Clinician Guide - Sarcopenia

Download as pdf or txt
Download as pdf or txt
You are on page 1of 7

International Journal of Osteopathic Medicine 45 (2022) 1–7

Contents lists available at ScienceDirect

International Journal of Osteopathic Medicine


journal homepage: www.elsevier.com/locate/ijosm

A clinician’s guide to the management of geriatric musculoskeletal disease:


Part 2 – Sarcopenia
Nicholas Tripodi a, b, c, Breanna Wright d, Amy Lawton d, Jesse Zanker c, e, Jack Feehan a, c, *
a
Institute for Health and Sport, Victoria University, Melbourne, Australia
b
First Year College, Victoria University, Melbourne, Australia
c
Australian Institute for Musculoskeletal Science, Victoria University, Western Health and the University of Melbourne, Melbourne, Australia
d
Osteopathy Group, College of Health and Biomedicine, Victoria University, Melbourne, Australia
e
Department of Medicine - Western Health, The University of Melbourne, Melbourne, Australia

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

mechanisms, but their duplicative effect on patient outcomes is more


important to consider. A patient with osteosarcopenia is more likely to
fall, and subsequently is at significantly greater risk of fracture than
individuals with sarcopenia or osteoporosis alone [6]. Research on
osteosarcopenia is growing [7], and although its true impact and inci­
dence are still unknown, it is implicated in a large number of fragility
fractures, making identification particularly important [5]. Holistic
patient management is key in the face of osteosarcopenia, and screening
of both bone and muscle will aid in the detection of disease.

1.2. Impact of sarcopenia

The true impact of sarcopenia can be difficult to quantify, as it has


effects on a wide range of critical health parameters. Estimates on its
prevalence vary widely, due in part to inconsistent methods of diagnosis
and widespread underdiagnosis, and vary from 4% to more than 40%
depending on the criteria used and the population characteristics [8].
Age of peak incidence is difficult to quantify, due to significant under­
diagnosis, slow onset, and disagreement between diagnostic criteria, but
it is strongly linked with increasing age [9]. The link between sex and
incidence is unclear, with some studies finding higher rates in males Fig. 1. Key pathophysiological changes in sarcopenia.
[10], but others finding no difference, particularly after adjustment for
body mass [11,12]. physiological changes intersect throughout the ageing process, leading
The impact of sarcopenia on patient morbidity is difficult to quantify, to the decline of muscle mass and function in later life. These include the
as opposed to osteoporosis, where there is a clear endpoint in fragility inflammation of ageing and chronic disease (termed “inflammaging”)
fracture. Perhaps the most well known adverse outcome of sarcopenia [20], changes to nutrition and physical activity, decreases in the number
are its associated falls. Falls in older adults are a significant cause of of motor units and satellite cells, alteration to endocrine signalling, an
injury, hospitalisation, disability, and mortality, with sarcopenia being a imbalance between muscle anabolism and catabolism and reduced
common contributing factor [13]. While falls account for a significant vascular and neurological supply [21,22]. These changes lead to dete­
portion of the burden of sarcopenia, the disease itself is also strongly rioration of muscle mass, quality and function (Fig. 1).
associated with a host of other detrimental health outcomes, including Structurally, the underlying pathogenic mechanisms lead to several
depression, physical disability, and loss of independence [14], as well as changes in both muscle mass and quality. Sarcopenic muscle has a lower
all-cause mortality [15], highlighting the importance of effective fibre density, with the change particularly affecting type II fibres [3].
management. There is also significant fat infiltration into the muscle, as well as
Few studies have examined the healthcare costs of sarcopenia, and neurological and vascular atrophy, leading to a smaller cross-sectional
the inconsistencies in diagnostic criteria make the few available difficult area overall. Consequently, there is a lesser volume of contractile tis­
to generalise. Despite this, there is agreement between studies that it sue, and a consequent reduction in capacity for force generation.
significantly increases healthcare spending [16]. One study found that Functionally, what active contractile tissue remains generates less force,
in the year 2000, sarcopenia related injury cost the US healthcare system due to the loss of type II fibres, less motor neuron input and fewer sar­
$18.5 billion USD [17], and between 1999 and 2004, hospitalisation of comeres, leading to significant losses in muscle strength, and ultimately
individuals with sarcopenia alone cost $40.4 billion USD [18]. The in­ the clinical impacts associated with sarcopenia [23].
dividual healthcare costs for patients with sarcopenia have been esti­
mated to increase by $2315 per patient USD annually compared to 2. Medical management of sarcopenia
non-sarcopenic individuals [18]. Despite these significant costs, trans­
lational and interventional research in sarcopenia remains under­ 2.1. Diagnosis of sarcopenia
studied, with significant scope to improve the outcomes of both patients
and healthcare systems. In an allied health setting, effective identifica­ The diagnosis of sarcopenia has been a contentious issue in recent
tion of those living with or at risk of sarcopenia could significantly years, with a range of proposed criteria by which it may be identified.
reduce this burden. Historically sarcopenia has been assessed through a range of body
composition parameters, such as appendicular lean mass adjusted for
1.3. Pathophysiology of sarcopenia height or body mass, alongside clinical evaluation of muscle strength
and performance, including grip strength, gait velocity and evaluation of
Sarcopenia can be classified as primary or secondary, depending sit to stand time [23]. The three primary diagnostic criteria used glob­
upon the underlying aetiology [3]. Primary sarcopenia is age-related, ally are the consensus-driven Revised European Working Group on
occurring in later life, while secondary is due to an underlying disease Sarcopenia in Older People (EWGSOP2) [24], and the data-driven Sar­
process, commonly malignancy, inflammatory disease, endocrine pa­ copenia Definitions and Outcomes Consortium (SDOC) criteria. The
thology or malnutrition [3]. Secondary sarcopenia in the oncology Asian Working Group for Sarcopenia (AWGS) have also generated a
setting is a contentious issue as it is commonly seen as a part of the regionally tailored definition based broadly on the EWGSOP2 guide­
process of cachexia, however, the two conditions are distinct, with lines, with modified cut-offs [25]. These guidelines are all principally
cachexia defined as loss of lean tissue of more than 5%, or a body mass based on physical performance testing, and body composition analysis,
index of <20kg/m2 in the presence of a chronic disease [19]. The and are summarised in Table 1.
mechanisms that underpin secondary sarcopenia are dependent on the The EWGSOP2 diagnostic process begins with clinical suspicion,
disease process but are in part mirrored by the pathophysiology of pri­ commonly based on falls or fear of falls, noted decrease in strength or
mary disease. gait speed. The strength, assistance with walking, rising from a chair,
The pathophysiology of primary sarcopenia is complex and multi­ climbing stairs, and falls (SARC-F) questionnaire can be used to aid in
factorial, and there remain a number of unanswered questions. Several

2
N. Tripodi et al. International Journal of Osteopathic Medicine 45 (2022) 1–7

Table 1 composition findings of less than 20 kg (males) and 15 kg (females) of


Key diagnostic criteria for sarcopenia. appendicular lean mass (ALM) (also called appendicular skeletal mus­
European Working Group on Sarcopenia in Older People 2 cle), or an ALM/height2 of less than 7kg/m2 and 6.0kg/m2 (mal­
e/female) confirming the diagnosis of sarcopenia [24]. The EWGSOP2
Probable Sarcopenia: Low Muscle Strength Sarcopenia: Severe Sarcopenia: Low
Low muscle muscle strength AND authors then recommend assessment of severity, using physical perfor­
strength muscle mass AND mance test, with specific evaluation of gait speed (<0.8 m/s), the short
AND muscle muscle performance physical performance battery (SPPB) (score of 8 or less) [28,29], timed
mass up and go (more than 20 s) [30], and 400 m walk test (more than 6 min
Low muscle strength Hand grip strength using dynamometer or non-completion) used to stratify the severity of disease. Compre­
Men: <27 kg hensive descriptions and outcomes of these assessments are available
Women: < 16 kg
through the cited references, and are widely available online for clini­
OR
Chair Stand (5 rises) cians. The EWGSOP2 criteria are widely used throughout Europe, and
Men and women: > 15 s have recently been adopted by the Australian and New Zealand Society
Low muscle mass ALM using whole-body DXA for Sarcopenia and Frailty Research [31].
Not adjusted for height To account for differences in body size and composition, the Asian
Men: < 20 kg
Women: <15 kg
Working Group for Sarcopenia AWGS) has generated a regionally spe­
OR cific protocol based on the EWGSOP2, with cut-offs adjusted for local
Adjusted for height2 populations [25]. The AWGS criteria follows a similar process to
Men: <7.0 kg/m2 EWGSOP2, but includes calf circumference measurement of less than 34
Women: <6.0 kg/m2
cm in males and 33 cm in females as at risk of sarcopenia. This mea­
Low physical performance Gait speed: ≤ 0.8 m/s
SPPB: ≤ 8 point score surement was also incorporated into a regionally specific SARC-F tool,
TUG: ≥ 20 s called the SARC-CalF to aid in clinician decision making [32]. Once high
400 m walk test: non-completion or > risk individuals are identified through screening, grip strength (<28 kg
6 min to complete in males and <18 kg in females) and chair stand testing (12 s or more for
Sarcopenia Diagnosis and Outcomes Consortium
Sarcopenia:
5 stands) is used to classify ‘possible sarcopenia’. Final diagnosis of
Low walking speed AND Low muscle strength sarcopenia is made in the presence of low muscle mass (BMI adjusted
Low normal walking speed Men and women: < 0.8 m/s ALM <7.0kg/m2 in males, <5.4kg/m2 in females) and low grip strength
Low muscle strength Handgrip strength (using the cut-offs above), or low physical performance (6 m walk test
Grip maximum value Men Women
<1 m/s, chair stand test >12s for 5 rises, and SPPB score of 9 or less).
Grip strength/BMI <35.5 kg <20 kg
Grip strength/total body fat <1.05/kg/kg/m2 <.79 kg/kg/m2 Severe sarcopenia is diagnosed in the presence of low muscle mass, grip
Grip strength/arm lean mass <1.66 kg/kg <.65 kg/kg strength and physical performance.
Grip strength/weight <6.08 kg/kg <3.26 kg/kg Recently, the sarcopenia definitions and outcomes consortium
<.45 kg/kg <.337 kg/kg (SDOC) undertook a classification and regression tree (CART) data-
Revised Asian Working Group on Sarcopenia
Sarcopenia: Severe sarcopenia:
informed approach to the diagnosis of sarcopenia, and identified gait
Low muscle mass AND low Muscle strength Low muscle mass AND low Muscle speed and grip strength as diagnostic criteria. These criteria grew from
OR Low Physical Performance strength and have since superseded the original Foundation for the National In­
AND Low Physical Performance stitutes of Health (FNIH) consensus criteria [33], in which ALM was
Low muscle mass ALM using whole-body DXA
included through consensus. Under the SDOC criteria, grip strength less
Adjusted for height2
Men: <7.0 kg/m2 than 35.5 kg in males and 20 kg in females, as well as gait velocity less
Women: <5.4 kg/m2 than 0.8 m/s are diagnostic of sarcopenia [34], with these factors linked
OR with key outcomes of disability, loss of mobility, falls, fractures and
Bioelectrical impedance analysis mortality [14,34]. Importantly for allied health clinicians, the SDOC
Men: <7.0 kg/m2
criteria specific do not require body composition analysis, allowing
Women: <5.7 kg/m2
Low muscle strength Hand grip strength using rapid assessment and management in the clinical setting.
dynamometer
Men: <28 kg 2.2. Management of sarcopenia
Women: < 18 kg
Low physical performance Men and women:
Gait speed: ≤ 1.0 m/s 2.2.1. Pharmacological management
Chair Stand (5 rises): Men and The treatment of primary sarcopenia is centred on reduction of falls
women: ≥12 s risk, exercise programs, and nutritional intervention. There are
SPPB: ≤ 9 point score currently no approved medications for primary sarcopenia [35] with
ALM: Appendicular lean mass; SPPB: Short physical performance battery; DXA: numerous targets of muscle anabolism, such as anti-myostatin anti­
Dual-Energy X-ray absorptiometry; BMI: Body Mass Index. bodies yet to produce clinically meaningful results [36]. In some cir­
cumstances, testosterone or oestrogen replacement has been used,
patient screening in clinical settings [26]. This prompts assessment of primarily in states of deficiency, such as post menopause and androgen
grip strength using a dynamometer, with results of less than 27 kg in deficiency syndromes. However the cardiovascular and other side ef­
males and 16 kg in females considered as probable sarcopenia. Chair fects associated with these medications makes them unsuitable for
stand testing can also be used (notably as it does not require any chronic use in a non-deficient population [37]. There has been some
equipment beyond a chair), with more than 15 s for 5 stands considered benefit shown with vitamin D supplementation, in the context of defi­
probable sarcopenia. Once probable sarcopenia is identified, it is ciency (<25 nmol/L) in older women, making this a worthwhile
considered enough clinical suspicion to initiate management and parameter to monitor and treat to a target of (75–100 nmol/L) –
investigation of causative factors, as well as referral for body composi­ particularly in light of the many other health benefits of adequate
tion assessment. This is done through dual x-ray absorptiometry (gold vitamin D levels [37]. However, notably there is some evidence to
standard), though bioelectrical impedance analysis and other higher suggest that large bolus or loading doses of vitamin D increase falls risk
resolution imaging methods can also be used in some settings [27]. Body [38], so supplementation of 800–1000IU of vitamin D daily is generally
sufficient in this population and may be associated with a decreased rate

3
N. Tripodi et al. International Journal of Osteopathic Medicine 45 (2022) 1–7

of falls [39]. While there are a number of other compounds under


investigation for sarcopenia, until they are approved, the mainstay of
treatment centres on exercise and nutrition.

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.

4
N. Tripodi et al. International Journal of Osteopathic Medicine 45 (2022) 1–7

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

5
N. Tripodi et al. International Journal of Osteopathic Medicine 45 (2022) 1–7

Achilles loading program.


If on the other hand the exercise program is being designed specif­
ically for sarcopenia, it should first take into factor in the programming
considerations proposed previously [56] which include: identifying
patient preferences; short and long-term goal setting; designing and
implementing a progressive, achievable, and sustainable program;
regularly evaluate the program and modify if necessary; and recommend
program supervision to increase compliance, motivation and safety.
Using this framework in conjunction with other sarcopenia exercise
recommendations [55,58] we have designed a general exercise program
to assist in the management of sarcopenia.
As with all geriatric interventions, safety, and in particular falls risk,
is paramount [60]. Although strength and aerobic training will reduce
falls risk, there are additional specific balance training exercises that can
be implemented [57]. In some patients, balance training may even need
to begin before any other gait, aerobic or resistance training can begin
[60]. Research suggests a common-sense approach be taken, performing Fig. 3. Key points for practice.
these exercises in a safe-environment (i.e. low falls risk), and slowly
progressing the difficulty of the exercises as the patient improves and 4. Conclusion
becomes more confident [60]. Some common balance exercises used in
this setting are standing on one leg, stepping over objects, and slowly In the face of a rapidly growing population of older adults, sarco­
moving up and down stairs, and can be progressed by increasing speed penia is a growing concern for individuals and health care systems. To
and volume, changing the surface characteristics, or closing one’s eyes counter this challenge, the musculoskeletal allied health workforce must
[60]. It is also crucial to ascertain if the sarcopenic individual’s home is be utilised to improve disease prevention, detection, and management
optimally set up to reduce falls risk. Elements such as railing, ramps and (Fig. 3). With relatively little impact on typical clinical routine, allied
non-slip matting, along with falls-prevention education should all be health providers can improve the long-term outcomes of their older
implemented in this population, and overseen by an appropriate mem­ patients. We hope this masterclass is a valuable tool, which empowers
ber of the healthcare team [4]. clinicians to incorporate strategies to prevent, detect and manage sar­
copenia in their daily practice. As musculoskeletal allied health pro­
viders play a continually expanding role in general health care globally,
3.6. Manual therapy: remember osteoporosis developing increasing competency in the care of older adults will
improve the impact of providers globally.
Manual therapy is an almost ubiquitous approach amongst osteo­
paths [61] and can aid joint range of motion and in decreasing pain Funding
levels from changes at the peripheral and central neurological level
[62]. Although manual therapy can be useful in managing a patients This research did not receive any specific grant from funding
presenting complaint, given current knowledge of sarcopenia’s patho­ agencies in the public, commercial, or not-for-profit sectors.
physiology, manual therapy is unlikely to have any utility in the primary
management of sarcopenia. Additionally, practitioners should be cog­
Ethical approval
nisant of the close relationship between osteoporosis and sarcopenia
(osteosarcopenia), and the potential for adverse reactions to manual
This research did not require human research ethics approval.
therapy, namely fractures [63]. If there is a clinical suspicion of osteo­
sarcopenia, in conjunction with a history of a fall, the patient should be
referred for radiology before any osteopathic management commences Declaration of competing interest
[4]. Additionally, it is estimated that up to 4.5% of back pain pre­
sentations can stem from an osteoporotic crush fracture [64], given the The authors declare no conflicts of interest for the project entitled ‘A
high proportion of osteopaths that manage back pain complaints [61], clinician’s guide to the management of geriatric musculoskeletal
patient with other risk factors of sarcopenia presenting acute or chronic disease: Part 2 - Sarcopenia.’
spinal pain is a clinical red flag, and should immediately be investigated
for fracture [64].
References

[1] Rosenberg IH. Summary comments. Am J Clin Nutr 1989;50(5):1231–3.


3.7. Management success [2] Anker SD, et al. Welcome to the ICD-10 code for sarcopenia. Wiley Online Library;
2016. p. 512–4.
[3] Cruz-Jentoft AJ, Sayer AA. Sarcopenia The Lancet 2019;393(10191):2636–46.
As with all clinical interventions, it is important to regularly evaluate [4] Feehan J, et al. A clinician’s guide to the management of geriatric musculoskeletal
interventions to determine if they have been meeting their set targets. disease: Part 1-Osteoporosis. Int J Osteopath Med 2022;43(March 2022):53–62.
Currently, in the clinical management of sarcopenia, clinicians should https://doi.org/10.1016/j.ijosm.2021.12.003.
[5] Kirk B, Zanker J, Duque G. Osteosarcopenia: epidemiology, diagnosis, and
look to assess the muscle strength and physical performance tests used in treatment—facts and numbers 2020;11(3):609–18.
the screening period and ideally should see improvements across the [6] Salech F, et al. Osteosarcopenia predicts falls, fractures, and mortality in Chilean
said tests, or at least see no further losses in strength or physical per­ community-dwelling older adults. J Am Med Dir Assoc 2021;22(4):853–8.
[7] Duque G. Osteosarcopenia: a geriatric giant of the XXI century. J Nutr Health Aging
formance [65]. The most important measures for assessing exercise
2021;25(6):716–9.
response are improvements in gait speed, patient quality of life, and [8] Mayhew AJ, et al. The prevalence of sarcopenia in community-dwelling older
their perceived strength and mobility, as grip strength rarely improves adults, an exploration of differences between studies and within definitions: a
significantly. That said, there is currently a need for further evaluation systematic review and meta-analyses. Age Ageing 2018;48(1):48–56.
[9] Therakomen V, Petchlorlian A, Lakananurak N. Prevalence and risk factors of
of many specific exercise, and non-exercise interventions’ effects on the primary sarcopenia in community-dwelling outpatient elderly: a cross-sectional
physical performance impediments posed by sarcopenia. study. Sci Rep 2020;10(1):19551.

6
N. Tripodi et al. International Journal of Osteopathic Medicine 45 (2022) 1–7

[10] Du Y, et al. Sex differences in the prevalence and adverse outcomes of sarcopenia [37] De Spiegeleer A, et al. Pharmacological interventions to improve muscle mass,
and sarcopenic obesity in community dwelling elderly in East China using the muscle strength and physical performance in older people: an umbrella review of
AWGS criteria. BMC Endocr Disord 2019;19(1):109. systematic reviews and meta-analyses 2018;35(8):719–34.
[11] Yamada M, et al. Prevalence of sarcopenia in community-dwelling Japanese older [38] Sanders KM, et al. Annual high-dose oral vitamin D and falls and fractures in older
adults. J Am Med Dir Assoc 2013;14(12):911–5. women: a randomized controlled trial. JAMA 2010;303(18):1815–22.
[12] Shafiee G, et al. Prevalence of sarcopenia in the world: a systematic review and [39] Smith LM, Gallagher JC, Suiter C. Medium doses of daily vitamin D decrease falls
meta- analysis of general population studies. J Diabetes Metab Disord 2017;16:21. and higher doses of daily vitamin D3 increase falls: a randomized clinical trial.
21. J Steroid Biochem Mol Biol 2017;173:317–22.
[13] James SL, et al. The global burden of falls: global, regional and national estimates [40] Yoshimura Y, et al. Interventions for treating sarcopenia: a systematic review and
of morbidity and mortality from the Global Burden of Disease Study 2017 2020;26 meta-analysis of randomized controlled studies 2017;18(6):553. e1–553. e16.
(Suppl 2):i3–11. [41] Dent E, et al. International clinical practice guidelines for sarcopenia (ICFSR):
[14] Kirk B, et al. Sarcopenia definitions and outcomes consortium (SDOC) criteria are screening, diagnosis and management. J Nutr Health Aging 2018;22(10):1148–61.
strongly associated with malnutrition, depression, falls, and fractures in high-risk [42] Izquierdo M, et al. International exercise recommendations in older adults (ICFSR):
older persons. J Am Med Dir Assoc 2021;22(4):741–5. expert consensus guidelines. J Nutr Health Aging 2021;25(7):824–53.
[15] Beaudart C, et al. Health outcomes of sarcopenia: a systematic review and meta- [43] Kim H, et al. Exercise and nutritional supplementation on community-dwelling
analysis 2017;12(1):e0169548. elderly Japanese women with sarcopenic obesity: a randomized controlled trial.
[16] Bruyère O, et al. The health economics burden of sarcopenia: a systematic review. J Am Med Dir Assoc 2016;17(11):1011–9.
Maturitas 2019;119:61–9. [44] Bull FC, et al. World Health Organization 2020 guidelines on physical activity and
[17] Janssen I, et al. The healthcare costs of sarcopenia in the United States. J Am sedentary behaviour 2020;54(24):1451–62.
Geriatr Soc 2004;52(1):80–5. [45] Robinson SM, et al. Does nutrition play a role in the prevention and management of
[18] Goates S, et al. Economic impact of hospitalizations in US adults with sarcopenia. sarcopenia? Clin Nutr 2018;37(4):1121–32.
J. Frailty Aging 2019;8(2):93–9. [46] H. Arai, [Chapter 4] Treatment of sarcopenia, 2018, 18, 28-44.
[19] Evans WJ, et al. Cachexia: a new definition 2008;27(6):793–9. [47] Baum JI, Kim I-Y, Wolfe RRJN. Protein consumption and the elderly: what is the
[20] Franceschi C, et al. Inflammaging and anti-inflammaging: a systemic perspective optimal level of intake? 2016;8(6):359.
on aging and longevity emerged from studies in humans 2007;128(1):92–105. [48] Oktaviana J, et al. The effect of protein supplements on functional frailty in older
[21] Riuzzi F, et al. Cellular and molecular mechanisms of sarcopenia: the S100B persons: a systematic review and meta-analysis 2020;86:103938.
perspective 2018;9(7):1255–68. [49] Phillips SM, Martinson W. Nutrient-rich, high-quality, protein-containing dairy
[22] Kirk B, et al. Muscle, bone, and fat crosstalk: the biological role of myokines, foods in combination with exercise in aging persons to mitigate sarcopenia. Nutr
osteokines, and adipokines 2020;18(4):388–400. Rev 2018;77(4):216–29.
[23] Kim TN, K.M.J.J.o.b.m. Choi. Sarcopenia: definition Epidemiol Pathophysiol 2013; [50] Liao C-D, et al. The role of muscle mass gain following protein supplementation
20(1):1–10. plus exercise therapy in older adults with sarcopenia and frailty risks: a systematic
[24] Cruz-Jentoft AJ, et al. Sarcopenia: revised European consensus on definition and review and meta-regression analysis of randomized trials 2019;11(8):1713.
diagnosis. Age Ageing 2019;48(1):16–31. [51] Akune T, et al. Exercise habits during middle age are associated with lower
[25] Chen LK, et al. Asian working Group for sarcopenia: 2019 consensus update on prevalence of sarcopenia: the ROAD study. Osteoporos Int 2014;25(3):1081–8.
sarcopenia diagnosis and treatment. J Am Med Dir Assoc 2020;21(3):300–307.e2. [52] Pratt J, et al. Genetic associations with aging muscle: a systematic review. Cells
[26] Malmstrom TK, et al. SARC-F: a symptom score to predict persons with sarcopenia 2019;9(1).
at risk for poor functional outcomes. J Cachexia Sarcopenia Muscle 2016;7(1): [53] Cruz-Jentoft AJ, et al. Sarcopenia: revised European consensus on definition and
28–36. diagnosis. Age Ageing 2019;48(1):16–31.
[27] Buckinx F, et al. Pitfalls in the measurement of muscle mass: a need for a reference [54] Beaudart C, et al. Sarcopenia in daily practice: assessment and management. BMC
standard 2018;9(2):269–78. Geriatr 2016;16(1):1–10.
[28] Pavasini R, et al. Short Physical Performance Battery and all-cause mortality: [55] Marzetti E, et al. Physical activity and exercise as countermeasures to physical
systematic review and meta-analysis. BMC Med 2016;14(1):215. 215. frailty and sarcopenia. Aging Clin Exp Res 2017;29(1):35–42.
[29] Guralnik JM, et al. A short physical performance battery assessing lower extremity [56] Phu S, Boersma D, Duque G. Exercise and sarcopenia. J Clin Densitom 2015;18(4):
function: association with self-reported disability and prediction of mortality and 488–92.
nursing home admission. J Gerontol 1994;49(2):M85–94. [57] Hewitt J, et al. Progressive resistance and balance training for falls prevention in
[30] Bischoff HA, et al. Identifying a cut-off point for normal mobility: a comparison of long-term residential aged care: a cluster randomized trial of the sunbeam
the timed ‘up and go’test in community-dwelling and institutionalised elderly program. J Am Med Dir Assoc 2018;19(4):361–9.
women 2003;32(3):315–20. [58] Yoo S-Z, et al. Role of exercise in age-related sarcopenia. J Exerc Rehabil 2018;14
[31] Zanker J, et al. The Australian and New Zealand society for sarcopenia and frailty (4):551.
research (ANZSSFR) sarcopenia diagnosis and management task force: findings [59] Hodges PW, Smeets RJ. Interaction between pain, movement, and physical
from the consumer delphi process 2021;40(S1):55–6. activity: short-term benefits, long-term consequences, and targets for treatment.
[32] Lim W, et al. Case for validated instead of standard cut-offs for SARC-CalF 2019;23 Clin J Pain 2015;31(2):97–107.
(4):393–5. [60] Izquierdo M, et al. International exercise recommendations in older adults (ICFSR):
[33] Studenski SA, et al. The FNIH sarcopenia project: rationale, study description, expert consensus guidelines. J Nutr Health Aging 2021;25(7):824–53.
conference recommendations, and final estimates. J Gerontol A Biol Sci Med Sci [61] Adams J, et al. A workforce survey of Australian osteopathy: analysis of a
2014;69(5):547–58. nationally-representative sample of osteopaths from the Osteopathy Research and
[34] Bhasin S, et al. Sarcopenia definition: the position statements of the sarcopenia Innovation Network (ORION) project. BMC Health Serv Res 2018;18(1):352.
definition and outcomes consortium 2020;68(7):1410–8. [62] Fryer G. Integrating osteopathic approaches based on biopsychosocial therapeutic
[35] Kwak JY, Kwon K-S. Pharmacological interventions for treatment of sarcopenia: mechanisms. Part 2: clinical approach. Int J Osteopath Med 2017;26:36–43.
current status of drug development for sarcopenia. Ann Geriatr Med Res 2019;23 [63] Bennell K, Khan K, McKay H. The role of physiotherapy in the prevention and
(3):98–104. treatment of osteoporosis. Man Ther 2000;5(4):198–213.
[36] Rooks D, R.J.T.J.o.f.. Roubenoff, and aging. Dev Pharmacother Treat Sarcopenia [64] Finucane LM, et al. International framework for red flags for potential serious
2019;8(3):120–30. spinal pathologies. J Orthop Sports Phys Ther 2020:1–23. 0.
[65] Marzetti E, et al. Sarcopenia: an overview. Aging Clin Exp Res 2017;29(1):11–7.

You might also like