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UNIVERSIDADE ESTADUAL DE CAMPINAS
FACULDADE DE EDUCAÇÃO FÍSICA
RICARDO AURÉLIO CARVALHO SAMPAIO
SARCOPENIA E FATORES ASSOCIADOS EM IDOSOS BRASILEIROS: DO
DIAGNÓSTICO À INTERVENÇÃO
SARCOPENIA AND ASSOCIATED FACTORS IN BRAZILIAN OLDER ADULTS:
FROM DIAGNOSIS TO INTERVENTION
CAMPINAS
2017
2
RICARDO AURÉLIO CARVALHO SAMPAIO
SARCOPENIA E FATORES ASSOCIADOS EM IDOSOS BRASILEIROS: DO
DIAGNÓSTICO À INTERVENÇÃO
SARCOPENIA AND ASSOCIATED FACTORS IN BRAZILIAN OLDER ADULTS:
FROM DIAGNOSIS TO INTERVENTION
Tese apresentada à Faculdade de Educação Física da
Universidade Estadual de Campinas como parte dos
requisitos exigidos para obtenção do título de Doutor em
Educação Física, na área de concentração Atividade Física
Adaptada.
ORIENTADOR: PROF. DR. GUSTAVO LUIS GUTIERREZ
CO-ORIENTADOR: PROF. DR. MARCO CARLOS UCHIDA
ESTE EXEMPLAR CORRESPONDE À VERSÃO FINAL
DA TESE DEFENDIDA PELO ALUNO RICARDO
AURÉLIO CARVALHO SAMPAIO, E ORIENTADA
PELO PROF. DR. GUSTAVO LUIS GUTIERREZ
CAMPINAS
2017
3
Agência(s) de fomento e nº(s) de processo(s): CAPES, 01P04373/2015
Ficha catalográfica
Universidade Estadual de Campinas
Biblioteca da Faculdade de Educação Física
Dulce Inês Leocádio dos Santos Augusto - CRB 8/4991
Sampaio, Ricardo Aurélio Carvalho, 1986-
Sa47s Sam Sarcopenia e fatores associados em idosos brasileiros: do diagnóstico à
intervenção / Ricardo Aurélio Carvalho Sampaio. – Campinas, SP : [s.n.], 2017.
Sam
Orientador: Gustavo Luis Gutierrez.
Coorientador: Marco Carlos Uchida.
Tese (doutorado) – Universidade Estadual de Campinas, Faculdade de
Educação Física.
Sam
1. Envelhecimento. 2. Força muscular. 3. Aptidão física - Testes. 4.
Qualidade de vida. I. Gutierrez, Gustavo Luis. II. Uchida, Marco Carlos. III.
Universidade Estadual de Campinas. Faculdade de Educação Física. IV. Título.
Informações para Biblioteca Digital
Título em outro idioma: Sarcopenia and associated factors in Brazilian older adults: from
diagnosis to intervention
Palavras-chave em inglês:
Aging
Strength
Physical fitness - Tests
Quality of life
Área de concentração: Atividade Física Adaptada
Titulação: Doutor em Educação Física
Banca examinadora:
Gustavo Luis Gutierrez [Orientador]
Edison Duarte
Flávia Silva Arbex Borim
Vanessa Helena Santana Dalla Déa
Reury Frank Pereira Bacurau
Data de defesa: 12-06-2017
Programa de Pós-Graduação: Educação Física
4
COMISSÃO EXAMINADORA:
Prof. Dr. Gustavo Luis Gutierrez
(Faculdade de Educação Física/UNICAMP)
(Presidente)
Dr. Edison Duarte
(Faculdade de Educação Física/UNICAMP)
(Membro titular)
Dra. Flávia Silva Arbex Borim
(Faculdade de Ciências Médicas/UNICAMP)
(Membro titular)
Dra. Vanessa Helena Santana Dalla Déa
(Universidade Federal de Goiás)
(Membro titular)
Dr. Reury Frank Pereira Bacurau
(Universidade de São Paulo)
(Membro titular)
A Ata da defesa com as respectivas assinaturas dos membros encontra-se no processo de vida
acadêmica do aluno.
4
AGRADECIMENTOS
Agradeço imensamente ao Prof. Dr. Gustavo Luis Gutierrez e ao Prof. Dr. Marco
Carlos Uchida, pelas orientações, incentivos e assistências que por diversas vezes excederam
os limites acadêmicos. Estendo, com mesmo empenho, o agradecimento às suas famílias.
À Priscila e Alice, esposa e filha, maiores parceiras da vida e prontas para
qualquer novo desafio.
Aos meus pais e irmãos, por toda a base, afeto e formação que me possibilitou
chegar muito longe.
À Silvia Toshie por estar presente nas incontáveis coletas, sempre disposta a
ajudar.
A TODOS os amigos integrantes do LCA – Laboratório de Cinesiologia Aplicada
e GEPEFAN – Grupo de Estudos e Pesquisa em Exercício Físico e Adaptações
Neuromusculares, pelo suporte, compromisso e empenho de estarem presentes em diversas
coletas de dados, mesmo que em diferentes cidades.
Aos participantes das pesquisas e aos que viabilizaram a sua execução de alguma
forma, sua confiança e colaboração proporcionaram um período de grande aprendizado.
À banca de qualificação e defesa, Dr. Edison Duarte, Dra. Flávia Silva Arbex
Borim, Dra. Vanessa Helena Santana Dalla Déa e Dr. Reury Frank Pereira Bacurau pela
valiosa contribuição dada ao trabalho.
Aos coordenadores da Pós-graduação, Dra. Cláudia Cavaglieri (anterior) e Dr.
Edivaldo Góis (atual), por todo o suporte quando necessário.
À secretária da pós-graduação da FEF, Simone Ide, por sempre estar de bom
humor e disposta a ajudar prontamente nas questões burocráticas.
Aos Professores e colegas com quem tive a oportunidade de cursar disciplinas,
discutir e aprender bastante durante o período de doutoramento, seja na FEF, seja na
Gerontologia/FCM.
À Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)
(#01P04373/2015), pelo apoio financeiro para a realização e conclusão desta tese.
5
RESUMO
O envelhecimento no Brasil representa grande desafio para a saúde pública
contemporânea, uma vez que acontece de forma acelerada e pode ser acompanhado de
diversas condições adversas, como a sarcopenia, síndrome da fragilidade, e o consequente
declínio da qualidade de vida (QV), que frequentemente resultam em institucionalização e
mortalidade. Esta tese está estruturada com base em três artigos científicos, além de capítulos
de introdução e conclusão. No primeiro artigo, “Cutoff values of appendicular skeletal
muscle mass and strength associated to fear of falling in Brazilian older adults”, foram
apresentados comparações entre grupos de idade por sexo em relação a aspectos
morfofuncionais; e valores específicos de corte para massa muscular apendicular (i.e., soma
da massa muscular dos membros) ajustada pelo índice de massa corporal (MMA(IMC)) e força
(i.e., força de preensão manual, absoluta e relativa [ajustada pelo índice de massa corporal])
em associação ao medo de cair em idosos brasileiros (n=578). Níveis de funcionalidade
diminuíram com a idade, enquanto a composição corporal variou entre sexos. Associados ao
medo de cair, os pontos de corte para MMA(IMC) foram <0,85 para homens e <0,53 para
mulheres; para força de preensão manual absoluta e relativa foram <30,0 kgf e <21,7 kgf; e
<1,07 e <0,66, para homens e mulheres, respectivamente. O segundo artigo verificou a
associação dos pontos de corte, assim como a combinação desses fatores, com QV (n=577).
Lentidão da caminhada foi estabelecida em <0,8 m/s. O artigo foi intitulado “Sarcopenia
cutoffs in Brazilian older adults are associated to health-related quality of life”. Em homens,
resultados da combinação de força de preensão manual absoluta e/ou velocidade de
caminhada foram associados com os domínios função física, aspectos físicos e saúde geral de
QV. Em mulheres, a combinação de força de preensão manual (absoluta e relativa) e/ou
velocidade da caminhada e MMA(IMC) apresentou associações com os domínios função física,
aspectos físicos, dor corporal, saúde geral e função social. O terceiro artigo analisou a
aplicação de exercícios de potência utilizando bandas elásticas (16 semanas), em idosos
frágeis (n=11) e residentes em uma instituição de longa permanência. O artigo foi intitulado
“Influence of power training on physical function and health-related quality of life in
institutionalized frail older adults: a case-study”. Pós-intervenção, mudanças foram
observadas nos domínios de QV – função física, aspectos físicos, dor corporal, aspectos
emocionais e sumário dos componentes físicos, em homens; e aspectos físicos, aspectos
emocionais e saúde mental, em mulheres. Em relação à função física, melhoras na velocidade
da caminhada e número de repetições no teste de remada com banda elástica foram
6
observadas, em homens; e velocidade da caminhada, repetições no teste de remada com
banda elástica e timed up and go, em mulheres. Os dados apresentados podem ser utilizados
como referência para pesquisadores ou na prática profissional. Mais ainda, podem servir de
referência para o desenvolvimento de políticas públicas relacionadas à saúde e bem estar dos
idosos. Pois uma vez conhecidas as demandas, intervenções podem ser melhores destinadas à
promoção da saúde dessa população.
Palavras-Chave: envelhecimento; força muscular; aptidão física - testes; qualidade de vida.
7
ABSTRACT
Aging in Brazil represents a major challenge for contemporary public health,
once happens fast and can be associated with several adverse health conditions, such as
sarcopenia, frailty syndrome, and decline in quality of life (QOL), which often result in
higher institutionalization and mortality rates. This work is structured on the basis of three-
paper format, as well as introduction and conclusion sections. In the first article, "Cutoff
values of appendicular skeletal muscle mass and strength associated with fear of falling in
Brazilian older adults", we presented comparisons between age groups by sex with regard to
morphological and functional aspects; and specific cutoff values for appendicular skeletal
muscle mass (i.e., sum of limbs muscle mass) adjusted by body mass index (ASM(BMI)) and
strength (i.e., handgrip strength, absolute and relative [adjusted by body mass index]) in
association with fear of falling in Brazilian older adults (n=578). Physical function decreased
as age increased, while body composition varied according to sex. In association to fear of
falling, cutoff values for ASM(BMI) were <0.85 for men and <0.53 for women; for absolute
and relative handgrip strength were <30.0 kgf and <21.7kgf; and <1.07 and <0.66, for men
and women, respectively. The second article verified the association of these cutoff points,
as well as the combination of such factors, with QOL (n=577). Slow walking speed was
established as <0.8 m/s. The article was entitled "Sarcopenia cutoffs in Brazilian older adults
are associated to health-related quality of life". In men, results of the combination of absolute
handgrip strength and/or walking speed were associated with physical functioning, role-
physical and general health domains of QOL. In women, the combination of handgrip
strength (both absolute and relative) and/or walking speed plus ASM(BMI) were associated
with physical functioning, role-physical, bodily pain, general health and social functioning.
The third article analyzed the application of power exercises using elastic bands (16 weeks),
in frail and institutionalized older people. The article was entitled "Influence of power
training on physical function and health-related quality of life in institutionalized frail older
adults: a case-study". Post-intervention results showed changes on physical functioning, role-
physical, bodily pain, role-emotional and physical component summary QOL domains, in
men; and role-physical, role-emotional and mental health, in women. Regarding physical
function, improvements on walking speed and number of repetitions in the elastic band
rowing test were observed, in men; and waking speed, repetitions in the elastic band rowing
test and the timed up and go, in women. The data presented herein might be useful as
reference for researchers and in professional practice. Moreover, might be useful for the
8
development of public policies related to older adults’ health. Once their demands are known,
more efficient intervention can be developed to promote health in this population.
Keywords: aging; strength; physical fitness - tests; quality of life.
9
LISTA DE ILUSTRAÇÕES
Artigo 1
Figure 1. ROC curves for appendicular skeletal muscle (ASM) with different
adjustments, and handgrip strength (HGS) (absolute and adjusted by body mass
index). Fear of falling was used as outcome variable. Data of men (A-B) and
women (C-D) are presented…………………………..................................................
33
Artigo 3
Figure 1. Flowchart of study procedures....................................................................... 61
10
LISTA DE TABELAS
Artigo 1
Table 1. Older adults’ characteristics………………................................................... 27
Table 2. Characteristics according to age in older men (n=122).................................. 28
Table 3. Characteristics according to age in older women (n=455)............................. 30
Table S1. Appendicular skeletal muscle adjusted by body mass index vs. Fear of
falling (Men).................................................................................................................
41
Table S2. Absolute handgrip strength vs. Fear of falling (Men).................................. 41
Table S3. Relative handgrip strength vs. Fear of falling (Men)................................... 42
Table S4. Appendicular skeletal muscle adjusted by body mass index vs. Fear of
falling (Women)............................................................................................................
42
Table S5. Absolute handgrip strength vs. Fear of falling (Women)............................ 43
Table S6. Relative handgrip strength vs. Fear of falling (Women).............................. 43
Artigo 2
Table 1. Subjects’ general characteristics.................................................................... 49
Table 2. Point biserial correlations for different cutoffs and combinations, and
health-related quality of life (men, n=122)...................................................................
51
Table 3. Point biserial correlations for different cutoffs and combinations, and
health-related quality of life (women, n=455)….…………………………………….
52
Artigo 3
Table 1. Participants’ general characteristics at baseline according to sex.................. 66
Table 2. Health-related quality of life pre and post intervention................................. 67
Table 3. Physical function tests pre and post intervention………………………….. 69
Table 4. Session rating of perceived effort at the beginning and at the final intensity
achieved……………………………………………………………………………….
69
11
LISTA DE ABREVIATURAS E SIGLAS
ACSM…………….... American College of Sports Medicine
ANOVA……………. Analysis of variance – Análise de variância
ANVISA…………… Brazilian Sanitary Agency – Agência de vigilância sanitária
ASM………………... Appendicular skeletal muscle
ASM(BMI)…..………. Appendicular skeletal muscle mass adjusted by body mass index
AUC………………... Area under the curve
AVD........................... Atividade da vida diária
AWGS……………... Asian Working Group for Sarcopenia
BIA………………… Bioelectrical impedance analysis
BMI……………....... Body mass index
Borg CR-10………... Adapted Borg scale 0-10
BP………………….. Bodily pain domain (Short-form 8 and 36)
d……………………. Cohen’s d effect size
EBRT………………. Elastic band rowing test
EWGSOP.................. European Working Group on Sarcopenia in Older People
FAST......................... Functional Assessment Staging of Alzheimer’s disease
FNIH……………….. Foundation for the National Institutes of Health
GH…………………. General health domain (Short-form 8 and 36)
HGS………………... Handgrip strength
HGS(ABS)…………… Absolute handgrip strength
HGS(BMI)…………… Handgrip strength adjusted by body mass index – relative handgrip
strength
HRQOL……………. Health-related quality of life
ICD-10....................... International Classification of Diseases
KCL………………... Kihon Checklist
LR+………………… Positive likelihood ratios
LR-…………………. Negative likelihood ratios
LTCI……………….. Long term care institution
MCS………………... Mental Component Summary (Short-form 36)
MH……………….… Mental health domain (Short-form 8 and 36)
MMA………………. Massa muscular appendicular
MMA(IMC)…………. Massa muscular appendicular ajustada pelo índice de massa corporal
12
MMSE……………... Mini-mental State Examination
NPV………………... Negative predictive value
PA/wk……………… Physical activity per week
PCS………………… Physical Component Summary (Short-form 36)
PF………………….. Physical functioning domain (Short-form 8 and 36)
PPV………………… Positive predictive value
QV.............................. Qualidade de vida
RE………………….. Role-emotional domain (Short-form 8 and 36)
RM…………………. Repetition maximum
ROC……………….. Receiver Operating Characteristics
RP………………….. Role-physical domain (Short-form 8 and 36)
Rpb…………………. Point biserial coefficient of correlation
SD………………….. Standard deviation
SF…………………... Social functioning domain (Short-form 8 and 36)
SF-8………………… Short-form 8 items
SF-36……………….. Short-form 36 items
SRPE………………. Session rating of perceived effort
TUG…………….….. Timed up and go
VO2max..................... Capacidade aeróbia máxima
VT………………….. Vitality domain (Short-form 8 and 36)
WHO......................... World Health Organization
WS…………………. Walking speed
13
SUMÁRIO
INTRODUÇÃO ....................................................................................................... 16
CUTOFF VALUES OF APPENDICULAR SKELETAL MUSCLE MASS AND
STRENGTH ASSOCIATED TO FEAR OF FALLING IN BRAZILIAN OLDER
ADULTS ......................................................................................................................
19
Abstract ……………………………………………………………………….. 19
Resumo ……………………………………………………………………….. 20
Introduction …………………………………………………………………... 21
Objective ………………………………………………………………............ 22
Methods ………………………………………………………………………. 22
Results …….………………………………………………………………….. 26
Discussion …………………………………………………………………….. 35
Conclusion ………………………………………………………………......... 38
References ………………………………………………………………......... 38
SARCOPENIA CUTOFFS IN BRAZILIAN OLDER ADULTS ARE
ASSOCIATED TO HEALTH-RELATED QUALITY OF LIFE ……………………
44
Abstract ……………………………………………………………………….. 44
Introduction …………………………………………………………………... 45
Methods ……...……………………………………………………………….. 45
Results ………………………………………………………………………... 47
Discussion …………………………………………………………………….. 53
References ……………………………………………………………………. 55
INFLUENCE OF POWER TRAINING ON PHYSICAL FUNCTION AND
HEALTH-RELATED QUALITY OF LIFE IN INSTITUTIONALIZED FRAIL
OLDER ADULTS: A CASE-STUDY …….................................................................
58
Abstract ……………………………………………………………………….. 58
Introduction ...………………………………………………………………… 59
Methods ………..……………………………………………………………... 59
Results ………………………………………………………………………... 65
Discussion …………………………………………………………………….. 70
References ……………………………………………………………………. 73
CONCLUSÃO ............................................................................................................. 77
14
REFERÊNCIAS ........................................................................................................... 78
ANEXO 1...................................................................................................................... 82
ANEXO 2...................................................................................................................... 83
16
INTRODUÇÃO
O envelhecimento é constituído e influenciado por mudanças complexas e
dinâmicas. Em nível biológico, é associado com o acúmulo gradual de uma ampla variedade
de danos moleculares e celulares. Com o tempo, estes danos levam a declínios graduais das
reservas fisiológicas, aumentando o risco para diversas doenças, o que resulta num declínio
geral na capacidade do indivíduo.1 Diversas condições adversas podem acompanhar o
envelhecimento tais como a sarcopenia, síndrome da fragilidade, incapacidade funcional, e o
consequente declínio da qualidade de vida (QV);2 que frequentemente resultam em
institucionalização e mortalidade.
A sarcopenia é entendida como a progressiva perda de massa muscular e
força/funcionalidade com o envelhecimento.2 Durante essa fase da vida, ocorre perda
quantitativa de massa muscular e alterações nas propriedades individuais das fibras
musculares, em particular, a redução seletiva no número e tamanho das fibras musculares do
tipo II, de contração rápida.3 Isso gera uma perda gradativa das capacidades físicas (e.g. força
e potência), o que resulta na diminuição do desempenho físico e das atividades da vida diária
(AVD), podendo culminar na perda da independência desses idosos.4
Idosos sarcopênicos apresentam risco elevados de quedas e maior prevalência de
medo de cair, levando a um ciclo vicioso de sarcopenia, declínio das capacidades físicas,
quedas e medo de cair, que resulta em incapacidade.5 Especialmente o medo de cair, é uma
condição associada a aspectos físicos e psicológicos, como quedas, perda de confiança,
restrição de atividades, isolamento social, que podem levar a dependência e incapacidade;6,7
ainda que não seja uma medida objetiva como os tradicionais desfechos, é uma importante
variável sobre condição de saúde dos idosos.
O termo sarcopenia (do grego, perda de carne) foi primeiro proposto por
Rosenberg, em 1989, para descrever o declínio de massa muscular associado à idade.8 No
entanto, conceitos contemporâneos, ainda que difiram em algumas características, suportam
que sarcopenia pode ser definida a partir de aspectos morfofuncionais: quantidade de massa
muscular, força muscular e função física. Assim, a quantidade e qualidade muscular são
utilizadas para o diagnóstico dos estágios sarcopênicos em idosos. Dentre as publicações
referentes à sarcopenia, alguns grupos se destacam no contexto internacional: “European
Working Group on Sarcopenia in Older People” (EWGSOP);2 “Society on Sarcopenia,
Cachexia and Wasting Disorders (study Sarcopenia with limited Mobility - an International
17
Consensus)”;9 “Asian Working Group for Sarcopenia (AWGS)”
10 e “Foundation for the
National Institutes of Health (FNIH) Sarcopenia Project”.11
A sarcopenia pode atingir cerca de 30% dos indivíduos com 65 anos ou mais e
50% das pessoas a partir dos 80 anos.2 No Brasil, Diz et al. (2016) verificaram uma
prevalência de 17%, indicando um alerta, à medida em que o crescimento da população idosa
se acentua.12
Tal condição influencia negativamente a QV e a saúde geral dos idosos, através
do aumento de incidência de morbidades (e.g. obesidade, hipertensão, diabetes tipo 2,
dislipidemias, osteoporose), aumento no risco de quedas e fraturas ósseas, diminuição do
condicionamento físico e capacidade aeróbia máxima (VO2max).13
Entende-se que a análise da QV constitui uma das avaliações mais representativas
da saúde de um indivíduo, partindo do pressuposto que uma percepção favorável da sua
própria saúde pode minimizar as condições que acompanham o processo de
envelhecimento.14
Além disso, QV pressupõe boa saúde mental, felicidade e sociabilização;
estando associado negativamente a doenças físicas e estados depressivos.15
Interessante, o
conceito de QV foi introduzido na pesquisa em saúde para complementar os já tradicionais
desfechos médicos, tais como mortalidade e morbidade.16
A literatura sugere que os fatores que contribuem para melhorar a QV de idosos
incluem manutenção da independência, autonomia, adaptabilidade, participação social, papel
na sociedade e outros.17
Adicionalmente, acredita-se que a prática regular de atividade física
pode preservar a saúde, bem–estar, vitalidade e a função social, entre outros fatores
importantes para a QV.18
Programas específicos de atividade física representam fator chave para a
manutenção das capacidades físicas, desaceleração ou até mesmo reversão dos aspectos de
sarcopenia e fragilidade;19,20
e recomendações na última década incluem a prática de
exercícios aeróbios, de força, de flexibilidade e de equilíbrio.21,22
É sabido que o treinamento de força possui papel importante na melhora das
funções musculares, físicas e até psicológicas, mesmo para idosos mais velhos.23,24
Estudos
também demonstraram a importância da utilização de treinos de potência (i.e. força
multiplicado pela velocidade, potência= força x velocidade) para idosos. Acredita-se que o
treinamento de potência pode promover benefícios adicionais à população idosa do que o
treinamento de força convencional,25
uma vez que a produção de força rápida se associa à
função física.26
De fato, em estudo de revisão, pesquisadores observaram que a taxa de
produção de força aumentou somente nos estudos em que os voluntários realizaram ações
explosivas;26
condição também observada em relação à função física.27
18
Esta tese está estruturada com base em três artigos. O primeiro, refere-se à
pesquisa “Cutoff values of appendicular skeletal muscle mass and strength associated to fear
of falling in Brazilian older adults”. Neste artigo, são propostos valores de referência de
massa muscular apendicular e força de preensão manual em idosos brasileiros, por acreditar
que valores baseados em idosos locais são preferíveis sob aqueles provenientes de
estrangeiros, principalmente pela diferença cultural e ambiental que influenciam bastante no
estilo de vida da população, o que por sua vez, é um fator determinante para como se
envelhece.
Assim, foram apresentados comparações entre grupos de idade no que concerne a
aspectos morfológicos e funcionais; e valores específicos de corte para massa muscular
apendicular (i.e., soma da massa muscular dos membros) ajustada pelo índice de massa
corporal (IMC) e força (i.e., força de preensão manual absoluta e relativa [ajustada pelo
IMC]) em associação ao medo de cair, em idosos brasileiros (n=578). A pesquisa foi
aprovada no Comitê de Ética da Universidade Estadual de Campinas (UNICAMP) sob o
protocolo #39437514.0.0000.5404 (ANEXO 1). Os dados estão também descritos no artigo
aceito para publicação no São Paulo Medical Journal/Evidence for Health Care, em maio de
2017.
O segundo artigo, verificou a associação dos pontos de corte específicos para
massa muscular apendicular ajustada pelo IMC, força de preensão manual absoluta e relativa,
velocidade da caminhada (com base em valores previamente estabelecidos), bem como a
combinação desses fatores, com QV (n=577). O artigo, com desenho transversal, foi
intitulado “Sarcopenia cutoffs in Brazilian older adults are associated to health-related
quality of life”. A pesquisa foi aprovada no Comitê de Ética da UNICAMP sob o protocolo
#39437514.0.0000.5404 (ANEXO 1).
O último artigo analisou a aplicação de um programa de exercícios em idosos
institucionalizados. O artigo foi intitulado “Influence of power training on physical function
and health-related quality of life in institutionalized frail older adults: a case-study”. A
hipótese do estudo foi que uma intervenção baseada em exercícios de potência poderia
influenciar a função física e melhora da QV. Onze idosos participaram das atividades de
intervenção que durou quatro meses. Eles foram avaliados antes do início do programa de
exercícios e após (17ª semana). Variáveis de função física e QV, entre outras, foram
realizadas. O protocolo de pesquisa foi aprovado pela UNICAMP sob o protocolo
#47092115.4.0000.5404 (ANEXO 2).
19
CUTOFF VALUES OF APPENDICULAR SKELETAL MUSCLE MASS AND
STRENGTH ASSOCIATED TO FEAR OF FALLING IN BRAZILIAN OLDER
ADULTS
ABSTRACT
CONTEXT AND OBJECTIVE: Sarcopenia is an emerging public health issue in
Brazil. Due to the rising prevalence, and the lack of national data, the objective was to
identify cutoff values for appendicular skeletal muscle (ASM), and handgrip strength
according to fear of falling in Brazilian older adults.
DESIGN AND SETTING: Cross-sectional study; community.
METHODS: 578 older adults participated in this study. Volunteers underwent to
morphological and functional evaluations; and were questioned about the prevalence of falls
and fear of falling. Different adjustments of ASM and handgrip strength were used. Slow
walking speed was established at <0.8m/s. Gender and age-groups were compared by T tests,
analysis of variance (ANOVA), chi-square or Fisher’s Exact Test. Receiver operating
characteristic curves identified cutoffs for ASM and handgrip strength in association to fear
of falling.
RESULTS: Physical function decreased with increasing age and body
composition varied according to gender. In association to fear of falling, ASM adjusted by
body mass index (ASM(BMI)) cutoffs were <0.85 for men and <0.53 for women; for absolute
handgrip strength and relative handgrip strength (adjusted by BMI) were 30.0 kgf, and 21.7
kgf; and 1.07, and 0.66, for men and women, respectively.
CONCLUSION: Values of physical function tests and other variables can be used
as reference at clinics and practice. Moreover, we encourage the use of ASM(BMI) and to
choose over absolute or relative handgrip strength for both men and women according to
study needs.
KEY WORDS: Aging; Hand strength; Muscle, Skeletal; Sarcopenia; Walking speed.
20
RESUMO
CONTEXTO E OBJETIVO: Sarcopenia é um problema de saúde emergente no
Brasil. Devido à alta prevalência e falta de valores nacionais, o objetivo foi identificar pontos
de corte para massa muscular apendicular (MMA) e força de preensão manual em associação
ao medo de cair em idosos brasileiros.
DESENHO E LOCAL: Transversal; comunidade.
MÉTODOS: 578 idosos foram submetidos a análises morfológicas e funcionais e
questionados sobre a prevalência de quedas e medo de cair. Diferentes ajustes de MMA e
força de preensão manual foram usados. Baixa velocidade da marcha foi estabelecida em
<0.8 m/s. Idosos divididos por gênero e idade foram comparados por testes T, análise de
variância (ANOVA), teste do qui-quadrado ou Exato de Fisher. Curvas Receiver operating
characteristic foram usadas para identificar os pontos de corte para MMA e força de
preensão manual em associação ao medo de cair.
RESULTADOS: Níveis de funcionalidade diminuíram com a idade, enquanto a
composição corporal variou entre sexos. Associados ao medo de cair, os pontos de corte para
MMA ajustada pelo índice de massa corporal (MMA(IMC)) foram <0.85 para homens e <0.53
para mulheres; para força de preensão manual absoluta e relativa (ajustada pelo IMC) foram
30.0 kgf e 21.7 kgf; e 1.07, e 0.66, para homens e mulheres, respectivamente.
CONCLUSÃO: Os valores apresentados podem ser usados como referência na
clínica e prática. Recomendamos o uso da MMA (IMC) e a escolha entre força de preensão
manual absoluta ou relativa para homens e mulheres de acordo com as necessidades do
estudo.
PALAVRAS-CHAVE: Envelhecimento; Sarcopenia; Músculo esquelético; Força da mão;
Marcha.
21
INTRODUCTION
Sarcopenia, defined as progressive loss of muscle mass and strength/functionality
with aging, is an emerging public health issue in Brazil.1 The loss of muscle mass and
function may result in loss of physical capabilities (e.g. endurance, strength, and muscle
power), poor quality of life, unfavorable metabolic effects, falls and fear of falling, frailty,
and mortality rate in older adults. Furthermore, sarcopenia is frequently associated with
multimorbidities, smoking habit, low body mass index (BMI), malnutrition, and physical
inactivity.2
Several consensuses and recommendations have been proposed by different
institutions attempting to standardize the conceptual approaches used to diagnose
sarcopenia.2,3,4,5
Among those, experts agree that three key factors should be approached:
body composition (muscle mass); functionality (e.g. walking speed), and muscle strength
(e.g. handgrip strength).
Studies estimate that after the age of 50 the muscle mass decreases consistently at
a rate of approximately 1% per year, walking speed at a rate of 2.0 - 2.2% and handgrip
strength at a rate of 1.9 - 5.0%, as a result of the transition process of decreasing lean body
mass and increasing fat accumulation.6,7
Cutoffs and reference values have also been
presented in the consensuses and recommendations. Besides the international characteristics
of the studies they compiled, most of them were conducted in developed countries and/or in
genetically, ethnically and culturally different countries than Brazil. Even when considering
the miscegenation of Brazilian population, inferences of such values in Brazilian older adults
are difficult and limited.
Therefore, considering the importance given to sarcopenia that recently
culminated in the determination of an International Classification of Diseases (ICD-10)
code;8 the rising prevalence in older Brazilians that already achieved 17%;
1 and the lack of
national preliminary data, the aim of this study was to identify cutoff values for appendicular
skeletal muscle (ASM), and handgrip strength according to fear of falling in Brazilian older
adults.
22
OBJECTIVE
The aim of this study was to identify evidence-based cutoff values for ASM, and
handgrip strength according to fear of falling; and secondarily, to verify the morphological
and functional characteristics in Brazilian older adults according to gender and age groups.
METHODS
Design
This study had a cross sectional design (frequency study) and data were collected
during 2015 and 2016.
Subjects
In total, 578 older adults (male n=122, female n=456) participated in this study.
They were recruited voluntarily from four community health centers for older adults in
southeastern and southern Brazil; however, individuals represent diversity of ethnicity, other
geographic areas, and a range of health and functional states.
The inclusion criteria were: a) community-dwelling people; b) 60 years old or
older, from both sexes; c) able to answer the questions, perform the functional and body
composition tests. Exclusion criteria were: a) individuals with uncontrolled cardiovascular or
pulmonary disease, with conditions associated with risk of falling (i.e. Parkinson’s disease or
stroke), physically and cognitively impaired (according to their report of chronical diseases
[e.g., presence of condition that might require assistance for basic activities of daily living],
and items present in the functional assessment staging of Alzheimer’s disease – FAST,
verified onsite); b) individuals using metal prosthesis and/or pacemaker (i.e., interference -
bioelectrical impedance analysis).
The present study was approved by the Ethical Committee of the University of
Campinas, protocol #39437514.0.0000.5404. All participants signed an informed consent
agreeing to participate in the study before data collection.
23
Assessments
The assessments were divided into two steps, to quote: a) indirect assessments
based on questionnaires, and b) direct assessments based on morphofunctional evaluations
(i.e., anthropometric characteristics and physical function). Before the evaluations, all tests
were explained in details by an experienced researcher to all participants. Verbal
encouragement was provided to assure that volunteers reached the best performance possible.
Indirect assessments
Chronical degenerative diseases, age, fear of falling and falls
A questionnaire was used to obtain data regarding the presence of chronical
diseases, age, the fear of falling and the occurrence of falls during the year prior to the
research. The questionnaire was based on simple questions, which were answered with
binary constructs (i.e., yes or no) avoiding possible misunderstanding among the researchers
and the volunteers. First, an extensive list of the most prevalent chronic diseases (e.g.,
hypertension, diabetes, osteoporosis) in older adults was presented to the volunteers. They
then stated yes or no if they presented a previous clinical diagnosis of the chronical
condition. These data are not shown and were used solely for exclusion purposes. In relation
to fear of falling, the following question was asked: “Are you afraid of falling?”. And the
following question was asked about the occurrence of falls: “Have you experienced a fall in
the past year?’’. Important to mention, only the question about occurrence of falls was
retrospective, so that all the other questions and evaluations were in relation to the period
where the study was performed.
Direct assessments
Anthropometrical measures
Height was measured by standard stadiometer and waist and hip circumferences
using a measuring tape. The body composition was assessed by bioelectrical impedance
analysis (BIA) (Tanita® BC-108, Tokyo, Japan). The equipment provided the weight of the
subject, and the height was inserted manually by the researcher. After analysis, values of
24
absolute and segmented muscle and fat mass were obtained. The Tanita BIA uses a frequency
of 50 kHz to measure the quantity of intra and extracellular water in the body. This
equipment has eight electrodes, four under the feet and four on volunteers’ hands.9,10
The
values of ASM (sum of muscle mass of limbs) are useful to diagnose sarcopenia. In this
study, we used several adjustments (i.e. by BMI, height squared, weight and non-adjusted
data) to verify the best approach in Brazilian older adults. Additional data concerning
absolute skeletal muscle was also provided.
Physical function
The walking speed was evaluated in a 10 meters distance. Outside marks of 12 m
in length were clearly placed on the ground during the walking test. Another 10-m long
delimitation was marked inside the previous one. Participants were asked to walk the entire
distance at their usual pace. The time required to complete the inner 10-m distance was
assessed.11
Continuous values of walking speed, as well as using 0.8m/s and 1.0m/s cutoffs
were also applied. The value 0.8 m/s has been suggested by other studies as representative of
slow walking. Also considering the range in walking speed that they found in such studies,
and the characteristics of the samples that we studied, 1 m/s was also used.2,3
The TUG has been widely described. The subject has to stand from a chair, to
walk three meters in straight line, to surround a cone and to return to the chair and sit.12
The handgrip strength was measured with a digital dynamometer Jamar (Jamar
Plus+®; Sammons Preston, Rolyon, Bolingbrook, IL). While seated, the subject held the
dynamometer with elbow flexed in 90° without touching his/her body. After preparation, they
were instructed to pull the lever at his/her maximum; each hand was tested once and the best
value was used in analysis. Subjects were also instructed to avoid the Valsava maneuver or
blocked breath while performing the test. Handle position two was set as standard for all
subjects as previously recommended.13
Statistical analyses
All analyses were carried out using the Statistical Package for the Social Sciences
(version 21.0, SPSS, IBM Inc., Chicago, IL, USA) and the MedCalc Statistical Software
version 17.2 (MedCalc Software, Ostend, Belgium). Descriptively, values are presented as
25
mean ± standard deviation (SD) for continuous variables and frequency (%) for categorical
values.
To compare older adults’ characteristics by gender, unpaired T tests and chi-
square tests were used for continuous and categorical variables, respectively. In analyzes by
age, subjects were divided into five groups (60 to 64, 65 to 69, 70 to 74, 75 to 79 and 80 +
years old). For continuous variables, analysis of variance (ANOVA) was used; when
statistical differences were found, Tukey Post Hoc test was applied. For categorical variables,
chi-square or Fisher’s Exact Test was used.
In addition, receiver operating characteristic (ROC) curve analyses were used to
verify cutoff values for ASM and handgrip strength in association to fear of falling. For this,
different adjustments of ASM, and handgrip strength were used; the curves were then
compared to verify statistical differences among them. The ROC curve compares true-
positive rate (sensitivity) versus false-positive rate (1 - specificity) across a range of values
for the ability to predict a dichotomous outcome. High sensitivity corresponds to high
negative predictive value, while high specificity corresponds to high positive predictive
value. Sensitivity and specificity were used to identify the cutoff values for ASM and
handgrip strength in this study.14
The area under the curve (AUC) is a measure of test
performance and describes the probability that a test will correctly identify individuals who
did and did not have a condition and were randomly selected from the cohort. Generally, the
closer the AUC is to 1, the better the overall diagnostic performance of the test, and the
closer to 0.5, the poorer the test.15,16
Sensitivity, specificity, positive (PPV) and negative
predictive values (NPV), and likelihood ratios (positive [LR+] and negative [LR-]) for ASM
and handgrip strength according to fear of falling were computed. Predictive values describe
the probability of a person having a condition once the results of his or her tests are known.
LR+ and LR- indicate how much the odds of a disease increase or decrease when a test is
positive and negative, respectively.
The fear of falling was selected as the primary outcome for this study because of
its association with psychological and physical aspects, such as falls, loss of confidence,
restriction of activities, social withdrawal, which may lead to dependence and disability.17,18
Other variables were considered as outcomes, such as falls and walking speed; however, due
to the small number of subjects with positive results or missing data further analyses were not
conducted. In all analyses, statistical significance was set at P <0.05.
26
RESULTS
In total, 578 older adults (male n=122, female n=456) participated in this study.
Their characteristics are descriptively shown in Table 1. The mean age was 70.0 ± 6.7 years
for male and 69.4 ± 6.6 for female. Women had lower strength and were more overweight
than men. Moreover, more women experienced a fall event in the year prior the research
(women 25.3% and men 14.4%) and reported fear of falling (women 65.7% and men 43.7%).
Regarding physical function, women had slow walking speed than men (Table 1).
Table 2 and 3 present study data according to gender, divided by age groups.
Higher rates of fear of falling in both groups were shown at the age group 80 years old or
more; however, only in men the difference was statistically significant. In older men, the age
group 60 to 64 years was stronger than those aged 80 or more when considering absolute
values of handgrip strength. Such difference was not verified when data was adjusted by
BMI. The age group 60 to 64 years also had higher skeletal muscle (total and adjusted by
height squared), and total ASM. Regarding walking speed and the TUG tests, the function
also decreased as age increased; a similar trend was observed regarding BMI, but not fat
percentage (Table 2).
It was evident that older women had slower walking speed, TUG, and lower
muscle strength than younger women, verified by both absolute and relative handgrip
strength. Fat percentage, BMI and skeletal muscle (total, adjusted by BMI, height squared,
and weight) also decreased with increasing age. Regarding ASM, only the total and the one
adjusted by height squared failed to show statistical differences (Table 3).
27
Table 1. Older adults’ characteristics
Older adults (n=578) P
Variables Male (n=122) Female (n=456)
Age (y) 70.5 ± 6.7 69.4 ± 6.6 0.11
Handgrip strength (kgf) 37.4 ± 8.1 24.2 ± 4.8 < 0.001
Relative handgrip strength
(Adjusted by body mass index)
1.4 ± 0.3 0.8 ± 0.2 < 0.001
Body mass index (kg/m2) 26.8 ± 3.5 28.3 ± 4.9 < 0.001
Fat percentage (%) 26.2 ± 6.1 41.1 ± 6.8 < 0.001
Total skeletal muscle mass (kg) 51.4 ± 6.7 36.2 ± 3.3 < 0.001
Skeletal muscle mass
(Adjusted by body mass index)
1.94 ± 0.2 1.31 ± 0.1 < 0.001
Skeletal muscle mass (kg/m2)
(Adjusted by height squared)
18.4 ± 1.4 15.3 ± 0.8 < 0.001
Skeletal muscle mass
(Adjusted by weight)
0.7 ± 0.05 0.5 ± 0.06 < 0.001
Total appendicular skeletal muscle (kg) 25.2 ± 4.0 16.4 ± 1.8 < 0.001
Appendicular skeletal muscle
(Adjusted by body mass index)
0.95 ± 0.1 0.59 ± 0.08 < 0.001
Appendicular skeletal muscle (kg/m2)
(Adjusted by height squared)
9.04 ± 1.0 6.9 ± 0.6 < 0.001
Appendicular skeletal muscle
(Adjusted by weight)
0.34 ± 0.03 0.25 ± 0.02 < 0.001
Falls in the year prior research 17 (14.4) 113 (25.3) 0.01
Fear of falling 52 (43.7) 291 (65.7) < 0.001
Waist circumference (cm) 97.5 ± 9.6 95.2 ± 11 0.03
Hip circumference (cm) 100.6 ± 6.3 103.5 ± 9.8 < 0.001
Timed Up and Go (s) 7.6 ± 2.6 8 ± 2.4 0.14
Usual walking speed (m/s) 1.3 ± 0.3 1.2 ± 0.2 0.03
Slow walking speed (by cutoff <0.8 m/s) 6 (5.0) 17 (3.8) 0.56
Slow walking speed (by cutoff <1.0 m/s) 18 (14.9) 62 (13.8) 0.77
Notes. Values are mean ± standard deviation and n (%).
28
Table 2. Characteristics according to age in older men (n=122)
Variables 60~64 (n=25) 65~69 (n=35) 70~74 (n=27) 75~79 (n=24) 80+ (n=11) P
Falls in the year prior research 3 (12.5) 5 (14.7) 3 (11.1) 3 (13.0) 3 (30.0) 0.69
Fear of falling 8 (32.0) 13 (38.2) 8 (30.8) 15 (65.2) 8 (72.7) 0.02
Waist circumference (cm) 99.9 ± 8.3 95.4 ± 8.1 99.6 ± 9.7 97.6 ± 11.3 93.4 ± 11.3 0.16
Hip circumference (cm) 102.3 ± 6 100.2 ± 4.6 100.8 ± 6.3 101.0 ± 7.4 96.4 ± 8.8 0.16
Handgrip strength (kgf) 40.4 ± 8.3 39.3 ± 6.5 37.7 ± 8.7 35.6 ± 6.8 28.6 ± 6.9ǂ < 0.001
Relative handgrip strength
(Adjusted by body mass index)
1.4 ± 0.2 1.4 ± 0.3 1.4 ± 0.4 1.3 ± 0.2 1.2 ± 0.2 0.13
Usual walking speed (m/s) 1.4 ± 0.2 1.4 ± 0.2 1.3 ± 0.3 1.2 ± 0.3† 1.0 ± 0.3
ǂ† < 0.001
Slow walking speed (by cutoff <0.8 m/s) -- -- 1 (3.7) 3 (12.5) 2 (18.2) 0.01
Slow walking speed (by cutoff <1.0 m/s) 1 (4) 1 (2.9) 5 (18.5) 5 (20.8) 6 (54.5) < 0.001
Timed Up and Go (s) 7 ± 1.8 6.6 ± 1.6 7.5 ± 2.10 8.8 ± 3.9† 10 ± 2.4
ǂ† < 0.001
Fat percentage (%) 27.5 ± 5.3 25.2 ± 5.9 26.7 ± 6.3 27.1 ± 5.3 22.3 ± 8.9 0.16
Body mass index (kg/m2) 27.8 ± 3.3 26.5 ± 3.2 27.1 ± 3.5 26.9 ± 3.8 23.4 ± 3.1
ǂ 0.03
Total skeletal muscle mass (kg) 54.4 ± 6.8 52.4 ± 4.4 50.4 ± 6.5 50.8 ± 7.8 44.0 ± 5.7ǂ 0.001
Skeletal muscle mass
(Adjusted by body mass index)
1.9 ± 0.2 1.9 ± 0.2 1.9 ± 0.2 1.9 ± 0.2 1.8 ± 0.2 0.51
Skeletal muscle mass (kg/m2)
(Adjusted by height squared)
18.9 ± 1.2 18.5 ± 1.5 18.4 ± 1.1 18.4 ± 1.5 17.1 ± 1.7ǂ 0.03
Skeletal muscle mass 0.6 ± 0.05 0.7 ± 0.05 0.7 ± 0.05 0.6 ± 0.05 0.7 ± 0.08 0.22
29
(Adjusted by weight)
Total appendicular skeletal muscle (kg) 26.3 ± 3.9 25.7 ± 2.8 26.6 ± 4.1 25.3 ± 5.0 21.6 ± 3.7ǂ 0.03
Appendicular skeletal muscle
(Adjusted by body mass index)
0.9 ± 0.1 0.9 ± 0.1 0.9 ± 0.1 0.9 ± 0.1 0.9 ± 0.1 0.70
Appendicular skeletal muscle (kg/m2)
(Adjusted by height squared)
9.1 ± 0.8 9.1 ± 0.9 8.9 ± 0.9 9.0 ± 1.1 8.4 ± 1.2 0.34
Appendicular skeletal muscle
(Adjusted by weight)
0.3 ± 0.02 0.3 ± 0.02 0.3 ± 0.03 0.3 ± 0.02 0.3 ± 0.04 0.15
Notes. Values are n (%) and mean ± standard deviation. Tukey Post Hoc test: ǂ: ≠60~64; †: ≠65~69.
30
Table 3. Characteristics according to age in older women (n=455)
Variables 60~64 (n=127) 65~69 (n=123) 70~74 (n=102) 75~79 (n=68) 80+ (n=35) P
Falls in the year prior research 25 (20.2) 30 (25.0) 27 (27.0) 21 (31.3) 9 (26.5) 0.52
Fear of falling 75 (60.5) 73 (60.8) 69 (69.7) 49 (73.1) 24 (75) 0.06
Waist circumference (cm) 95.7 ± 10.9 94.9 ± 10.1 97.2 ± 12.1 92.7 ± 10.8 93.3 ± 10.2 0.07
Hip circumference (cm) 104.7 ± 9 102.7 ± 8.9 105.2 ± 11.7 101.7 ± 9.9 100.7 ± 7.3 0.03
Handgrip strength (kgf) 25.5 ± 5 25.1 ± 4.5 24.5 ± 4.4 21.5 ± 3.8ǂ†‖
20.9 ± 4.7ǂ†‖
< 0.001
Relative handgrip strength
(Adjusted by body mass index)
0.8 ± 0.2 0.9 ± 0.2 0.8 ± 0.2 0.8 ± 0.1† 0.8 ± 0.2 0.01
Usual walking speed (m/s) 1.3 ± 0.2 1.3 ± 0.2 1.2 ± 0.2ǂ 1.2 ± 0.3
ǂ† 1 ± 0.3
ǂ†‖‡ < 0.001
Slow walking speed (by cutoff <0.8 m/s) -- 3 (2.5) 1 (1.0) 7 (10.4) 6 (17.6) < 0.001
Slow walking speed (by cutoff <1.0 m/s) 8 (6.5) 11 (9.2) 13 (12.7) 15 (22.4) 15 (44.1) < 0.001
Timed Up and Go (s) 7.0 ± 1.4 7.5 ± 1.9 8.2 ± 2.1ǂ 9.0 ± 2.9
ǂ† 11.0 ± 3.8
ǂ†‖‡ < 0.001
Fat percentage (%) 42.0 ± 6.1 40.9 ± 6.5 42.6 ± 6.7 39.4 ± 6.9‖ 37.3 ± 8.2
ǂ†‖ < 0.001
Body mass index (kg/m2) 29.2 ± 5.5 28.1 ± 4.2 29.1 ± 4.9 27.0 ± 4.3
ǂ‖ 25.9 ± 4.1
ǂ‖ < 0.001
Total skeletal muscle mass (kg) 36.9 ± 3.2 36.5 ± 3.2 35.9 ± 3.3 35.2 ± 3.4ǂ 34.9 ± 3.7
ǂ 0.001
Skeletal muscle mass
(Adjusted by body mass index)
1.3 ± 0.2 1.3 ± 0.1 1.2 ± 0.1 1.3 ± 0.1 1.3 ± 0.2‖ 0.008
Skeletal muscle mass (kg/m2)
(Adjusted by height squared)
15.4 ± 0.8 15.3 ± 0.8 15.4 ± 0.7 15.1 ± 0.6 14.9 ± 0.8ǂ‖ 0.009
Skeletal muscle mass 0.5 ± 0.05 0.5 ± 0.06 0.5 ± 0.05 0.5 ± 0.06ǂ‖ 0.5 ± 0.07
ǂ†‡ < 0.001
31
(Adjusted by weight)
Total appendicular skeletal muscle (kg) 16.4 ± 1.7 16.6 ± 1.8 16.4 ± 1.8 16.1 ± 2.0 16.3 ± 2.1 0.62
Appendicular skeletal muscle
(Adjusted by body mass index)
0.5 ± 0.07 0.5 ± 0.07 0.5 ± 0.07 0.6 ± 0.08ǂ 0.6 ± 0.09
ǂ‖ < 0.001
Appendicular skeletal muscle (kg/m2)
(Adjusted by height squared)
6.8 ± 0.6 6.9 ± 0.6 7.1 ± 0.6 6.9 ± 0.6 7.0 ± 0.7 0.15
Appendicular skeletal muscle
(Adjusted by weight)
0.2 ± 0.02 0.2 ± 0.02 0.2 ± 0.02 0.2 ± 0.03ǂ‖ 0.2 ± 0.03
ǂ†‖ < 0.001
Notes. Values are n (%) and mean ± standard deviation. Tukey post hoc test: ǂ: ≠60~64; †: ≠65~69; ‖: ≠70~74; ‡: ≠75~79.
32
The ROC curves and comparisons among them are presented in Figure 1.
Regarding ASM, the adjustment by BMI showed the best AUC for the association with fear
of falling. Then, cutoff values were identified for both men (0.85; AUC=0.81; confidence
interval 95% [CI 95%]: 0.73 – 0.89; P <0.001; sensitivity=33.3% and specificity=93.1%;
PPV=73% and NPV=70%; LR+=4.71 and LR-=0.72) and women (0.53; AUC=0.76; CI 95%:
0.71 – 0.81; P <0.001; sensitivity=30.6% and specificity=92.1%; PPV=87% and NPV=41%;
LR+=3.75 and LR-=0.76).
Concerning handgrip strength, absolute values showed slight better AUC than
relative handgrip strength in men, while the AUC of relative handgrip strength showed better
results in women. Considering this, cutoff values for both data will be provided. Thus, in
men, the identified cutoffs for absolute handgrip strength were 30.0 kgf (AUC=0.75; CI 95%:
0.66 – 0.84; P <0.001; sensitivity=39.1% and specificity=94.7%; PPV=81% and NPV=71%;
LR+=6.5 and LR-=0.64), and for women 21.7 kgf (AUC=0.56; CI 95%: 0.51 – 0.62; P=0.02;
sensitivity=29.9% and specificity=73.2%; PPV=67% and NPV=36%; LR+=1.07 and LR-
=0.97). Identified cutoffs for relative handgrip strength were 1.07 (AUC=0.74; CI 95%: 0.65
– 0.83; P <0.001; sensitivity=27.9% and specificity=93.2%; PPV=70% and NPV=69%;
LR+=3.85 and LR-=0.78), and 0.66 (AUC=0.67; CI 95%: 0.62 – 0.73; P <0.001;
sensitivity=22% and specificity=90%; PPV=82% and NPV=39%; LR+=2.2 and LR-=0.86),
for men and women, respectively. For computed 2x2 tables, refer to supplementary Tables
S1 to S6.
33
Men
A
B
AUC ASM (adjusted by BMI): 0.81 ASM (adjusted by height squared): 0.66 ASM (adjusted by weight): 0.74 ASM (non-adjusted): 0.73
AUC Handgrip strength (absolute): 0.75 Relative handgrip strength (adjusted by BMI): 0.74
ASM (non-adjusted) ≠ ASM (adjusted by height squared), p = 0.03 ASM (adjusted by BMI) ≠ ASM (adjusted by height squared), p = 0.02
34
Women
C
D
Figure 1. ROC curves for appendicular skeletal muscle (ASM) with different adjustments,
and handgrip strength (HGS) (absolute value and adjusted by BMI). Fear of falling was used
as outcome variable. Data of men (A-B) and women (C-D) are presented. Statistical
difference among or between curves were presented, when they occurred. AUC: area under
the curve.
ASM (non-adjusted) ≠ ASM (adjusted by BMI), p<0.001 ASM (adjusted by BMI) ≠ ASM (adjusted by weight), p<0.001 ASM (adjusted by BMI) ≠ ASM (adjusted by height squared), p<0.001 ASM (adjusted by height squared) ≠ ASM (adjusted by weight), p<0.001
Handgrip strength (absolute) ≠ Relative handgrip strength (adjusted by BMI), p<0.001
AUC ASM (adjusted by BMI): 0.76 ASM (adjusted by height squared): 0.43 ASM (adjusted by weight): 0.70 ASM (non-adjusted): 0.55
AUC Handgrip strength (absolute): 0.56 Relative handgrip strength (adjusted by BMI): 0.67
35
DISCUSSION
This study presented reference values of strength, physical function tests, body
composition, anthropometric measures, falls, and fear of falling by age in a community-based
cohort of older men and women from 60 years old. Moreover, cutoff values for ASM and
handgrip strength, useful to verify sarcopenia in older adults, were also presented according
to fear of falling.
As extensively reported in the literature, differences by gender concerning ASM,
strength, and body composition were observed, as well as decline in physical function with
increasing aging in older adults. The tests used in this study have clinical relevance, and
reference values of this nature are limited in Brazilian literature, increasing external validity
of this study. Even though some of them presented similar values as found in other
populations, local values are preferable when available, once regional characteristics can alter
results and comparison. This data can be useful for the clinician that needs reference values
to compare observed performance at clinical practice and in research, to compare different
populations.
Evidence from this study highlights the imminent hazard that surrounds the oldest
old group (80 years or more). They showed the highest fear of falling, which might have
impacted on their worst physical performance among groups. It is difficult to predict the
beginning of such cascade effect; however, for health promoters, it is crucial to implement
interventions addressing physical and psychosocial aspects to face these conditions.
The values we found herein for handgrip strength were similar to those shown by
Yoshimura et al., 2011; however, the subjects in this study performed better in walking
speed. Importantly, in such study subjects were categorized by decades and walking speed
was measured in a 6-m path.19
The Asian Working Group for Sarcopenia (AWGS)
recommended using the lower 20th
percentile of handgrip strength of the study population as
the cutoff value for low strength, due to lack of outcome-based cutoff values. Then, they
suggest values of <26 kgf for men and <18 kgf for women.2 Similarly, the European Working
Group on Sarcopenia in Older People (EWGSOP) suggests <30 kgf for men and <20 kgf for
women3 as cutoff values; in this study, we found the cutoffs of 30 kgf for Brazilian men and
21.7 kgf for Brazilian women, when considering absolute handgrip strength values. Despite
the fact we could not contribute providing cutoff values for walking speed in Brazilian older
36
adults at this time, both studies (AWGS and EWGSOP) recommend the use of <0.8 m/s as
the cutoff for slow walking performance.2,3
Concerns have been raised regarding the influence of body mass on the
relationships among performance, strength, and muscle mass, especially by the Foundation
for the National Institutes of Health (FNIH Sarcopenia Project), a large sample study that
used multiple existing data sources to identify criteria for clinically relevant weakness and
low lean mass.5,20,21
Then, we performed several analyses to clarify the need to adjust
handgrip strength and muscle mass for body mass. In this sense, we found the cutoffs for
relative handgrip strength adjusted for BMI of 1.07 for men and 0.66 for women. The values
suggested by FNIH Sarcopenia Project were: men with ratio <1.0 and women with a ratio
<0.56 defined as weak.21
The necessity of this adjustment will be further discussed.
Regarding the TUG, Bohannon (2006), in a descriptive meta-analysis verified
mean values (95% confidence intervals - CI) according to age (60 to 69, 70 to 79 and 80 to
99 years) of 8.1s (95% CI=7.1 – 9.0), 9.2s (95 % CI=8.2 – 10.2) and 11.3s (95% CI=10.0 –
12.7), respectively.12
Indicating that those whose performance exceeds the limits of reported
confidence intervals can be considered to have worse than average performance. These
values are within the range we found in this study. Furthermore, considering healthy
Japanese individuals from 60 years or more, Kamide, Takahashi and Shiba (2011) verified
the weighted mean of TUG with maximum effort at 6.60 (95% CI=6.18 – 7.02) seconds, and
that at usual pace was 8.86 (95% CI=7.99 – 9.72) seconds;22
certainly, shorter than other
populations.
The study data presented the decline of physical performance through specific
tests in both genders as age increases, but the changes in skeletal muscle depended on the
adjustment applied. The identified ASM (adjusted by BMI) cutoff values for older adults
according to gender were 0.85 for men and 0.53 for women. Interestingly, the values
proposed by the FNIH sarcopenia project were 0.789 and 0.512, for men and women,
respectively.5 We also verified that adjustments by BMI were the best approach in both
genders; then, we suggest the use of these cutoffs to screen older adults from both sexes for
increasing disability risk, according to fear of falling, being these values a more realistic
approach to Brazilian older individuals.
Because of the adjustments of data we conducted herein, our results are not
directly comparable to other proposed definitions of low ASM or sarcopenia. Initially, both
the EWGSOP and AWGS groups suggested the approach of using – 2 SD of ASM of young
individuals as cutoff points of muscle mass.2,3
However, low muscle mass alone is not
37
consistently associated with adverse health outcomes5 challenging new approaches. Then, the
adopted methodology in this study limits our comparisons, but stimulates other researchers to
provide more suitable and comparable data.
Considering the role of body mass, it was different according to gender. In men,
the AUC was slightly lower in the relative than absolute handgrip strength. However, in
women the relative handgrip strength showed better results. Interestingly, a similar finding
was verified by Alley et al. (2014); and even with our small sample size in men’s group and
with a different outcome-based variable we verified a similar condition.20
It remains unclear
why this occurs, and BMI would be more important for women than for men.
To our knowledge, this is the first study providing reference data and cutoff
values adjusted by body mass in Brazilian older adults. We expect that these data will be
useful for both clinicians at practice and researchers, which can use national data regarding
physical function and muscle mass in older adults.
We provided several adjustments of data, but for consistency, we encourage
researchers to use ASM adjusted by BMI and to choose by convenience absolute handgrip
strength or relative handgrip strength adjusted by BMI for both men and women, or even
different types of indicators for each gender. For walking speed, a cutoff value <0.8 m/s, as
previously suggested2,3,5
can be applied to research and clinical practice to identify mobility
impairment. Values of physical function tests and other variables can be used as reference by
age categories as we presented in this study.
The limitations of this study included: (i) its cross-sectional design that did not
permit the determination of a cause-effect relationship between variables; (ii) the small
number of older male subjects; (iii) the retrospective nature of data about the occurrence of
falls that might be biased; and (iv) the use of fear of falling, and no other disability condition
or mortality, as outcome. However, although longitudinal analyses are preferable over cross-
sectional designs, it is appropriate for establishing clinical diagnostic cutoff values.5
Moreover, even though mortality or other disability outcomes seems more representatives to
sarcopenia, fear of falling was highly associated to sarcopenia in older adults23
, as previously
verified, certifying its use. We suggest future studies to recruit a higher number of male
subjects, to use different sampling fields and alternative methods to verify body composition,
such as dual-energy x-ray absorptiometry. In addition, longitudinal studies using disability or
mortality as an outcome are necessary to determine optimal cutoffs for ASM, handgrip
strength and walking speed.
38
In summary, we have identified age-related decline in physical function, changes
in body composition and anthropometrical measures. Moreover, cutoff values of handgrip
strength (absolute: men <30 kgf; women <21.7 kgf; and relative: men <1.07; women <0.66)
and ASM (ASM adjusted by BMI: men <0.85; women <0.53) in association with fear of
falling in Brazilian older adults were also provided. Further analyses also suggested that
adjustment for BMI may influence how data can be interpreted. Value of walking speed was
established at <0.8 m/s as previously recommended. In future studies, we intend to evaluate
the capacity of these cutoff values to discriminate those in vulnerable conditions, especially
regarding low quality of life and frailty.
CONCLUSION
The values of physical function tests and the other variables presented by age
groups highlights the hazard surrounding the oldest old. Such data are useful references for
both clinicians at practice and researchers. Moreover, ASM adjusted by BMI was the best
approach, while adjustment of handgrip strength varied by gender. We recommend the use of
ASM adjusted by BMI and to choose over absolute handgrip strength or relative handgrip
strength (adjusted by BMI) for both men and women according to study needs.
REFERENCES
1. Diz JB, Leopoldino AA, Moreira BS, et al. Prevalence of sarcopenia in older Brazilian: A
systematic review and meta-analysis. Geriatr Gerontol Int. 2017;17(1):5-16.
2. Chen L-K, Liu LK, Woo J, et al. Sarcopenia in Asia: Consensus Report of the Asian
Working Group for Sarcopenia. J Am Med Dir Assoc. 2014;15(2):95-101.
3. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia: European consensus on
definition and diagnosis: Report of the European Working Group on Sarcopenia in Older
People. Age and ageing. 2010;39(4):412-23.
4. Morley JE, Abbatecola AM, Argiles JM, et al. Sarcopenia with Limited Mobility: An
International Consensus. J Am Med Dir Assoc. 2011;12:403-9.
39
5. Studenski SA, Peters KW, Alley DE, et al. The FNIH Sarcopenia Project: Rationale, study,
description, conference recommendations, and final estimates. J Gerontol A Biol Sci Med
Sci. 2014;69(5):547-58.
6. Goodpaster BH, Park SW, Harris TB, et al. The loss of skeletal muscle strength, mass, and
quality in older adults: the health, aging and body composition study. J Gerontol A Biol Sci
Med Sci. 2006;61:1059-64.
7. Auyeung TW, Lee SW, Leung J, Kwok T, Woo J. Age-associated decline of muscle mass,
grip strength and gait speed: a 4-year longitudinal study of 3018 community dwelling older
Chinese. Geriatr Gerontol Int. 2014;14(Suppl 1):76–84.
8. Morley JE, CAO L. Rapid screening for sarcopenia. Journal of Cachexia, Sarcopenia and
Muscle. 2015;6:312-4.
9. TANITA CORPORATION Website. TANITA Bioimpedance Analyzer BC-108 (In
Japanese). Available from: http://www.tanita.co.jp/shop/g/_BC10800001/. Accessed in 2017
(Apr 25).
10. Pietrobelli A, Rubiano F, St-Onge M-P, Heymsfield SB. New bioimpedance analysis
system: improved phenotyping with whole-body analysis. European Journal of Clinical
Nutrition. 2004;58(11):1479-84.
11. Sampaio RAC, Sewo Sampaio PY, Uchida MC, et al. Walking speed and balance
performance are associated with Short-Form 8 bodily pain domain in Brazilian older female.
Journal of Clinical Gerontology & Geriatrics. 2015;6:89-94.
12. Bohannon RW. Reference values for the timed up and go test: a descriptive meta-
analysis. J Geriatr Phys Ther. 2006;29(2):64-8.
13. Trampisch US, Franke J, Jedamzik N, Hinrichs T, Platen P. Optimal Jamar dynamometer
handle position to assess maximal isometric hand grip strength in epidemiological studies. J
Hand Surg. 2012;37(11):2368-73.
14. Florkowski CM. Sensitivity, specificity, receiver-operating characteristic (ROC) curves
and likelihood ratios: communicating the performance of diagnostic tests. Clin Biochem Rev.
2008;29 Suppl 1:S83-7.
40
15. Akobeng AK. Understanding diagnostic tests 1: sensitivity, specificity and predictive
values. Acta Paediatrica. 2006;96(3):338-41.
16. Akobeng AK. Understanding diagnostic tests 3: receiver operating characteristic curves.
Acta Paediatrica. 2007;96(5):644-7.
17. Denkinger MD, Lukas A, Nikolaus T, Hauer K. Factors associated with fear of falling
and associated activity restriction in community-dwelling older adults: a systematic review.
Am J Geriatr Psychiatry. 2015;23:73-86.
18. Trombetti A, Reid KF, Hars M, et al. Age-associated declines in muscle mass, strength,
power, and physical performance: impact on fear of falling and quality of life. Osteoporos
Int. 2016;27(2):463-71.
19. Yoshimura N, Oka H, Muraki S, et al. Reference values for hand grip strength, muscle
mass, walking time, and one-leg standing as indices for locomotive syndrome and associated
disability: the second survey of the ROAD study. J Orthop Sci. 2011;16:768-77.
20. Alley DE, Shardell MD, Peters KW, et al. Grip strength cutpoints for the identification of
clinically relevant weakness. J Gerontol A Biol Sci Med Sci. 2014;69(5):559-66.
21. Cawthon PM, Peters KW, Shardell MD, et al. Cutpoints for low appendicular lean mass
that identify older adults with clinically significant weakness. J Gerontol A Biol Sci Med Sci.
2014;69(5):567-75.
22. Kamide N, Takahashi K, Shiba Y. Reference values for the Timed Up and Go in healthy
Japanese elderly people: Determination using the methodology of meta-analysis. Geriatr
Gerontol Int. 2011;11:445-51.
23. Yamada M, Nishiguchi S, Fukutani N, et al. Prevalence of sarcopenia in community-
dwelling Japanese older adults. JAMDA. 2013;14(12):911-5.
41
Supplementary tables
Table S1. Appendicular skeletal muscle adjusted by body mass index vs. fear of falling
(Men).
Fear of falling Total
Had fear of falling No fear of falling
ASM(BMI) < 0.85 14 5 19
ASM(BMI) > 0.85 28 67 95
Total 42 72 114
Pearson Chi-square P<0.001. ASM(BMI)= Appendicular skeletal muscle adjusted by body
mass index.
Sensitivity: {14/(14+28)}=0.33=33%
Specificity: {67/(5+67)}=0.93=93%
Positive predictive value (PPV): {14/(14+5)}=0.73=73%
Negative predictive value (NPV): {67/(28+67)}=0.70=70%
Positive likelihood ratio (LR+): sensitivity/(1-specificity)=4.71
Negative likelihood ratio (LR-): (1-sensitivity)/specificity=0.72
Table S2. Absolute handgrip strength vs. fear of falling (Men).
Fear of falling Total
Had fear of falling No fear of falling
Absolute HGS < 30 kgf 18 4 22
Absolute HGS > 30 kgf 28 71 99
Total 46 75 121
Pearson Chi-square P<0.001. HGS= Handgrip strength.
Sensitivity: {18/(18+28)}=0.39=39%
Specificity: {71/(4+71)}=0.94=94%
Positive predictive value (PPV): {18/(18+4)}=0.81=81%
Negative predictive value (NPV): {71/(28+71)}=0.71=71%
Positive likelihood ratio (LR+): sensitivity/(1-specificity)=6.5
Negative likelihood ratio (LR-): (1-sensitivity)/specificity=0.64
42
Table S3. Relative handgrip strength vs. fear of falling (Men).
Fear of falling Total
Had fear of falling No fear of falling
HGS(BMI) < 1.07 12 5 17
HGS(BMI) > 1.07 31 69 100
Total 43 74 117
Pearson Chi-square P=0.002. HGS(BMI)= Handgrip strength adjusted by body mass index.
Sensitivity: {12/(12+31)}=0.27=27%
Specificity: {69/(5+69)}=0.93=93%
Positive predictive value (PPV): {12/(12+5)}=0.70=70%
Negative predictive value (NPV): {69/(31+69)}=0.69=69%
Positive likelihood ratio (LR+): sensitivity/(1-specificity)=3.85
Negative likelihood ratio (LR-): (1-sensitivity)/specificity=0.78
Table S4. Appendicular skeletal muscle adjusted by body mass index vs. fear of falling
(Women).
Fear of falling Total
Had fear of falling No fear of falling
ASM(BMI) < 0.53 84 12 96
ASM(BMI) > 0.53 194 140 334
Total 278 152 430
Pearson Chi-square P<0.001. ASM(BMI)= Appendicular skeletal muscle adjusted by body
mass index.
Sensitivity: {84/(84+194)}=0.30=30%
Specificity: {140/(12+140)}=0.92=92%
Positive predictive value (PPV): {84/(84+12)}=0.87=87%
Negative predictive value (NPV): {140/(194+140)}=0.41=41%
Positive likelihood ratio (LR+): sensitivity/(1-specificity)=3.75
Negative likelihood ratio (LR-): (1-sensitivity)/specificity=0.76
43
Table S5. Absolute handgrip strength vs. fear of falling (Women).
Fear of falling Total
Had fear of falling No fear of falling
Absolute HGS < 21.7 kgf 87 42 129
Absolute HGS > 21.7 kgf 204 115 319
Total 291 157 448
Pearson Chi-square P=0.48. HGS= Handgrip strength.
Sensitivity: {87/(87+204)}=0.29=29%
Specificity: {115/(42+115)}=0.73=73%
Positive predictive value (PPV): {87/(87+42)}=0.67=67%
Negative predictive value (NPV): {115/(204+115)}=0.36=36%
Positive likelihood ratio (LR+): sensitivity/(1-specificity)=1.07
Negative likelihood ratio (LR-): (1-sensitivity)/specificity=0.97
Table S6. Relative handgrip strength vs. fear of falling (Women).
Fear of falling Total
Had fear of falling No fear of falling
HGS(BMI) < 0.66 kgf 65 14 79
HGS(BMI) > 0.66 kgf 218 141 359
Total 283 155 438
Pearson Chi-square P < 0.001. HGS(BMI) = Handgrip strength adjusted by body mass index.
Sensitivity: {65/(65+218)} = 0.22 = 22%
Specificity: {141/(14+141)} = 0.90 = 90%
Positive predictive value (PPV): {65/(65+14)} = 0.82 = 82%
Negative predictive value (NPV): {141/(218+141)} = 0.39= 39%
Positive likelihood ratio (LR+): sensitivity/(1-specificity) = 2.2
Negative likelihood ratio (LR-): (1-sensitivity)/specificity = 0.86
44
SARCOPENIA CUTOFFS IN BRAZILIAN OLDER ADULTS ARE ASSOCIATED
TO HEALTH-RELATED QUALITY OF LIFE
ABSTRACT
As age increases, physical limitations become frequent and might be related to
sarcopenia, with implications in older adults’ health-related quality of life (HRQOL). The
aim of this study was to verify the relationship of cutoffs for appendicular skeletal muscle
adjusted by body mass index (ASM(BMI)), absolute handgrip strength (HGS(ABS)), relative
handgrip strength adjusted by BMI (HGS(BMI)) and walking speed (WS), as well as the
combination of these factors, with HRQOL in older adults. This study had a cross sectional
design and 577 older adults (men n=122, women n=455) participated. All of them had
collected information about age and the Short-form 8 (SF-8); and the BMI, appendicular
muscle mass, the WS, and handgrip strength. To compare older adults’ characteristics,
unpaired t tests and chi-square tests or Fisher’s exact test were used. Variables were
categorized as normal and low HGS(ABS) and/or WS; normal and low HGS(BMI) and/or WS;
normal and low ASM(BMI); normal and low HGS(ABS) and/or WS plus ASM(BMI); and normal
and low HGS(BMI) and/or WS plus ASM(BMI). Point biserial correlation coefficient was run to
determine the relationship between these categories and HRQOL. In men, the results of the
combination HGS(ABS) and/or WS were linked to SF-8 physical functioning, role-physical
and general health domains. In women, the combination of the three factors, HGS (both,
absolute and adjusted by BMI) and/or WS plus ASM(BMI) showed associations with physical
functioning, role-physical, bodily pain, general health and social functioning. Physical and
mental components of HRQOL were associated with the specific cutoffs.
KEYWORDS: Aging; Cutoffs; Muscle mass; Physical function; Sarcopenia.
45
INTRODUCTION
As age increases, physical limitations become frequent and might be related to
sarcopenia, the progressive loss of muscle mass and strength/functionality with aging,1 with
implications in older adults’ health-related quality of life (HRQOL).
Several studies verified that HRQOL is related to physical activity levels,
physical function, chronic disease, self-rated health and others;2,3,4,5
sharing common
associated factors with sarcopenia.
Previously, we identified cutoffs of appendicular skeletal muscle mass adjusted
by body mass index [ASM(BMI)] (<0.85 and <0.53, for men and women), absolute handgrip
strength [HGS(ABS)] (<30.0 kgf and <21.7 kgf for men and women) and handgrip strength
adjusted by BMI [HGS(BMI)] (<1.07 and <0.66 for men and women)6; walking speed (WS)
<0.8 m/s was considered as mobility impairment.1,7,8
These values are useful to identify
vulnerable older adults, especially because muscle mass and strength are subject to ethnic
differences9 and to provide local data.
Specific cutoffs seem effective to identify morphological and functional changes
in older adults; however, aging process goes beyond physical changes and is associated to
several psychosocial alterations. This made us hypothesize their ability to identify differences
in HRQOL in older adults.
Therefore, the aim of this report was to verify the relationship of specific cutoffs
for ASM(BMI), HGS(ABS), HGS(BMI) and WS, as well as the combination of these factors, with
HRQOL in older adults.
METHODS
Design
This study had a cross sectional design and was approved by the Ethical
Committee of the University of Campinas, protocol #39437514.0.0000.5404. All participants
signed an informed consent agreeing to participate in the study before data collection.
46
Subjects
In total, 577 older adults (men n=122, women n=455) participated in this study.
They were recruited in community health centers in southeastern and southern Brazil.
The inclusion criteria were: a) community-dwelling people; b) 60 years old or
older, from both sexes; c) able to answer the questions, perform the physical and body
composition tests.
Exclusion criteria were: a) individuals with uncontrolled cardiovascular or
pulmonary disease, with conditions associated with risk of falling (e.g., Parkinson’s disease
or stroke); b) individuals using metal prosthesis and/or pacemaker (i.e. interference
bioelectrical impedance analysis).
Assessments
All participants had collected by questionnaire the information about age and
HRQOL [by the Short-form 8 items (SF-8)]; and had objectively measured BMI,
appendicular muscle mass by bioelectrical impedance analysis, the WS, and handgrip
strength. For those illiterate, SF-8 was performed by interview.
The SF-8 is a brief, generic, and multipurpose survey of health status. It is
composed by eight domains: physical functioning, role-physical, bodily pain, general health,
vitality, social functioning, role-emotional, and mental health. Among its application, it has
been used for evaluating and monitoring functioning and well-being of populations.10
Appendicular muscle mass was assessed by bioelectrical impedance analysis
(Tanita® BC-108, Tokyo, Japan). The equipment provided the subject’s weight, and height
was inserted manually by the researcher. After analysis, values of BMI and segmented
muscle mass were obtained. The equipment uses a frequency of 50 kHz to measure the
quantity of intra and extracellular water in the body; it has eight electrodes, four under the
feet and four on volunteers’ hands.11,12
The WS was evaluated in a 10 meters distance. Outside marks of 12 m in length
were clearly placed on the ground during the walking test. Another 10-m long delimitation
was marked inside the previous one. Participants were asked to walk the entire distance at
their usual pace. The time required to complete the inner 10-m distance was assessed.13
And handgrip strength was measured with a digital dynamometer Jamar (Jamar
Plus+®; Sammons Preston, Rolyon, Bolingbrook, IL). While seated, the subject held the
47
dynamometer with elbow flexed in 90° without touching his/her body. Then, they were
instructed to pull the lever at their maximum; each hand was tested once. Subjects were also
instructed to avoid the Valsava maneuver or blocked breath while performing the test. As
standard, handle position two was set for all participants.14
Statistical analyses
Values are presented as mean ± standard deviation for continuous variables and
frequency (%) for categorical values. To compare older adults’ characteristics, unpaired t
tests were used for continuous variables, while chi-square tests or Fisher’s exact test were
used for categorical variables.
Appendicular muscle mass, handgrip strength and WS were adjusted and/or
divided by specific cutoffs. ASM(BMI) cutoffs were <0.85 and <0.53, for men and women;
HGS(ABS) cutoffs were <30.0 kgf and <21.7 kgf, for men and women; and 1.07 and 0.66 for
HGS(BMI), for men and women.6 WS <0.8 m/s was considered mobility impairment according
to previous recommendations.1,7,8
Continuous values of appendicular muscle mass, handgrip strength and WS were
used to characterize participants. Moreover, such variables were categorized as (i) normal
and low HGS(ABS) and/or WS; (ii) normal and low HGS(BMI) and/or WS; (iii) normal and low
ASM(BMI); (iv) normal and low HGS(ABS) and/or WS plus ASM(BMI); and (v) normal and low
HGS(BMI) and/or WS plus ASM(BMI).
Point biserial correlation coefficient was run to determine the relationship
between (i) to (v) categories and HRQOL.
Statistical significance was set at P <0.05 and all analyses were carried out using
the Statistical Package for the Social Sciences (version 21.0, SPSS, IBM Inc., Chicago, IL,
USA).
RESULTS
Table 1 represents participants’ general characteristics. Men had more years of
education and were more engaged on work activities. In addition, they had lower BMI and
polypharmacy than women; moreover, men presented more total and adjusted appendicular
muscle mass and better performance on HGS(ABS) and HGS(BMI) and WS. Regarding
48
HRQOL, men presented better results on role-physical, bodily pain, social functioning, role-
emotional and mental health than women (Table 1).
Table 2 presents point biserial correlations for different cutoffs combinations
for men, considering strength and physical function; and strength and physical function plus
ASM(BMI) with HRQOL. Most of the combinations showed similar results, varying on the
coefficient of correlation (Rpb)) found, except for the combination HGS(BMI) and/or WS.
Results were especially linked to SF-8 physical functioning, role-physical and general health
domains.
Table 3 presents point biserial correlations for different cutoffs arrangements for
women. The combination of the three factors, HGS (both absolute and adjusted by BMI)
and/or WS plus ASM(BMI) showed the best approach in the association with HRQOL. Even
though the Rpb coefficients were lower than those found for men, they were statistically
significant.
49
Table 1. Subjects’ general characteristics.
Variables Men (n=122) Women (n=455) P
Age (y) 70.5 ± 6.7 69.4 ± 6.5 0.11
Educational level <0.001
Illiterate 6 (5%) 14 (3.1%)
Elementary school 43 (35.8%) 215 (47.7%)
Junior high school 22 (18.3%) 95 (15.1%)
High school 15 (12.5%) 68 (15.1%)
Technical school 15 (12.5%) 9 (2%)
University 19 (15.8%) 50 (11.1%)
Work status 0.007
None/retired 82 (68.3%) 347 (78.7%)
Formal work 2 (1.7%) 18 (4.1%)
Autonomous work 14 (11.7%) 41 (9.3%)
Farmwork 14 (11.7%) 17 (3.9%)
Other 8 (6.7%) 18 (4.1%)
BMI (kg/m2) 26.8 ± 3.5 28.3 ± 4.9 <0.001
HGS(BMI) 1.4 ± 0.3 0.8 ± 0.2 <0.001
HGS(ABS) 37.4 ± 8.1 24.2 ± 4.8 <0.001
Walking speed (m/s) 1.3 ± 0.3 1.2 ± 0.2 0.03
Walking speed < 0.8 m/s 6 (5%) 17 (3.8%) 0.60
ASM(BMI) 0.95 ± 0.13 0.59 ± 0.08 <0.001
Total ASM (kg) 25.2 ± 4.0 16.4 ± 1.8 <0.001
Polypharmacy 15 (12.6%) 95 (22%) 0.02
Non-engaged on PA 30 (25.2%) 96 (21.2%) 0.34
< 150 min of PA/wk 63 (57.3%) 253 (59.4%) 0.68
SF-8 PF 48.1 ± 7.3 47.7 ± 8.1 0.58
SF-8 RP 50.5 ± 6.3 48.9 ± 7.8 0.02
SF-8 BP 52.8 ± 8.8 48.9 ± 10.0 <0.001
SF-8 GH 46.2 ± 5.8 46.2 ± 7.1 0.96
SF-8 VT 49.6 ± 8.5 50.7 ± 8.7 0.28
SF-8 SF 51.7 ± 5.4 50.2 ± 7.3 0.02
SF-8 RE 51.8 ± 6.3 48.6 ± 8.7 <0.001
50
SF-8 MH 49.4 ± 6.2 48.0 ± 6.8 0.03
Values are mean ± standard deviation or frequency (%). BMI: body mass index; HGS(BMI):
handgrip strength adjusted by the body mass index; HGS(ABS):handgrip strength absolute
values; ASM(BMI): appendicular muscle adjusted by the body mass index; ASM: appendicular
skeletal muscle; PA/wk: physical activity/week; SF: short-form; PF: physical functioning;
RP: role-physical; BP: bodily pain; GH: general health; VT: vitality; SF: social functioning;
RE: role-emotional; MH: mental health.
51
Table 2. Point biserial correlations for different cutoffs and combinations, and health-related quality of life (men, n=122).
Variables Normal (n=97) and low
HGS(ABS) and/or WS
(n=25)
Normal (n=113) and
low HGS(BMI) and/or
WS (n=9)
Normal (n=95) and
low ASM(BMI) (n=19)
Normal (n=110) and
low HGS(ABS) and/or
WS + ASM(BMI) (n=11)
Normal (n=111)
and low HGS(BMI)
and/or WS +
ASM(BMI) (n=11)
Rpb P Rpb P Rpb P Rpb P Rpb P
SF-8 PF -0.19 0.04 -0.005 0.96 -0.29 0.002 -0.24 0.01 -0.25 0.007
SF-8 RP -0.26 0.005 0.10 0.30 -0.31 0.001 -0.41 <0.001 -0.38 <0.001
SF-8 BP -0.10 0.30 0.11 0.22 -0.60 0.55 -0.89 0.36 -0.11 0.24
SF-8 GH -0.18 0.04 -0.01 0.91 -0.03 0.73 -0.10 0.27 -0.08 0.35
SF-8 VT -0.12 0.18 0.21 0.02 -0.11 0.26 -0.95 0.32 -0.10 0.26
SF-8 SF -0.11 0.22 0.02 0.77 -0.18 0.06 -0.14 0.13 -0.14 0.14
SF-8 RE 0.10 0.29 0.07 0.46 -0.76 0.44 -0.10 0.28 0.01 0.89
SF-8 MH -0.07 0.42 0.03 0.69 0.009 0.92 -0.06 0.52 -0.008 0.93
SF: short-form; PF: physical functioning; RP: role-physical; BP: bodily pain; GH: general health; VT: vitality; SF: social functioning; RE: role-
emotional; MH: mental health.
52
Table 3. Point biserial correlations for different cutoffs and combinations, and health-related quality of life (women, n=455).
Variables Normal (n=318) and
low HGS(ABS) and/or
WS (n=137)
Normal (n=364) and
low HGS(BMI) and/or
WS (n=91)
Normal (n=334) and
low ASM(BMI) (n=96)
Normal (n=417) and
low HGS(ABS) and/or
WS + ASM(BMI) (n=38)
Normal (n=410)
and low HGS(BMI)
and/or WS +
ASM(BMI) (n=45)
Rpb P Rpb P Rpb P Rpb P Rpb P
SF-8 PF -0.04 0.36 -0.08 0.08 -0.17 <0.001 -0.16 <0.001 -0.14 0.002
SF-8 RP -0.07 0.11 -0.08 0.06 -0.18 <0.001 -0.16 0.001 -0.12 0.01
SF-8 BP -0.06 0.14 -0.10 0.02 -0.16 0.001 -0.16 0.001 -0.13 0.006
SF-8 GH -0.003 0.95 -0.06 0.15 -0.11 0.02 -0.11 0.01 -0.13 0.004
SF-8 VT -0.05 0.21 -0.04 0.40 -0.09 0.06 -0.09 0.05 -0.07 0.13
SF-8 SF -0.07 0.11 -0.05 0.25 -0.04 0.31 -0.11 0.01 -0.10 0.02
SF-8 RE 0.07 0.10 0.05 0.22 -0.04 0.37 -0.001 0.98 -0.02 0.61
SF-8 MH -0.01 0.70 0.02 0.60 -0.03 0.53 -0.02 0.57 -0.03 0.46
SF: short-form; PF: physical functioning; RP: role-physical; BP: bodily pain; GH: general health; VT: vitality; SF: social functioning; RE: role-
emotional; MH: mental health.
53
DISCUSSION
This study tested associations of different combinations of cutoff values
(HGS(ABS), HGS(BMI), WS and ASM(BMI)) with HRQOL in Brazilian older adults. It aimed to
verify their ability to be associated with psychosocial factors beyond morphological aspects
and physical function.
To characterize normal and low values, we used the cutoffs we previously
identified for each variable in association to fear of falling.6 Fear of falling is highly
associated to sarcopenia;15
thus, representative of disability. A walking speed < 0.8 m/s was
used to represent mobility impairment.1,7,8
.
When combining strength and physical function variables, was considered the
association between strength and walking speed.16
In addition, the small number of
participants with slow walking, made impossible consider this category alone.
Several differences by sex concerning educational level, work status, muscle
mass, strength, walking speed and BMI were observed. In addition, women had more
polypharmacy and worse HRQOL scores on role-physical, bodily pain, social functioning,
role-emotional and mental health than men.
The abovementioned sex differences are well reported in the literature16,17,18,19
and some factors may be involved in this condition. In a cross-sectional study involving 2420
individuals (725 men and 1695 women, > 40 years old) Campolina et al. (2011) verified, by
the SF-8, that women had worse HRQOL scores in most domains, as we also verified.17
Furthermore, men had less polypharmacy comparing to women. Similar findings were
verified by Sebastião et al. (2009) when authors verified that men had a better perception of
HRQOL and less use of medications than women.18
Concerning physical function, higher fat mass was associated with slower
walking speed and greater likelihood of functional limitation, while higher lean mass was
associated with increased handgrip strength.19
Moreover, being overweight was correlated
with impaired HRQOL (also measured by the SF-8) but not with mental HRQOL (n=2399).20
Dealing with the association of strength and/or function, muscle mass alone, and
the combination of strength and/or function plus muscle mass with HRQOL, similar results
were found for men, except for the condition HGS(BMI) and/or WS that showed significant
association only for vitality. In our previous study, HGS(ABS) showed the best cutoff for men,6
and this situation seems sustained. The other approaches we followed herein were similar
among them; however, the combination of HGS(ABS) and/or WS showed association with
54
physical functioning, role-physical and general health domains of the SF-8. In the others,
general health domain did not show significant associations. This might represent that
strength and function are important factors for apparently healthy older men, more than
muscle mass itself.
In fact, some reports have been provided stating that although muscle strength
and mass are highly correlated, low muscle mass did not explain the strong association of
strength with mortality, demonstrating that muscle strength as a marker of muscle quality is
more important than quantity in estimating mortality risk.16
Although it is more important
than quantity to estimate mortality risk; regarding HRQOL in older women, it seems that
strength and/or function plus quantity was more relevant than strength and function alone.
Contrastingly, when analyzing the association between sarcopenia, sarcopenic
obesity and muscle strength and variables related to HRQOL (Short-form 36) in elderly
women (n=56, age=64.9 ± 5.7 years), Silva Neto et al. (2012) verified that although there
were no statistically significant differences between the studied parameters and HRQOL
among those with sarcopenia or sarcopenic obesity, the values were lower in affected
individuals. Interestingly, handgrip strength correlated positively and significantly with all of
the SF-36 dimensions except vitality and mental health.21
Our results do not explain why different results were found by sex; however,
HRQOL is a subjective measure and individual factors, including living environment,
educational level, working status and others, should be taken into account when analyzing it.
Indeed, environmental factors and educational level are essential in determine a person
HRQOL.17,22
The limitations of this study included: (i) its cross-sectional design that did not
permit the determination of a cause-effect relationship between variables; (ii) the small
number of older subjects with slow walking speed that impede analyze this variable alone.
The evidences from this study were that the combination of low strength, slow
walking and low muscle mass was associated with poorer HRQOL results in older adults. In
men, this association was identified especially by strength and/or function in physical
functioning, role-physical and general health domains; while in women, the combination of
strength, walking and muscle showed association with physical functioning, role-physical,
bodily pain, general health and social functioning. Then, physical and mental components
were associated with the specific cutoffs.
This study is useful once the development of approaches aiming to identify those
at risk of develop a pathological condition is imperative. We provided comparable data that
55
can be useful for researchers and clinical professionals when evaluating HRQOL in older
adults.
REFERENCES
1. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia: European consensus on
definition and diagnosis: Report of the European Working Group on Sarcopenia in Older
People. Age and ageing. 2010; 39(4):412–23.
2. Sewo Sampaio PY, Sampaio RAC, Yamada M, Ogita M, Arai H. Importance of physical
performance and quality of life for self-rated health in older Japanese women. Physical &
Occupational Therapy in Geriatrics. 2013;21(1):1-11.
3. Toscano JJO, Oliveira ACC. Qualidade de vida em idosos com distintos níveis de
atividade física. Rev Bras Med Esporte. 2009;15(3):169-173.
4. Lima MG, Barros MBA, César CLG, Goldbaum M, Carandina L, Ciconelli RM. Impact of
chronic disease on quality of life among the elderly in the state of São Paulo, Brazil: a
population-based study. Rev Panam Salud Publica. 2009;25(4):314-21.
5. Acree LS, Longfors J, Fjeldstad AS, et al. Physical activity is related to quality of life in
older adults. Health and Quality of Life Outcomes. 2006;4:37.
6. Sampaio RAC, Sewo Sampaio PY, Castaño LA, et al. Cutoff values of appendicular
skeletal muscle mass and strength associated to fear of falling in Brazilian older adults. São
Paulo Medical Journal/Evidence for Health Care. 2017. In press.
7. Chen L, Liu LK, Woo J, et al. Sarcopenia in Asia: Consensus Report of the Asian Working
Group for Sarcopenia. J Am Med Dir Assoc. 2014;15(2):95-101.
8. Studenski SA, Peters KW, Alley DE, et al. The FNIH Sarcopenia Project: Rationale, study,
description, conference recommendations, and final estimates. J Gerontol A Biol Sci Med
Sci. 2014;69(5):547-58.
9. Sousa M, Pinheiro MM, Szejnfeld VL, Castro CH. Body composition parameters in
healthy Brazilian women differ from white, black, and Hispanic American women reference
range. J Clin Densitom. 2013;16(3):360–7.
56
10. Maruish ME. (Ed.). User’s manual for the SF-36v2 Health Survey (3rd ed.). Lincoln, RI:
QualityMetric Incorporated. 2011
11. TANITA CORPORATION Website. TANITA Bioimpedance Analyzer BC-108 (In
Japanese). Retrieved from: http://www.tanita.co.jp/shop/g/_BC10800001/. Accessed on 12
Aug 2014.
12. Pietrobelli A, Rubiano F, St-Onge M-P, Heymsfield SB. New bioimpedance analysis
system: improved phenotyping with whole-body analysis. European Journal of Clinical
Nutrition. 2004; 58(11):1479-84.
13. Sampaio RAC, Sewo Sampaio PY, Uchida MC, et al. Walking speed and balance
performance are associated with Short-Form 8 bodily pain domain in Brazilian older female.
Journal of Clinical Gerontology & Geriatrics. 2015;6(3):89-94.
14. Trampisch US, Franke J, Jedamzik N, Hinrichs T, Platen P. Optimal Jamar dynamometer
handle position to assess maximal isometric hand grip strength in epidemiological studies. J
Hand Surg. 2012;37A:2368-73.
15. Yamada M, Nishiguchi S, Fukutani N, et al. Prevalence of sarcopenia in community-
dwelling Japanese older adults. JAMDA. 2013;14(12):911-5.
16. Newman AB, Kupelian V, Visser M, et al. Strength, but not muscle mass, is associated
with mortality in the Health, Aging and Body Composition Study cohort. Journal of
Gerontology: MEDICAL SCIENCES. 2006; 61A(1):72-7.
17. Campolina AG, Pinheiro MM, Ciconelli RM, Ferraz MB. Quality of life among the
Brazilian adult population using the generic SF-8 questionnaire. Cad Saúde Pública.
2011;27(6):1121-31.
18. Sebastião E, Christofoletti G, Gobbi S, Hamanaka AYY, Gobbi LTB. Atividade física,
qualidade de vida e medicamentos em idosos: diferenças entre idade e gênero. Rev Bras
Cineantropom Desempenho Hum. 2009;11(2):210-6.
19. Sternfeld B, Ngo L, Satariano WA, Tager IB. Associations of body composition with
physical performance and self-reported functional limitation in elderly men and women.
American Journal of Epidemiology. 2002;156(2):110-21.
57
20. Takahashi Y, Sakai M, Tokuda Y, et al. The relation between self-reported body weight
and health-related quality of life: a cross-sectional study in Japan. Journal of Public Health.
2011;33(4):518-26.
21. Silva Neto LS, Karnikowiski MGO, Tavares AB, Lima RM. Association between
sarcopenia, sarcopenic obesity, muscle strength and quality of life variables in elderly
women. Rev Bras Fisioter. 2012;16(5):360-7.
22. Sewo Sampaio PY, Ito E, Sampaio RAC. The association of activity and participation
with quality of life between Japanese older adults living in rural and urban areas. Journal of
Clinical Gerontology and Geriatrics. 2013;4:51-56.
58
INFLUENCE OF POWER TRAINING ON PHYSICAL FUNCTION AND HEALTH-
RELATED QUALITY OF LIFE IN INSTITUTIONALIZED FRAIL OLDER
ADULTS: A CASE-STUDY
ABSTRACT
Frailty is a syndrome composed by physical and psychological aspects that can
lead to institutionalization and mortality. This study verified the influence of power training
on physical function and health-related quality of life (HRQOL) in institutionalized frail older
adults. Eleven participants (men n=5, 74 ± 8.3 years; women n=6, 83.8 ± 5.5 years)
concluded all research procedures and had collected physical function tests and
questionnaires before and after intervention. The physical training lasted 16 weeks (2x/week,
60 min/session, using elastic bands) and was composed by upper and lower limbs exercises,
in which participants had to perform the concentric actions as fast as possible. At baseline,
Mann Whitney U test and Fisher’s exact test were used. To compare moments, Wilcoxon
Signed Ranks tests were performed and Cohen’s d test was used to verify the effect size.
After intervention, we observed improvements on HRQOL domains physical functioning
[P=0.04, d=1.39], role-physical [d=1.18], bodily pain [P=0.04, d=1.62], role-emotional
[d=0.66] and the physical component summary [P=0.04, d=2.31] of SF-36, in men. In
women, role-physical (d=1.03) and role-emotional (d=0.82) showed small magnitude of
changes. Concerning physical function, improvements in walking at usual (d=0.75) and
maximum speeds (d=0.52); and number of repetitions in the elastic band rowing test (EBRT)
(P=0.004, d=1.30) were observed in men. In women, maximum walking speed (P=0.02,
d=0.98), EBRT (d=0.83) and the timed up and go (P=0.02, d=1.41) showed better results
after intervention. Power training is a useful strategy to promote physical function and
HRQOL in institutionalized older adults.
KEYWORDS: Aging; Exercise; Elastic bands; Frailty; Long-term care institution.
59
INTRODUCTION
Frailty is a geriatric syndrome composed by physical and psychological aspects.1
It is associated to sarcopenia, functional impairment, and decline in quality of life.2
Moreover, frailty is reversible but if not adequately approached often lead to higher
institutionalization and mortality rates.1
According to Santiago and Mattos (2014), evidences regarding frailty are
alarming in Brazil. A study verified that the prevalence of frailty reached 52% in 442 older
adults living in a long term institution when using the Tilburg Frailty Indicator.3 Similar
results we found previously when analyzing aged people from day care centers using the
Kihon Checklist (KCL), 52%; while in community-dwelling older adults, frail represented
approximately 45% of the individuals.4
Studies have been developed to verify the reversibility condition of frailty
through strength and power training (i.e., strength multiplied by speed) or multicomponent
exercises in community-dwelling, and institutionalized older adults.5,6,7,8,9
And verified
improvement on strength, muscle power output, functional outcomes, and decreased fear of
falling and risk of falls.
Thus, considering that (i) strength and power training are important non-
pharmacological approaches to maintain physical and morphological functions; (ii) studies
about exercise protocols involving different muscle groups and cadence of movement in
institutionalized older people are still scarce; (iii) the importance in evaluate health-related
quality of life (HRQOL), since it is often affected due to institutionalization (e.g., by the need
to adapt to a new routine, need of sharing personal environment, living away from
relatives);10
the aim of this study was to verify the influence of power training on physical
function and HRQOL in institutionalized frail Brazilian older adults.
METHODS
This was a case-study, using power training as therapeutic intervention on frail
older adults from a long term care institution (LTCI) in southeastern Brazil. According to the
Brazilian Sanitary Agency (acronym in Portuguese ANVISA), LTCI’s are institutions
maintained by the government or not, destined to promote integral attention assuring equal
conditions of liberty and dignity to residency, in which target-population is people aged over
60 years old, regardless family support, costless or private organizations. Each institution has
60
maximum capacity of 40 residents. Multidisciplinary team includes medical doctors, nurse,
nutritionist and physical therapist, with strategies to promote health.11
Although they follow
common regulations, LTCI’s has peculiarities and own demands. Therefore, we decided to
study a single LTCI in this research that was chosen because there weren’t physical exercise
intervention included on residents’ routine. The LTCI had in total, 37 residents, all of them
over 60 years old. The multidisciplinary team was composed by geriatrician, nutritionist,
nurse, technical nursing staff, social assistant, and volunteers (e.g., physical therapist,
occupational therapist, and psychologist).
The geriatrician made the preliminary screening of all residents to verify who
were able to participate in this study, ensuring their safety during intervention. From them, 17
were allowed to begin the data collection. Inclusion criteria were: to live in the LTCI for at
least 3 months; be diagnosed as frail by the institution’s geriatrician and by the KCL; and be
able to perform physical activity and answer to the questionnaires. Were excluded residents
with heart or pulmonary diseases, musculoskeletal impairment, diseases associated to
increasing risk of falls (i.e., Parkinson’s disease or stroke); cognitive impairment according to
the Mini-mental State Examination (MMSE); use of pacemaker; any other condition that
affect physical activity or the understanding about research procedures; and frequency in
exercise sessions less than 75%.
Residents that succeeded the initial screening and were willing to participate in
this study signed an informed consent. This study was approved by the Ethical Committee of
University of Campinas, protocol #47092115.4.0000.5404.
From the initial 17 subjects allowed by the geriatrician to participate in this study,
11 concluded all research procedures. Figure 1 is a flowchart of study procedures. During the
study period, one participant died of causes unrelated to the exercise intervention, and three
others had fall incidents; one of them was recurrent and with medical complications, which
induced dropout from the study. The falls incidents did not happen during exercise sessions.
61
Figure 1. Flowchart of study procedures.
62
Assessments
Data collections were performed in two moments: 1) pre-intervention (one week
before training program); and 2) on the week after intervention (17th
week). All participants
had collected (i) physical function tests (i.e., walking speed, handgrip strength, the timed up
and go [TUG], and the elastic band rowing test [EBRT]); and (ii) answered questionnaires
(i.e., socio-demographic and lifestyle topics, KCL and the Short-form 36 [SF-36] for
HRQOL). The KCL was collected only at baseline to characterize individuals according to
frailty status. Aiming to avoid physical or mental distress, each data collection was divided in
two consecutive days. All assessments were performed by the same researcher to avoid
interevaluator bias. Moreover, to minimize the risk of accidents, each participant was assisted
during tests by at least two researchers.
Physical function tests
To verify the usual walking speed, the participants were asked to walk 12 meters
in a normal cadence. To assess maximum walking speed, they were requested to walk the
same distance at their maximum pace, returning to the initial position. Even though they
walked 12 meters in each length, only the time to complete the inner 10 meters was registered
(disregarding one meter by side to avoid acceleration and deceleration).12
Handgrip strength was verified with a Jamar digital dynamometer (Jamar Plus+®;
Sammons Preston, Rolyon, Bolingbrook, IL) once on each hand, the best value achieved was
used in analysis. Moreover, relative handgrip strength adjusted by BMI was also used.13
The
participants, while seated, were asked to push the dynamometer using maximum strength.
Elbows were kept at 90 degrees, without touching their bodies. Volunteers were requested to
avoid Valsava like maneuvers during the test.
In the TUG, the participants had to stand from a chair, walk three meters in
straight line, return and sit again. They were not allowed to run during this test, but were
encouraged to safely perform the test as fast as possible.14
The EBRT is a test designed to verify upper limbs muscle function. For this,
Thera-Band® was used (i.e., blue bands for women, and black bands for men) with the same
length of participant’s arm (from the olecranon to the greater tubercle [humerus]). The
participants, while standing, had to hold the elastic band on the dominant hand; on the other
extremity, the elastic band was fixed in a bar at the same height of participant’s elbow. The
63
movement recruited three joints simultaneously (elbow, shoulder and scapulothoracic) and
the radioulnar joint had to stay in a semi pronated grip during the test. The participant’s
elbow joint started from a full extension to full flexion, and full shoulder extension;
participant’s hand had to finish each movement at the anterolateral of the trunk. This test
lasted 15 seconds, and the participant had to perform the maximum number of repetitions
within this time. Important to mention, eccentric muscle actions had to be controlled to assure
safety and integrity of the joints involved in this task.15
Questionnaires
At baseline, the participants had socio-demographic and lifestyle information
collected. Data included, but were not restricted to age, educational level, time living at the
LTCI, history of falls, and medical history. The frailty syndrome was approached by the 25
items of the KCL as complement to the geriatrician assessment. This instrument is separated
into domains (i.e., instrumental activities of daily living, physical function, nutrition, eating,
socialization, memory, and mood) and a score higher than seven suggest a frail health
condition.16
At baseline and after intervention, the HRQOL was assessed by the SF-36
questionnaire. It is a questionnaire composed by eight domains: physical functioning, role-
physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental
health; and two summaries of specific physical and mental domains.17
All questionnaires
were performed by interview.
Physical training protocol
The physical training lasted 16 weeks, twice a week, with 72 h interval between
sessions. Each session lasted approximately 60 minutes, and was supervised by a physical
education professional. Besides, it was used elastic bands (Theraband®) to induce external
resistance, aiming to promote a positive and effective response from the training, also
favoring accessibility, low cost, and easy to perform exercises.
During the first four weeks, participants had a period of familiarization and
adaptation. In this phase, they were taught the correct movements (i.e., chest press [pectoralis
major muscle], squat [lower limbs muscles], seated rowing [dorsal muscles], plantar flexion
[triceps surae muscle], front lift [deltoid and upper pectoral], elbow curl [elbow flexor
64
muscles], hip abduction [leg and gluteus muscles], and hip flexion (knee at 90 degrees) [thigh
muscles]. Importantly, in this phase, participants were instructed about how to use the elastic
bands, starting from those with low resistance (e.g., yellow band), and progressively
increasing to those with higher resistance. Intensity planned to this stage was “easy” and
controlled by the Borg Scale adapted by Foster et al. (2001), and the number of repetitions
was 10-15. During the first week, a single set was performed and from the second week
ahead, multiple sets (e.g., two or three). Warm-up was composed by the same exercises for
each muscle group; however, using a set with 12-15 repetitions, in a “very easy” to “easy”
intensity. Interval was 1-2 two minutes and/or respecting participants’ recovery.
To monitor training loads it was used the session rating of perceived effort
(SRPE), proposed by Foster et al. (2001), in which the researcher asks to each participant
individually “How was your training?” 30 minutes after the end of the session.18
In this
research, we verified this data after 10 minutes,19
and the participant answered according to
his/her global perception indicating a value 0 to 10 in the Borg Scale CR-10.18
The first four
weeks was also useful to participants familiarize how to report their efforts by the Borg CR-
10 scale. The SRPE information was registered from the fifth week to the end of intervention.
And for analytical purposes, mean SRPE was calculated in two moments, values regarding
the fifth to eighth week (initial intensity), and 12th
to 16th
week (final intensity).
From the fifth week of intervention, participants performed the power training.
Considering study protocol, intensity was progressively increased by changing elastic bands
monthly (i.e., yellow, red, green and blue). Intensity of elastic bands by color can be found in
our previous study.20
When performing concentric actions, participants were asked to perform
as fast as possible, aiming to promote neuromuscular adaptations to increase muscle power;
and during eccentric actions, cadence was slower (e.g., between three to six seconds to assure
safety and integrity of the joints involved in the exercise); following other protocols designed
to promote power, strength and hypertrophy.21,22,23
Statistical analyses
Variables are presented as mean ± standard deviation or frequency (%). At
baseline, variables were compared by Mann Whitney U test and Fisher’s exact test. Then,
Wilcoxon Signed Ranks tests were performed to verify differences pre and post intervention
in older men and women. Finally, to verify the effect size (d), Cohen’s d test was performed.
Interpretation of the magnitude of effect sizes in strength training research followed Rhea
65
(2004) (i.e., magnitude of effect sizes in strength training research in untrained individuals:
<0.5 trivial; 0.50 - 1.25 small; 1.25 - 1.9 moderate; and >2.0 large).24
Statistical difference
was set at P <0.05. All analyses were conducted using the Social Package for the Social
Sciences (SPSS, IBM Inc., Chicago, IL, USA), version 20.0.
RESULTS
In total, 11 participants (men n=5, 74 ± 8.3 years; women n=6, 83.8 ± 5.5 years)
concluded all research procedures. Table 1 presents subjects general characteristics. Most of
them had low educational level; institutionalization period longer than 4 years, fall
experience in previous year and polypharmacy. Important to note, participants presented
similar characteristics regarding educational level, institutionalization time, falls,
hospitalization, previous femur or hip fracture, number of medications and frailty scores even
though women were older than men. Important to mention, in addition to the geriatrician’s
diagnosis, all the subjects were identified as frail according to the KCL (Table 1).
Table 2 presents subjects pre and post results for HRQOL. In men, there were
improvements on physical functioning (P=0.004, d=1.39), role physical (d=1.18), bodily pain
(P=0.04, d=1.62), role emotional (d=0.66) and the physical component summary (P=0.004,
d=2.31) of SF-36. In women, role physical (d=1.03), role emotional (d=0.82) and mental
health (d=0.69) showed small magnitude of changes by the intervention (Table 2).
66
Table 1. Participants’ general characteristics at baseline according to sex.
Variable Men (n=5) Women (n=6) P
Age (y) 74.0 ± 8.3 83.8 ± 5.5 0.05
Education 1.00
Illiterate 1 (20) --
Elementary school 3 (60) 4 (66.7)
High School -- 1 (16.7)
Technical School 1 (20) --
University -- 1 (16.7)
Time at institution (y) 4.6 ± 2.70 4.17 ± 5.67 0.42
Smoking (yes) 2 (40) -- 0.18
Alcohol (yes) -- 1 (16.7) 1.00
Fall in previous year 0.74
No 1 (20) 3 (50)
1 fall 3 (60) 2 (33.3)
2 ~ 4 falls 1 (20) 1 (16.7)
Hospitalization in 6 months (yes) 1 (20) -- 0.45
Previous femur or hip fracture 2 (40) 2 (33.3) 1.00
Number of medications 4.50 ± 2.38 5.16 ± 2.63 0.91
Kihon Checklist score 11.0 ± 3.0 13.6 ± 3.1 0.17
Values are mean ± standard deviation or frequency (%).
67
Table 2. Health-related quality of life pre and post intervention.
Variable Men (n=5) Women (n=6)
Baseline Post P ES Baseline Post P ES
Short-form 36
Physical Functioning 38.7 ± 9.7 53.3 ± 3.4 0.04 1.39 35.5 ± 3.1 40.6 ± 10.0 0.24 0.43
Role-physical 44.5 ± 4.3 54.4 ± 4.8 0.07 1.18 33.9 ± 6.1 47.4 ± 11.2 0.07 1.03
Bodily Pain 43.4 ± 5.7 52.4 ± 7.8 0.04 1.62 48.8 ± 8.1 43.5 ± 11.1 0.34 0.31
General Health 50.3 ± 4.5 53.2 ± 12.6 0.50 0.25 54.6 ± 12.4 48.4 ± 15.3 0.50 0.40
Vitality 53.7 ± 4.9 57.3 ± 11.6 0.59 0.27 53.5 ± 4.0 55.5 ± 8.4 0.58 0.17
Social Functioning 53.3 ± 5.4 48.3 ± 11.9 1.00 0.34 50.6 ± 12.1 47.3 ± 11.4 0.46 0.20
Role-emotional 40.1 ± 10.6 51.2 ± 6.7 0.22 0.66 35.8 ± 10.8 47.4 ± 10.0 0.11 0.82
Mental Health 55.0 ± 3.9 49.8 ± 14.4 0.71 0.32 60.4 ± 1.3 53.4 ± 9.5 0.11 0.69
PCS 42.2 ± 5.1 54.5 ± 1.6 0.04 2.31 39.5 ± 4.9 42.5 ± 8.5 0.75 0.24
MCS 53.8 ± 9.6 50.1 ± 15.0 0.68 0.18 55.3 ± 5.9 54.2 ± 6.0 0.75 0.17
Values are mean ± standard deviation. PCS: physical component summary; MCS: mental component summary; ES: effect size.
68
Table 3 presents comparisons concerning physical function pre and post
intervention in older men and women. In men, there were improvements regarding walking at
usual (d=0.75) and maximum speeds (d=0.52); and number of repetitions in the EBRT
(P=0.004, d=1.30). In women, maximum walking speed (P=0.02, d=0.98), EBRT (d=0.83)
and the TUG (P=0.02, d=1.41) showed better results after intervention; relative handgrip
strength (adjusted by BMI) decreased after intervention (pre 0.9 ± 0.3, post 0.8 ± 0.2, P=0.04,
d=1.26) (Table 3). The BMI for men were 25.1 ± 3.0 at baseline and 25.1 ± 3.5 after
intervention (P=0.06, d=1.65). For women were 21.2 ± 4.1 at baseline and 21.5 ± 3.9 (P=0.46,
d=0.29).
Difference in the SRPE from the beginning to the end of the intervention in both
groups was observed. As expected, volunteers reported higher SRPE at final intensity. In
agreement, there were large effects regardless sexes. These values are presented in Table 4.
69
Table 3. Physical function tests pre and post intervention.
Variable Men (n=5) Women (n=6)
Baseline Post P ES Baseline Post P ES
Absolute handgrip strength (kg) 28.4 ± 10.6 28.5 ± 8.2 0.89 0.02 18.7 ± 4.0 18.3 ± 4.3 0.46 0.39
Relative handgrip strength (kg/BMI) 1.1 ± 0.4 1.2 ± 0.2 0.46 0.22 0.9 ± 0.3 0.8 ± 0.2 0.04 1.26
Walking at usual speed (m/s) 0.6 ± 0.2 0.7 ± 0.2 0.22 0.72 0.6 ± 0.1 0.6 ± 0.2 0.17 0.64
Walking at maximum speed (m/s) 0.9 ± 0.2 1.0 ± 0.3 0.22 0.52 0.7 ± 0.1 0.9 ± 0.3 0.02 0.98
Timed Up and Go (sec) 14.2 ± 2.5 14.5 ± 5.7 0.50 0.06 20.0 ± 7.2 17.2 ± 7.0 0.02 1.41
Elastic band rowing test (#rep) 12.8 ± 3.7 18.6 ± 4.9 0.04 1.30 14.7 ± 3.8 16 ± 2.0 0.18 0.83
Values are mean ± standard deviation. BMI: body mass index; ES: effect size.
Table 4. Session rating of perceived effort at the beginning and at final intensity achieved.
Variable Men (n=5) Women (n=6)
Initial intensitya Final intensity
b P ES Initial intensity
a Final intensity
b P ES
SRPE 3.36 ± 0.62 4.5 ± 0.58 0.04 3.48 3.0 ± 0.40 4.8 ± 0.66 0.02 3.06
Values are mean ± standard deviation. SRPE: session rating of perceived effort; ES: effect size. aInitial intensity represents 5
th to 8
th week of intervention
(participants using red elastic bands); bFinal intensity represents 12
th to 16
th week of intervention (participants using blue elastic bands).
70
DISCUSSION
This study aimed to verify the effects of power training using elastic bands on
physical function and HRQOL in institutionalized frail older adults. The studied sample was
particularly vulnerable, most of them had several years of institutionalization, more than half
reported fall incident in previous year of the study, had hip or femur fractures as consequence
of fall, and were under polypharmacy condition. After intervention, we verified improvement
in several aspects as result of power training; study volunteers improved physical function
and physical and mental aspects of HRQOL.
In the case of interpreting only the P values, our evidences might be considered
modest, as older men had improvements on HRQOL, especially on physical components, but
not women. Regarding physical functioning, men presented improvement on EBRT scores,
while women presented better functional performance on maximum walking speed and the
TUG; and lower relative handgrip strength adjusted by BMI, justified by the slight increase
in BMI after intervention.
On the other hand, when analyzing the effect sizes we confirmed potential change
magnitudes due to the exercise protocol we followed herein.
Indeed, strength training has an important role to improve muscle function, even
in the oldest-old. A classic study by Fiatarone et al., (1994) verified that strength training
with nutritional supplementation in institutionalized older adults (n=100) increased strength
and gait speed. Moreover, authors verified increase in the stair-climbing power test and cross
sectional thigh-muscle area increased in the exercisers. The nutritional supplement had no
effect on any primary outcome measure and total energy intake was significantly increased
only in the exercising subjects who also received nutritional supplementation.9
In this study, exercise was applied solely; we did not use nutritional
supplementation. Despite this fact, we observed improvements in walking speed and EBRT
in men and women. Nutritional supplementation has important effect on older adults’
physical condition; however, its association with exercise in frail older adults still needs
further evidence.25
And frailty may be delayed or even reversed by exercise, with or without
nutritional supplementation.26
As confirmed by Cadore et al., (2014) that performed a multicomponent training
(12-week, twice a week, composed by muscle power training [8-10 repetitions, 40-60% of
the one-repetition maximum – 1RM] combined with balance and gait retraining) on muscle
power output, muscle mass, and muscle tissue attenuation; and functional outcomes in frail
71
nonagenarians (n=24; 91.9 ± 4.1 years old). Authors verified that the intervention group
improved the TUG, ability to rise from a chair and balance performance, and a reduced
incidence of falls. In addition, they also showed enhanced muscle power and strength.
Moreover, there were increases in the total and high-density muscle cross-sectional area in
the intervention group; while the control group reduced strength and functional outcomes.7
Interestingly, similar results were found when authors verified the effects of
multicomponent exercise intervention in frail older adults with dementia after long-term
physical restraint, followed by 24 weeks of training cessation. After the first 4 weeks of
training, there was improvement only in the balance test; however, after the second part of
the training, the participants required less time for the TUG, and improved the handgrip
strength, hip flexion and knee extension strength, as well as the leg press 1RM. Moreover,
after 24 weeks of training cessation, decreases were observed in almost all of the physical
outcomes; showing that exercise should be a chronic intervention in this population.6
The values we found for the SRPE at the end of the intervention were similar to
that proposed in other study (i.e., moderate intensity about 5 or 6 on a scale from 0 to 10 to
frail older adults).21
However, the time in which the participants exercised at this intensity
possibly was short to promote all changes we expected. Even though, we found important
psychological and functional improvements after intervention. High-intensity resistance
exercise is a feasible and effective means of counteracting muscle weakness and physical
frail in very elderly people;9 but, low intensity exercise showed a similar effect on the
adverse health consequences as well.27
Our interventions lasted 16 weeks and within this period the first four weeks were
adaptation. Although it was possible to achieve progress, we suppose that a longer
intervention would favor more improvements. Studies supported that interventions to frail
older adults should last at least 12 weeks.25
Indeed, it seems that interventions lasting longer
than five months resulted in greater gains on the adverse health outcomes of the frail people
than shorter duration interventions. These differences likely occur because frail adults need
more time to reach a level of exercise that may engender health and fitness benefit. However,
longer duration interventions had more dropouts that shorter duration interventions since
many frail people would experience several health problems and/or not survive to complete a
long intervention;27
this condition has been verified by other studies, especially in
institutionalized people.7
Exercise seems to benefit the older frail females more than younger frail males.
This difference may be explained by the fact that younger frail people may experience effects
72
on some outcome measures (e.g., activities of daily living, disability, mobility, balance). Sex-
related differences were also verified herein and may be due the fact that baseline physical
and functional ability were less in women compared to men; therefore, it seems that women
are more likely to improvement than men.27
Regarding HRQOL, a review study verified firm evidences for training effects on
physical fitness, functional performance, activity of daily living performance, and quality of
life in institutionalized older adults. Especially for depression, vitality, and perceived
health.28
A large number of disease-specific quality of life instruments exist, but none
specific for sarcopenia or frailty. It is considered necessary specific tools and without a clear
conceptual framework of quality of life in these patients, an important element in the
characterization and follow-up of these conditions seems to be missing.29
Concerning this,
the SF-36 should still serve as a generic-core to compare populations across studies and that
it should complement other health outcome measures, as we followed in this study.
Interestingly, after intervention the magnitude of change effects in physical
domains in men and in physical and mental domains in women were observed, confirming
the influence of exercise on people’s quality of life. Also important to mention, the mental
health domain presented a discrete decline in women. Punctual situations experienced by
these participants and the limited sample size are important to clarify this finding, especially
because some women were facing mourning for friends and relatives during research
activities.
Limitations should be pointed in this study: (i) the small sample size in men and
women groups; but, due to the highly specificity of this population, and its case-study nature
can justify it and do not limit our general conclusions; (ii) nutritional supplementation was
not used because of study logistics and financial condition; but as verified in other studies,
exercise alone can be used as intervention to promote physical and psychological outcomes.
Evidence shows that there is a relationship among training, improvement in
physical function and some aspects of HRQOL.28
Thus, interventions to promote physical
function are essential for institutionalized older adults once it can lead to other several
adaptations. Moreover, such interventions are important for governments and healthcare
providers to understand and implement strategies by the needs and concerns of this specific
population. By this understanding, it is possible to allocate resources and define healthcare
politics at LTCI’s accordingly. We also consider that as important as the geriatrician or
gerontologist approaches; patient-reported outcomes (such as HRQOL) should be valued,
73
once subjective report of the patients’ health condition, especially in frailty and sarcopenia,
seems to reliably represent individual’s health.
REFERENCES
1. Morley JE, Vellas B, Kan A, et al. Frailty Consensus: A Call to Action. JAMDA. 2013;
14:392-7.
2. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia: European consensus on
definition and diagnosis: Report of the European Working Group on Sarcopenia in Older
People. Age and ageing. 2010;39(4):412-23.
3. Santiago LM, Mattos IE. Prevalência e fatores associados à fragilidade em idosos
institucionalizados das regiões Sudeste e Centro-Oeste do Brasil. Rev Bras Geriatr Gerontol.
2014;17(2):327-37.
4. Sewo Sampaio PY, Sampaio RAC, Yamada M, Arai H. Comparison of frailty between
users and nonusers of a day care center using the Kihon Checklist in Brazil. Journal of
Clinical Gerontology and Geriatrics. 2014, 5(3):82-5.
5. Tarazona-Santabalbina FJ, Gómez-Cabrera MC, Pérez-Ros P, et al. A Multicomponent
Exercise Intervention that Reverses Frailty and Improves Cognition, Emotion, and Social
Networking in the Community-Dwelling Frail Elderly: A Randomized Clinical Trial.
JAMDA. 2016, 17(5):426-33.
6. Cadore EL, Moneo ABB, Mensat MM, et al. Positive effects of resistance training in frail
elderly patients with dementia after long-term physical restraint. Age. 2014, 36(2):801-11.
7. Cadore EL, Casas-Herrero A, Zambom-Ferraresi F, et al. Multicomponent exercises
including muscle power training enhance muscle mass, power output, and functional
outcomes in institutionalized frail nonagenarians. Age. 2014, 36(2):773-85.
8. Yamada M, Arai H, Uemura K, et al. Effect of resistance training on physical performance
and fear of falling in elderly with different levels of physical well-being. Age ageing. 2011,
40(5):637-41.
74
9. Fiatarone MA, O’Neil EF, Ryan ND, et al. Exercise training and nutritional
supplementation for physical frailty in very elderly people. N Eng J Med. 1994,330:1769-75.
10. Creutzberg M, Gonçalves LHT, Sobotka EA. Instituição de Longa Permanência para
Idosos: a imagem que permanece. Florianópolis (SC): Texto Contexto Enferm. 2008,
17(2):273-9.
11. Agência Nacional de Vigilância Sanitária (ANVISA). Consulta pública no. 41, de 18 de
janeiro de 2004. D.O.U de 21/06/2004. Available in:
www4.anvisa.gov.br/base/visadoc/CP/CP%5B7626-1-0%5D.PDF. Accessed on 06 April
2017.
12. Sampaio RAC, Sewo Sampaio PY, Yamada M, et al. Arterial stiffness is associated with
low skeletal muscle mass in Japanese community-dwelling older adults. Geriatr Gerontol Int.
2014, 14(Suppl.1):109–114.
13. Sampaio RAC, Sewo Sampaio PY, Castaño LAA, et al. Cutoff values of appendicular
skeletal muscle mass and strength associated to fear of falling in Brazilian older adults. Sao
Paulo Medical Journal. 2017. In press.
14. Bohannon RW. Reference values for the Timed Up and Go test: a descriptive meta-
analysis. Journal of Geriatric Physical Therapy. 2006, 29(2:06):64-8.
15. Uchida MC (2015). [Research project: Elastic band rowing test]. Unpublished data.
16. Sewo Sampaio PY, Sampaio RAC, Yamada M, Ogita M, Arai H. Validation and
Translation of the Kihon Checklist (frailty index) into Brazilian Portuguese. Geriatr Gerontol
Int. 2014, 14(3):561-9.
17. Optum Inc. An excerpt from the User’s Manual for the SF-36v2 Health Survey, Second
Edition, Chapter 1, pages 3-12. Available in:
https://www.optum.com/content/dam/optum/resources/Manual%20Excerpts/SF-
36v2_Manual_Chapter_1.pdf. Accessed on 9 May 2015.
18. Foster C, Florhaug JA, Gottschall L, et al. A new approach to monitoring exercise
training. J Strength Cond Res. 2001, 15(1):109-15.
75
19. Uchida MC, Teixeira LF, Godoi VJ, et al. Does The Timing of Measurement Alter
Session-RPE in Boxers? J Sports Sci Med. 2014, 13(1):59-65.
20. Uchida MC, Nishida MM, Sampaio RAC, Moritani T, Arai H. Thera-band elastic band
tension: reference values for physical activity. J Phys Ther Sci. 2016, 28:1266-71.
21. Aguirre LE, Villareal DT. Physical exercise as therapy for frailty. In Fielding RA, Sieber
C, Vellas B (eds): Frailty: pathophysiology, phenotype and patient care. Nestlé Nutr Inst
Workshop Ser. 2015, 83:83-92.
22. Shepstone TN, Tang JE, Dallaire S, et al. Short-term high- vs. low-velocity isokinetic
lengthening training results in greater hypertrophy of the elbow flexors in young men. J Appl
Physiol. 2005, 98(5):1768-76.
23. Farthing JP, Chilibeck PD. The effects of eccentric and concentric training at different
velocities on muscle hypertrophy. Eur J Appl Physiol. 2003, 89(6):578-86.
24. Rhea MR. Determining the magnitude of treatment effects in strength training research
through the use of the effect size. Journal of Strength and Conditioning Research. 2004,
18(4):918-20.
25. Cruz-Jentoft AJ, Landi F, Schneider SM, et al. Prevalence of and interventions for
sarcopenia in ageing adults: a systematic review. Report of the International Sarcopenia
Initiative (EWGSOP and IWGS). Age and ageing. 2014; 0:1-12.
26. Michel JP, Cruz-Jentoft AJ, Cederholm T. Frailty, exercise and nutrition. Clin Geriatr
Med. 2015, 31:375-387.
27. Theou O, Stathokostas L, Roland KP, et al. The effectiveness of exercise intervention for
the management of frailty: a systematic review. Journal of Aging Research. 2011, 2011,
Article ID: 569194.
28. Weening-Dijksterhuis E, de Greef MHG, Scherder EJA, Slaets JPJ, van der Schans CP.
Frail institutionalized older persons: a comprehensive review on physical exercise, physical
fitness, activities of daily living, and quality-of-life. Am J Phys Med Rehabil. 2011;90:156-
68.
76
29. Rizzoli R, Reginster JY, Arnal JF, et al. Quality of life in sarcopenia and frailty. Calcif
Tissue Int. 2013,93(2):101-20.
77
CONCLUSÃO
Os artigos aqui apresentados, quando considerados em conjunto, abordaram a
sarcopenia e QV numa perspectiva a partir do diagnóstico, usando como base idosos
residentes na comunidade, até a intervenção com exercícios de potência em idosos frágeis e
institucionalizados.
No primeiro artigo, os valores de referência para massa muscular apendicular
ajustada pelo IMC foram <0.85 para homens e <0.53 para mulheres; para força de preensão
manual absoluta foram <30.0 kgf para homens e <21.7 kgf para mulheres; enquanto para
força de preensão manual relativa (também ajustada pelo IMC) foram <1.07 para homens e
<0.66 para mulheres. O medo de cair foi usado como desfecho das análises, que indicaram
que o peso do indivíduo deve ser considerado em relação à massa muscular apendicular em
ambos os sexos; já em relação à força, mostrou-se o melhor ajuste para mulheres, mas não
para homens.
Valores de referência baseados em amostras locais são preferíveis sobre valores
estrangeiros; assim, recomenda-se o uso de massa muscular apendicular ajustada pelo IMC
em homens e mulheres, e a escolha entre força de preensão manual absoluta ou relativa de
acordo com as necessidades do estudo. Tais pontos de corte podem auxiliar profissionais da
área da saúde na avaliação, planejamento e atuações mais eficientes visando identificar e
intervir prontamente naqueles vulneráveis.
Sobre o segundo artigo, verificou-se que a combinação de baixa força, lentidão
da marcha e baixa massa muscular appendicular ajustada pelo IMC foi associada à baixa QV
em idosos residentes na comunidade. Nos homens, essa associação foi identificada
especialmente pela condição força e/ou velocidade da marcha, que se relacionou com os
domínios capacidade funcional, aspectos físicos e estado geral da saúde. Em mulheres, a
combinação de força, velocidade da marcha e massa muscular foi associada com os domínios
capacidade funcional, aspectos físicos, dor, estado geral da saúde e aspectos sociais. Logo, os
pontos de corte previamente identificados, além de verificarem diferenças morfofuncionais,
também estão associados a aspectos subjetivos em idosos.
No terceiro artigo, verificou-se o efeito do treinamento de potência em variáveis
de função física e QV em idosos frágeis e institucionalizados. Após as atividades de
pesquisa, melhoras foram verificadas na velocidade da marcha, número de repetições do teste
remada com banda elástica, em homens e mulheres; e no teste timed up and go,
especificamente em mulheres. Componentes físicos e mentais da QV também melhoraram -
78
função física, aspectos físicos, dor corporal e aspectos emocionais, em homens; e aspectos
físicos e aspectos emocionais, em mulheres.
Há de se ressaltar a dificuldade na realização da pesquisa com idosos frágeis,
uma amostra vulnerável, com anos de institucionalização, incidência de quedas e fraturas,
que necessitam de cuidados e motivação constantes. Fora a necessidade de lidar com fatores
além da pesquisa, mas que certamente influenciam os resultados e participação, como morte
de parentes e amigos, e até mesmo negligência da família; situações comuns em idosos
residentes em instituições de longa permanência. Assim, intervenções para promover a
função física de idosos institucionalizados são essenciais uma vez que podem provocar outras
adaptações positivas, incluindo melhora da QV.
O desenvolvimento de estratégias para identificar idosos vulneráveis e propostas
de intervenção visando maximizar suas capacidades, sejam físicas ou mentais, é imperativo.
Os estudos incluídos nessa tese apresentaram dados que podem ser utilizados tanto por
pesquisadores como na prática profissional. Mais ainda, podem servir de referência ao
desenvolvimento de políticas públicas relacionadas à saúde e ao bem estar da população
idosa.
REFERÊNCIAS
1. WORLD HEALTH ORGANIZATION – WHO. World report on ageing and health. World
Health Organization, 2015.
2. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia: European consensus on
definition and diagnosis: Report of the European Working Group on Sarcopenia in Older
People. Age and Ageing. 2010;39(4):412-23.
3. Reid KF, Fielding RA. Skeletal muscle power: a critical determinant of physical
functioning in older adults. Exercise and Sport Sciences Reviews. 2012; 40(1):4-12.
4. Hautier C, Bonnefoy M. Training for older adults. Ann Readapt Med Phys.
2007;50(6):475-9,469-74.
5. Yamada M, Nishiguchi S, Fukutani N, et al. Prevalence of sarcopenia in community-
dwelling Japanese older adults. JAMDA. 2013;14(12):911-5.
79
6. Denkinger MD, Lukas A, Nikolaus T, Hauer K. Factors associated with fear of falling and
associated activity restriction in community-dwelling older adults: a systematic review. Am J
Geriatr Psychiatry. 2015;23:73-86.
7. Trombetti A, Reid KF, Hars M, et al. Age-associated declines in muscle mass, strength,
power, and physical performance: impact on fear of falling and quality of life. Osteoporos
Int. 2016;27(2):463-71.
8. Rosenberg I. Summary comments: epidemiological and methodological problems in
determining nutritional status of older persons. Am J Clin Nutr. 1989;50:1231–3.
9. Morley JE, Abbatecola AM, Argiles JM, et al. Sarcopenia With Limited Mobility: An
International Consensus. J Am Med Dir Assoc. 2011;12(6):403-9.
10. Chen L-K, Liu LK, Woo J, et al. Sarcopenia in Asia: Consensus Report of the Asian
Working Group for Sarcopenia. J Am Med Dir Assoc. 2014;15(2):95-101.
11. Studenski SA, Peters KW, Alley DE, et al. The FNIH Sarcopenia Project: Rationale,
study, description, conference recommendations, and final estimates. J Gerontol A Biol Sci
Med Sci. 2014;69(5):547-58.
12. Diz JB, Leopoldino AA, Moreira BS, et al. Prevalence of sarcopenia in older Brazilian: A
systematic review and meta-analysis. Geriatr Gerontol Int. 2017;17(1):5-16.
13. Liu-Ambrose T, Donaldson MG, Ahamed Y, et al. Otago Home-Based Strength and
Balance Retraining Improves Executive Functioning in Older Fallers: A Randomized
Controlled Trial. J Am Geriatr Soc. 2008;56(10):1821-30.
14. Elavsky S, McAuley E, Motl RW, et al. Physical activity enhances long-term quality of
life in older adults: Efficacy, esteem, and effective influence. Annals of Behavioral Medicine.
2005; 30(2):138-45.
15. Guedea MTD, Albuquerque FJB, Tróccoli BT, Noriega JAV, Seabra MAB, Guedea
RLD. Relação do bem-estar subjetivo, estratégias de enfrentamento e apoio social em idosos.
Psicologia: Reflexão e Crítica. 2006;19(2):301-8.
16. Paskulin LMG, Molzahn A. Quality of life of older adults in Canada and Brazil. Western
Journal of Nursing Research. 2007;29(1):10–26.
80
17. Walker A. A European perspective on quality of life in old age. European Journal of
Ageing. 2005;2(1):2–12.
18. Guedes DP, HatmannAC, Martini FA, Borges MB, Bernardelli RJr. Quality of life and
physical activity in a sample of Brazilian older adults. J Aging Health. 2012;24(2):212-26.
19. Bauman A, Merom D, Bull F, Buchner DM, Singh MA. Updating the Evidence for
Physical Activity: Summative Reviews of the Epidemiological Evidence, Prevalence, and
Interventions to Promote “Active Aging”. The Gerontologist. 2016; 56(S2):S268-80.
20. Vina J, Rodriguez-Mañas L, Salvador-Pascual A, Tarazona-Santabalbina FJ, Gomez-
Cabrera MC. Exercise: the Lifelong Supplement for Healthy Ageing and Slowing Down the
Onset of Frailty. J Physiol. 2016;594(8):1989-99.
21. AMERICAN COLLEGE OF SPORTS MEDICINE. American College of Sports
Medicine position stand. Progression models in resistance training for healthy adults.
Medicine and Science in Sports and Exercise. 2009;41(3):687-708.
22. Matsudo SMM. Envelhecimento, atividade física e saúde. BIS, Bol. Inst. Saúde. 2009;47:
46-9.
23. Fiatarone MA, O’Neil EF, Ryan ND, et al. Exercise training and nutritional
supplementation for physical frailty in very elderly people. N Eng J Med. 1994,330:1769-75.
24. Yamada M, Arai H, Uemura K, et al. Effect of resistance training on physical
performance and fear of falling in elderly with different levels of physical well-being. Age
and Ageing. 2011;40(5):637-41.
25. Sayers SP. High-speed power training: a novel approach to resistance training in older
men and women. A brief review and pilot study. The Journal of Strength & Conditioning
Research. 2007;21(2):518-26.
26. Cadore EL, Pinto RS, Kruel LFM. Adaptações neuromusculares ao treinamento de força
e concorrente em homens idosos. Revista Brasileira de Cineantropometria & Desempenho
Humano. 2012;14(4):483-95.
81
27. Bottaro M, Machado SN, Nogueira W, Scales R, Veloso J. Effect of high versus low-
velocity resistance training on muscular fitness and functional performance in older men.
European Journal of Applied Physiology. 2007;99(3): 257-64.
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ANEXO 1
83
ANEXO 2