Clinician Guide - Sarcopenia
Clinician Guide - Sarcopenia
Clinician Guide - Sarcopenia
A R T I C L E I N F O A B S T R A C T
Keywords: Sarcopenia, the decrease of muscle mass and performance, is a growing health concern in the face of an ageing
Sarcopenia population. Sarcopenia is an important contributor to falls and fall related injury in older adults, and allied
Clinical practice guidelines health musculoskeletal clinicians are well placed to play a key role in the prevention, diagnosis, and management
Gerontology
of the disease. This masterclass aims to provide clinical confidence for musculoskeletal allied health professionals
Allied health
working with older adults to incorporate management of sarcopenia into their practice. Specifically it will focus
Musculoskeletal disease
on diagnosis of disease, appropriate and safe therapeutic exercise prescription, as well as appropriate referral for
these patients. We hope that equipping clinicians with skills and knowledge of sarcopenia directly translates into
more effective prevention and management of disease, and improved patient outcomes in older age.
Implications for practice present, there are no effective pharmacological interventions with
strong efficacy in treating sarcopenia, with progressive resistance
- Osteopaths and other allied health clinicians can, and should play a training the key management strategy. While exercise improves both
role in the early detection, prevention and management of function and health outcomes, early detection and prevention are crit
sarcopenia. ical for maximum benefit to both patients and healthcare systems. In
- Allied health musculoskeletal practitioners can easily incorporate this, musculoskeletal allied health professionals are well positioned to
sarcopenia assessment into clinical practice. play a vital role, in both the diagnosis and management of this debili
- The implementation of resistance training programs in older adults tating condition. This masterclass is intended to provide a clinical guide
should be a priority to prevent and manage sarcopenia. for osteopaths, and other allied health professionals, in the assessment
- Awareness of falls risk is critically important when prescribing ex and management of those at risk of or living with sarcopenia. It aims to
ercise to patients in this demographic. provide confidence in the clinical evaluation and management of these
patients in tandem with medical professionals, and through this improve
1. Introduction the health outcomes of older adults.
Since its first description in 1989 [1], sarcopenia has gained 1.1. Interconnected tissues: a primer on osteosarcopenia
increasing notoriety as a public health issue globally, receiving a
standalone ICD-10 code in 2016 [2]. Sarcopenia, the pathological loss of As we have described in a previous masterclass on osteoporosis [4],
muscle mass, strength and physical performance, places a significant the intertwined physiology of bone and muscle makes the co-existence
burden on patients and health care systems globally, which are only of osteoporosis and sarcopenia important to consider. While osteopo
likely to grow with an ageing population. Sarcopenia, and its associated rosis is beyond the scope of this masterclass, a growing body of evidence
falls and loss of physical independence, is associated with ageing, as well has identified the coexistence of both diseases – termed osteosarcopenia
as a host of other common conditions affecting people in later life [3]. At [5]. The likely cause of this is their shared pathophysiological
* Corresponding author. Institute for Health and Sport, Victoria University, Melbourne, Australia.
E-mail address: [email protected] (J. Feehan).
https://doi.org/10.1016/j.ijosm.2022.05.003
Received 24 March 2022; Received in revised form 25 May 2022; Accepted 27 May 2022
Available online 31 May 2022
1746-0689/© 2022 Elsevier Ltd. All rights reserved.
N. Tripodi et al. International Journal of Osteopathic Medicine 45 (2022) 1–7
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2.2.2. Exercise
Resistance training has a multi-factorial benefit in patients with
sarcopenia, as well as in its prevention. Most clearly, resistance training
improves muscle mass, and strength in people with sarcopenia, making
it an essential component of management [40]. Current clinical practice
guidelines specific to sarcopenia recommend resistance exercise as a
first-line therapy but with no specific recommendations regarding
amount, frequency, or intensity [41]. However, general guidelines for
implementing exercise programs for older adults which recommend a
mixed program of resistance, aerobic and balance exercise, with focus
on the typical training parameters of power, strength and endurance are
likely appropriate in this cohort. A generalized program with 2–3 ses
sions of resistance training, targeting multi-joint exercises, beginning
with 1–2 sets of 8–12 reps, alongside more frequent bouts (3–7/week) of
progressive aerobic and balance exercise [42]. While it appears that
exercise is beneficial, there is little known about optimal parameters for
prescription directly in sarcopenia. Some programs that have been
studied include two 60-min comprehensive resistance training programs Fig. 2. General clinical recommendations for musculoskeletal allied
per week, using a combination of banded and machine exercises health clinicians.
alongside stationary cycling. Exercises were initiated in a seated position
initially for prevention of falls, but progressed to standing over time, and
3. Osteopathic management of sarcopenia
after three months there were improvements in strength, gait speed and
muscle mass [40,43]. The key objectives for exercise prescription should
Musculoskeletal allied health clinicians are strongly positioned to aid
prioritise safety, progressive overload, and effective recovery. Particu
in the detection and management of sarcopenia in the community. With
larly in the early stages of management, and in more severe disease,
an appropriate level of clinical vigilance in practice, individuals with, or
supervised programs are preferred, to minimise risk of falls and training
at risk of sarcopenia can be effectively detected and managed. A sum
injuries. Importantly, in addition to the resistance training, individuals
mary of recommendations at each stage of a typical consultation is
should be encouraged to meet the World Health Organization (WHO)
presented in Fig. 2.
guidelines of 150 min of moderate intensity exercise per week, to offset
the deleterious effects of sarcopenia on general health [44]. Further
clinical guidance on exercise prescription will be provided below. 3.1. Prevention first
Evaluating patient response to exercise programs is an important
component of management. Important factors to evaluate at follow up The setting of allied health practice provides significant opportunity
are gait speed, quality of life and patient perception of strength and to identify high-risk individuals in mid-life, allowing for preventative
mobility. Grip strength may also be used, but seldom improves with action prior to onset of disease and loss of function. While the key risk
exercise programs, so may be a less useful measure. factor for sarcopenia is age, other factors during mid-life can aid in risk
stratification. Perhaps the most critical indicator in middle age is
2.2.3. Nutrition physical inactivity, which has been shown to be independently associ
The evidence on nutritional intervention for sarcopenia is less clear. ated with later development of sarcopenia [51]. Familial history and
Some emerging evidence suggests that a high-quality diet has beneficial genetic risk factors should also be considered, as there are some heri
outcomes in sarcopenia, with nutrients such as vitamin D, long chain table components of the disease [52]. Other factors such as diet quality,
polyunsaturated fatty acids and protein improving patient outcomes chronic diseases, and low muscle mass have not been independently
[45]. However, much of the evidence available is of low quality, or were associated with onset of disease but should be considered within a
conducted alongside exercise interventions, making a direct assessment broader consideration of risk. In the clinical context of musculoskeletal
of the impact of nutrition hard to quantify [46]. Current guidelines allied health, priority should be on engaging at-risk individuals with
recommend ensuring adequate protein intake, whether through diet or resistance training programs, and ensuring adequate nutrition, to pre
supplementation. These recommendations are based on low quality vent or delay the deterioration of muscle structure and function.
evidence, and in the context of the general health benefits of adequate
protein intake in older adults [41]. General population guidelines 3.2. History taking and education
recommend 0.8 g of protein per kilogram of bodyweight, however a
number of sources recommend increasing this to 1.0–1.5 g/kg/day with As with osteoporosis, sarcopenia is often a silent disease, making a
or without supplementation in older adults due to inefficient absorption, through clinical history imperative. Along with the standard history
decreased protein anabolism and changes to body composition [31,47]. taking line of questioning, and paying attention to any lifestyle, nutri
An important exception to this is in the context of chronic kidney dis tional, or morbidity factors (see medical management above) that could
ease, where clinical judgement must be used to balance risk and benefit contribute to sarcopenia, there are specific signs and symptoms that can
[48]. Particularly in the context of sarcopenia, aiming for higher raise suspicion of sarcopenia. Specifically, these include: falls, weakness
recommendation targets is likely to improve outcomes, particularly or slowness and a decrease in general function and ability to perform
when combined with an exercise program (further increasing protein activities of daily living [3]. Importantly, care must be taken to avoid
demand) [49,50]. Other conditional recommendations include ensuring generating fear of movement, physical activity and falls. Patient edu
adequate caloric intake, vitamin D sufficiency, and adequate hydration cation must be initiated from the very beginning of the clinical inter
to prevent falls, however there is little available evidence for these action, to ensure that patients are aware of the risk of falls, but are
factors directly [41]. encouraged and empowered to participate in physical activity safely.
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Table 2 Table 3
Key referrals for patients with sarcopenia. General exercise program considerations for sarcopenia adapted from [42].
Service/Practitioner Goals Resistance Training Aerobic Training Balance Training
General practitioner or For medication review, mental health assessment, and Frequency 2–3 3–7 1–7
Geriatrician co-morbid disease management. (days per
Imaging Body composition – muscle and bone week)
Dietician/Nutrition Dietary advice to meet recommended protein and Volume 1-4 sets of 8–12 20–60 min per 1-2 sets of 4–10
calorie intake, as well as micronutrient (inc. vitamin D) repetitions or as session different exercises
sufficiency, with or without supplementation. tolerated. Aim to
Occupational Therapist Mobility and independence aids, at-home falls risk target all major
review muscle groups.
Community services Social programs, such as social exercise Intensity Depends on function 55–70% threshold Progressively
but generally start at heart rate, or increase difficulty as
30–40% of 1RM and higher if tolerated by changing
This will also have important considerations for discussions around progress up to performing high variables such as:
70–80% of 1RM or intensity interval narrowing base of
physical activity and the musculoskeletal pain they are likely to be
appropriate training support,
presenting to the clinic with, which should again encourage physical intensity for the perturbation,
activity and exercise participation in a way that will both maintain or desired decrease in
improve muscle mass, as well as the patients pain experience. Open, physiological proprioception input
clear communication, and strong therapeutic alliance and rapport are adaptation i.e. (i.e. eyes closed),
power, strength, dual tasking.
critical in supporting this.
hypertrophy etc.
Examples -Compound lifts -Running (indoor -Tai-Chi/Yoga
3.3. Networks of care: collaborative multidisciplinary management such as squats, or outdoor) -Standing on one leg,
deadlifts, bench -Cycling -Running or stepping over
press, etc. (indoor or objects
While exercise prescription is the mainstay of management, effective -Leg press, leg curls/ outdoor) -Ballet movements
and collaborative referral can further improve patient outcomes. Man extension, rows, lat. -Rowing
aging co-morbid disease, such as depression or chronic pain, as well as pull downs -Dancing
improving functional independence significantly improve patient out -Palof press, wood -Walking/Hiking
chops, land mines
comes and quality of life. Some key referrals are suggested in Table 2. -Machine weights
(particularly those
3.4. Assessment and diagnosis at risk of falls)
Despite the identification and clinical management of sarcopenia facilitate referral for further diagnostic and prognostic testing such as
being a relatively new clinical consideration for medical and allied MRI and/or DXA [53].
health practitioners to consider, there are multiple ways in which cli
nicians can screen for and diagnose sarcopenia. Following on from the
diagnosis section earlier in this masterclass, the easiest and most-time 3.5. Exercise rehabilitation
efficient tools at an osteopath’s disposal are gait and grip strength, as
well as sit to stand if no synamometer is available. Our recommendation Exercise is a mainstay in the management of sarcopenia [55], and
for musculoskeletal allied health providers is to use the SDOC criteria, as therefore should form the major part of osteopathic management with
they require no imaging and are more sensitive to disease. If suspicious these patients. In particular, resistance training shows promise in
of sarcopenia from either the history or a basic examination, a simple improving muscle mass and strength, and functional performance in
grip strength measurement can further aid in its diagnosis, in line with sarcopenic individuals [56], and can also reduce the risk of falls in the
the criteria described in Table 1 [53]. This can be easily followed by gait elderly [57], and importantly, their subsequent seqeulae. Additionally,
speed assessment, using a 3–10 m walking space with a 2 m acceleration despite aerobic training having little effect on muscle mass or strength, it
and deceleration zone. Speeds less than 0.8 m/s are suggestive of sar appears to have utility in preserving pre-existing muscle and improving
copenia. It is important to consider the effect of common musculoskel mitochondrial function [58]. Therefore, the current evidence suggest a
etal conditions such as osteoarthritis on these tests, as they may limit the mixed resistance and aerobic training program is best practice when
individual through stiffness or pain. However, do not allow this to trying to improve the physiological changes induced by sarcopenia [55,
equate to a negative test, as these conditions can, and do, co-exist – if 58]. An example program has been provided in Table 3.
there is enough clinical suspicion, referral for body composition As most people with sarcopenia will present to the osteopath with
assessment will aid in assessment. In some allid health settings, a grip symptoms of a separate musculoskeletal condition, which may, or may
strength dynamometer may not be available, or space constraints may not be related to their underlying sarcopenia, exercise rehabilitation
make assessment of gait speed challenging. In these cases, an alternative prescription should firstly consider the presenting patient complaint.
is the chair stand test, which measures how fast an individual can sit up The patient’s pain and level of function may make it challenging for
and down in a chair five times [53,54]. If it takes longer than 12 s to them to complete a whole-body resistance program. In this instance, the
complete this it can also indicate the presence of sarcopenia [53]. program should focus on decreasing pain and increasing function of the
Also consider the implementation of various other physical perfor injured area, guided by general principles of exercise rehabilitation,
mance tests for screen and/or monitoring, such as: gait speed; short slowly progressing load and difficulty, and eventually transitioning
physical performance battery (SPPB); the timed-up-and-go-test (TUG); them to a specific sarcopenia exercise program. It is also important to
or the 400-m walk test, however, these are not required for diagnosis, take into consideration that although the program will focus on the area
and will depend on the time available with a patient, and clinical fa of concern, if a patient is willing and able to, exercises prescribed for
cilities [53]. If any of these assessment tools reach the thresholds for non-painful areas of body, and the physiological effect they have, may
sarcopenia, it is appropriate to assume the patient has sarcopenia until have two-fold benefits on both the painful condition [59] and the sar
proven otherwise. Importantly, and if not done already, the referral to a copenia itself [3]. For example, if sarcopenic patient presents with
general practitioner or specialist geriatrician should commence to Achilles’ tendon pain, prescribing seated upper-body resistance exer
oversee the patient’s pharmacological and overall management and cises may be have added benefit, when used in conjunction with an
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