Insight into Clinical Assessment and Management of Sarcopenia

Ganesh Sankarrajan,

PT.DPT.OCS.GCS

Board-Certified Clinical Specialist

Bio

• Doctoral degree – Texas Tech Univ Health Sciences Center
• American Board Of Physical Therapy Specialties
• Orthopedic Clinical Specialist - OCS
• Geriatric Clinical Specialist – GCS
• 20 plus years in the field of physical therapy
• Michigan, California and Texas – 16 years

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Texas Medical Center

Objectives

• Why Sarcopenia is important for clinicians to identify, educate and treat.
• Types of Sarcopenia in clinical practice.
• Physiological basis of Sarcopenia.
• Outcome Measures and tools to quantify effects of intervention
• Therapy exercise interventions in Sarcopenia
• Nutritional background during Sarcopenia exercise sessions

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Why Sarcopenia demands clinical attention

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• Two hundred and eighty‐eight participants (mean age: 81.1 ± 6.6 years).

Forty‐nine participants (17.0%) were identified as having sarcopenia.

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• This condition was similar in men and women (16.9% vs. 17.5%, respectively, P = 0.915). During the 3 year follow‐up period, 49 men (22.7%) and 9 women (16.4%) died (P = 0.307).

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• The mortality of sarcopenic participants was significantly increased compared with non‐sarcopenic participants (40.8% vs. 17.1%, respectively, P < 0.001).

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• After adjusting for age, sex and other confounders, sarcopenia was an independent predictor of 3 year mortality (adjusted hazard ratio: 2.49; 95% confidential interval: 1.25–4.95) and readmission (adjusted hazard ratio: 1.81; 95% confidential interval: 1.17–2.80)

• 239,953 patients undergoing lumbar spine arthrodesis, 1087 had a recent diagnosis of sarcopenia (0.45%) before surgery.

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• Patients with sarcopenia were significantly more likely to experience a urinary tract infection (odds ratio = 1.41, P = 0.035) and undergo incision and drainage (odds ratio = 2.66, P = 0.010) within 90 days after lumbar arthrodesis.

• Patients with sarcopenia were at a 24% greater risk of 1-year all-cause hospital readmission.

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• The 90-day cost of care was significantly greater in patients with sarcopenia ($37,689.86 vs. $26,635.72; P < 0.001)

• The prevalence of sarcopenia and severe sarcopenia in this cohort according to the updated AWGS criteria was 35.5% and 21.7%.

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• Prevalence of sarcopenia and severe sarcopenia significantly increased with advancing age (p = .003, p = .040, respectively). Although not statistically significant, the proportion of severe sarcopenia among sarcopenia also increased with age.

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• Multivariate logistic regression analysis revealed that lower BMI and lower 25-OH-vitamin D3 level were independent risk factors associated with sarcopenia in women awaiting TKA

• NRS 2002 (OR = 3.43, 95% CI: 1.10–10.72, P=0.034) and sarcopenia (OR = 4.25, 95% CI: 1.13–16.02, P=0.033) were found to be independently associated with unplanned readmission within 30 days of radical gastrectomy for cancer.

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• Other factors such as age, sex, BMI, American Society of Anesthesiologists grade, surgical method, operation and reconstruction type, TNM stage, surgical duration, previous abdominal surgery, and preoperative albumin and hemoglobin level were not associated with unplanned readmission after radical gastrectomy for cancer.

The sarcopenia group had higher

• 30-day reoperation rate (14.3% vs 3.1%, p=.037)

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• 30-day readmission rate (16.3% vs 3.1%, p=.018)

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• Rate of discharge to a facility (83.7% vs 50.8%, p<.001), and

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• Longer length of stay (LOS) (7.3±4.2 days vs 5.6±3.5 days, p=.023).

Slow-progressing

PUBLIC HEALTH ISSUE

Prior to hospital admissions

https://www.cdc.gov/pcd/issues/2020/20_0167.htm

https://www.cdc.gov/falls/index.html

Types of Sarcopenia

Primary Sarcopenia

Secondary sarcopenia

Compound Sarcopenia

SO – Sarcopenic Obesity

Sarcopenia – frailty axis

Traditional MUSCLE MASS body composition measurements

• The skeletal muscle mass assessment is done using various indirect and direct techniques such as anthropometry, bioelectrical impedance analysis (BIA), dual-energy X-ray absorptiometry (DXA), ultrasound, MRI and CT in many studies pertaining to chronic liver disease. However, the use of these techniques to quantify skeletal muscle mass index or SMI is limited by cost, availability, time consuming nature, accessibility.

Sarcopenia is defined as a gradual loss of muscle mass, strength and function.

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EWGSOP

• The criteria by which sarcopenia is diagnosed as per EWGSOP (European Working Group on Sarcopenia in Older People) are typically divided into 3 categories: strength, quality and function.
• Per the revised EWGSOP2 guidelines, sarcopenia can be suspected in males with < 27kg of handgrip strength and for females with <16kg, and regarding the chair rise test sarcopenia is suspected in an individual who takes longer than 15s to rise out of chair five times.
• For low skeletal mass or quality, appendicular mass is considered with regard to height, with the reference values of <7.0 kg/m2 in males or <5.5 kg/m2 in females.
• And in terms of muscle function gait speed of ≤0.8 m/s or Short Physical Performance battery or SPPB of ≤ 8 is recommended.

ESPEN-SIG

• The ESPEN-SIG (European Society for Clinical Nutrition and Metabolism Special Interest Groups) recommends low skeletal mass in terms of appendicular skeletal mass per height <7.26/m2 in males and <5.5kg/m2 for females along with one of the following…
• For low skeletal muscle strength with grip strength values of <30kg in males and <20kg in females, and for muscle function the gait speed of <0.8-1.0 m/s, respectively.

AWGS

• The AWGS (Asian Working Group for Sarcopenia) recommends low skeletal muscle mass using appendicular skeletal mass per height of <7.0 kg/m2 in males or 5.4 kg/m2 in females by DEXA (Dual Energy X-ray Absorbmetry)
• or 5.7kg/m2 by BIA and one of the following …
• with grip strength of <28kg for males and <18 for females, or gait speed of <1m/sec or SPPB ≤ 9.

FNIH

• The FNIH (Foundations of National Institute of Health) recommends grip strength < 26 kg in males and < 16 kg in females and for low muscle mass,
• Appendicular lean mass per BMI < 0.789 kg and < 0.512 kg in females..

IWGS

• And finally, the IWGS or International Working Group on Sarcopenia recommends appendicular skeletal muscle mass per height 7.23 kg/m2 in males and 5.67 kg/m2 for low skeletal muscle mass and
• Gait speed of < 1m/s for low muscle performance

Objective outcome measures

• Hand Grip JAMAR
• SPPB – Short Physical Performance Battery
• 5 rep STS
• Gait speed
• + 6 MWT/TUG

JAMAR GS

• Excellent test-retest reliability (ICC = 0.81-0.99) for preferred and non-preferred hands in men
• Excellent test-retest reliability (ICC = 0.83-1.0) for preferred and non-preferred hands in women
• Excellent interrater reliability (ICC = 0.996-0.998)

SPPB

• 3 items are present on the SPPB:
• 1- Gait speed, 2- 5-time sit-to-stand test, 3- Balance assessment.
• Individual items are scored from 0 to 4 and summed to identify the total score,
• 12 indicates the highest function and 0 indicates the lowest function.
• Test-retest reliability of the SPPB was high: 0.87 (CI95%: 0.77-0.96)

Subjective measure

• SARC-F questionnaire

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• The SARC-F consists of five items:
• (1) Strength: How much difficulty do you have in lifting and carrying 4.5 kg?
• (2) Assistance in walking: How much difficulty do you have walking across a room?
• (3) Rising from a chair: How much difficulty do you have transferring from a chair or bed?
• (4) Climbing stairs: How much difficulty do you have climbing a flight of 10 stairs?
• (5) Falls: How many times have you fallen in the past year?

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• Each item is scored on a scale of 0 (best) to 2 (worst).
• Consequently, the total score ranges from 1 to 10 points, with higher values (SARC-F 4)
• indicating a higher risk of sarcopenia

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• INTERNAL CONSISTENCY AND DIAGNOSTIC VALIDITY OF SARC-F QUESTIONNAIRE IN CHRONIC LIVER DISEASE PATIENTS WITH SARCOPENIA.

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• Prevalence of sarcopenia in chronic liver disease is about 30%–70%
• The common causes of chronic liver disease has been alcohol-related liver disease or ALD, non-alcoholic steatohepatitis or NASH and Viral Hepatitis. The condition non-alcoholic fatty liver disease or NAFLD is the milder form of non-alcohol related liver disease with fat accumulation in liver and is reversible.
• However, NAFLD can progress to steatohepatitis or NASH with inflammation thereby leading to fibrosis and cirrhosis.
• Both NAFLD and NASH is associated with comorbidities including diabetes, hyperlipidemia, metabolic syndrome, hypertension and obesity.

• NAFLD, is also associated with sarcopenic obesity, observed in 27% of patients with chronic liver disease and is characterized by increase in visceral body fat with decrease in skeletal muscle mass.
• In June 2023, a multi society group agreed to change the name nonalcoholic fatty liver disease or NAFLD to metabolic dysfunction–associated steatotic liver disease or MASLD.

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• Sarcopenia from chronic liver disease is multi-factorial, characterized by protein-metabolism imbalance with increase in its catabolism, decreased nutritional intake, malabsorption, altered metabolism, hormonal changes, hyperammonemia, myosteatosis and loss of muscle mass.
• Further, portal hypertension, refractory ascites, recurrent hospitalization, comorbidities, along with socioeconomic and environmental factors influence inactivity, muscle wasting and frailty in these subjects.
• Sarcopenia also has liver specific drivers that invariably potentiate the progression of sarcopenia in both ALD and NASH. Alcohol promotes skeletal muscle protein breakdown, muscle autophagy, and cachexia.

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• And NAFLD and NASH has pathological mediators, including chronic inflammation, insulin resistance and physical inactivity.
• It is also to be noted that subjects seen with chronic liver disease can exhibit compound sarcopenia due to age-related loss of muscle mass and contractile strength (1% per year up-to the age of 70 from middle-age, and a loss of 1.5-2.5% thereafter) along with NAFLD, NASH and ALD which can lead to drastic functional decline and frailty.

Recall Pathology to design an outcome measure

RECALL SPPB

Frailty in liver disease patients and has cutoffs for robust, prefrail, and frail categories. The LFI score for robust is defined as <3.2, prefrail is defined as LFI between 3.2 and 4.4, and frail is defined as LFI ≥4.5. The LFI had excellent reliability with ICC of 0.93 (95% confidence interval, 0.91-0.95). LFI also has external validity in non-cirrhotic populations as well and is highly reproducible among different raters. And an LFI cut-off of >4.62 discriminated best between patients with and without elevated risk for re-hospitalization within 30 days.

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LFI = (–0.330 × sex-adjusted grip strength) + (–2.529 × number of chair stands per second) + (–0.040 × balance time) + 6

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The classifications of frailty were determined by using previously established cutoffs of the LFI with robust defined as LFI <3.2, prefrail defined as LFI between 3.2 and 4.4, and frail defined as LFI ≥4.5

Objectives

The primary objective of this study is an attempt to identify sarcopenia in chronic liver disease patients using SARC-F questionnaire and to find out its internal consistency and diagnostic validity in relation to LFI.

The secondary objective is to identify which among the 5 functional tasks has highest sensitivity and specificity with reference to objective measures used in the study.

Using regression analysis find out whether the accepted cut off score of ≥ 4 in SARC-F questionnaire is applicable to patients with CLD

How scoring can impact a change in clinical practice.

Study Design

Description of the design of the study -Cross-Sectional single-center study design

Expected duration of study and subject participation -6 months to 8 months, A total of 10-15 min for administration of SARC-F questionnaire and to perform basic testing with outcomes measures.

Study Population

The study population and inclusion criteria- Patients with Chronic Liver Disease (CLD) from the outpatient transplant center and from the hospital being treated for chronic liver disease will be included in this study. The study will include CLD patients who has underwent TIPS, liver transplant in the part or on wait-list for liver transplant also will be included.

Exclusion Criteria - The study will exclude subjects if they have cognitive disorders or hepatic encephalopathy, with inability to fill the SARC-F questionnaire. The study will also exclude subjects with orthopedic disorders due to inability to complete the 4MWT and Short Physical Performance battery.

Describe the recruitment strategy – Since its a cross sectional design, subjects with Chronic Liver disease, incl Alcoholic cirrhosis and NASH will be recruited based on their verbal consent to fill up the SARC-F questionnaire and followed up by objective tests which include as grip strength, 4MWT and SPPB.

Study Procedures

Total amount of time required of each subject to participate in the project – 1

10 -15 Min for each subject in the cross -sectional study design

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Type of information the PI will gather, along with the means for collecting and recording it -

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MRN, Age, Sex, Education level, BMI, Type of CLD with regard to cirrhosis type, co-morbidness, MELD score, Transplant status, SARC-F questionnaire with 5 elements, Grip strength, Short Physical Performance Battery, Gait speed, Stairs

• PT acts to fill the gaps*
• Early “case finding”* – Observation* skills
• Promote early mobility, exercise intervention
• Persistent customized tailored therapy
• Community Dwelling – PT education*

Therapeutic Interventions

• TYPE-II muscle fibers – Fast Glycolytic
• Resisted exercises
• Aerobic exercises
• Balance exercises

Exercise (at 30% of peak work-load) significantly increased arterial pressure and cardiac output and decreased systemic vascular resistance. This was associated with a significant increase in HVPG (from 16.7 +/- 1.5 to 19.2 +/- 1.6 mm Hg; P < 0.01) and a significant reduction in hepatic blood flow (from 1291 +/- 216 to 1034 +/- 152 mL-min-1; P < 0.05). All of these changes were intensified at 50% of target workload.

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Conclusions: The present study shows that moderate exercise increases portal pressure and may therefore increase the risk of variceal bleeding in patients with esophageal varices. These findings suggest that cirrhotic patients with portal hypertension should be advised of potential risks during exercise.

Nutritional education

• Calories – 70k - 1-1.5 g/kg daily
• Protein energy balance