis anterior muscle thickness compared to the healthy control group (19.49 ± 4.92 vs. 28.94 ± 3.63 mm, p < 0.05) with significant correlation with SarQoL values (r = 0.80, p < 0.05), dynamometer hand strength (r = 0.72, p < 0.05) and SMI (r = 0.76, p < 0.05). Moreover, we found reduced stiffness (32.21 ± 12.31 vs. 27.07 ± 8.04 Kpa, p < 0.05). AUC measures of ROC curves were 0.89 predicting reduced muscle strength, and 0.97 predicting reduced SMI for tibialis anterior muscle thickness, while they were 0.73 and 0.85, respectively, for muscle stiffness. Our findings showed that ultrasound assessment of tibialis anterior muscle might be considered a reliable measurement tool to evaluate sarcopenia.

Jaw-retraction exercise increases anterior hyoid excursion during swallowing in older adults with mild dysphagia

OBJECTIVES

The present study aimed to evaluate the effectiveness of a newly designed jaw-retraction exercise for strengthening the geniohyoid muscle and thus improving the anterior movement of the hyoid bone during swallowing.

BACKGROUND

Although previous studies suggest a relationship between anterior hyoid excursion and upper esophageal sphincter (UES) opening, there are currently no reports of physical exercises without the use of special equipment that can effectively improve this movement of the hyoid bone during swallowing.

MATERIALS AND METHODS

This before-after study included patients presenting to the authors' hospital with mild dysphagia (Level 5 on the Dysphagia Outcome and Severity Scale). The participants were instructed to perform a jaw-retraction exercise designed to strengthen the geniohyoid muscle. Each participant was instructed to perform two sets of the exercise daily for four weeks, with each set consisting of five repetitions. Before and after the four-week training period, videofluoroscopic swallowing studies were performed and later analysed.

RESULTS

Twenty-five patients with a median age of 77 were included. The median peak anterior hyoid position before and after exercise were 129.82 and 132.74 (%C2-C4 length), respectively, and this increase was found to be significant (P = .007). The median extent of UES opening before and after exercise were 8.6 and 9.3 (mm), respectively, and this increase was also found to be significant (P = .040).

CONCLUSION

Our findings demonstrate that the jaw-retraction exercise can effectively improve the anterior movement of the hyoid bone. This exercise may be effective in individuals with oral frailty when signs of swallowing disorders are observed.

Sarcopenic obesity and function in women with subacute hip fracture: a short-term prospective study

BACKGROUND

The prognostic role exerted by the concurrent presence of sarcopenia and obesity after hip fracture has not been elucidated.

AIM

To assess the effect of sarcopenic obesity on ability to function in women with subacute hip fracture.

DESIGN

Short-term prospective study.

SETTING

Rehabilitation hospital.

POPULATION

Women with subacute hip fracture.

METHODS

At admission, grip strength, by a Jamar dynamometer, and body composition by dual-energy x-ray absorptiometry were assessed. Sarcopenia was defined according to the criteria released by the European Working Group for Sarcopenia in Older People in 2019, with both grip strength < 16kg and appendicular lean mass (aLM) < 15kg. Alternatively, aLM/(height)2 < 5.5kg/m2 was substituted for aLM < 15kg to confirm sarcopenia in the women with grip strength < 16kg. Obesity was diagnosed with fat mass exceeding 40% of total body mass. Function was assessed by the Barthel index.

RESULTS

We assessed 183 of 200 women. Sarcopenic women had lower Barthel index scores assessed at the end of subacute inpatient rehabilitation (U=300,0; z=-4.3; P<0.001) and lower Batrhel index effectiveness (U=310,0; z=-4.2; P<0.001) than non-sarcopenic women. Conversely, we found no significant differences in function between obese and non-obese women. The concurrent presence of sarcopenia and obesity did not worsen the functional prognosis versus the presence of isolated sarcopenia. After adjustment for Barthel index scores before rehabilitation, age, hip-fracture type and cognitive impairment, sarcopenia was significantly associated with Barthel index scores (P=0.001) and Barthel index effectiveness (P<0.001), whereas obesity was not. The results did not materially change when aLM/(height)2 < 5.5kg/m2 was substituted for aLM <15kg to confirm sarcopenia in the women whose handgrip strength was < 16kg.

CONCLUSIONS

The concurrent presence of obesity did not worsen the negative prognostic role of sarcopenia in the short-term recovery of ability to function after hip fracture in women.

CLINICAL REHABILITATION IMPACT

In women with subacute hip fracture, sarcopenia but not obesity should be assessed to contribute to the prediction of the short-term functional outcome.