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Adherence to a standardized protocol for measuring grip strength and appropriate cut-off values in adults over 65 years with sarcopenia: a systematic review protocol Benjamin Fox
1 1
Tim Henwood
2
Laura Schaap
Olivier Bruyère
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Jean-Yves Reginster Charlotte Beaudart Fanny Buckinx Helen Roberts Cyrus Cooper
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3
3
5
4 6
Antonio Cherubini
Giuseppina dell’ Aquilla Marcello Maggio Stefano Volpato 1
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7
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The University of Queensland, UQ/Blue Care Research and Practice Development Centre, Brisbane, Australia; Australian Centre for Evidence Based Community Care: a Joanna Briggs Collaborating Centre
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Department of Health Sciences, VU University Amsterdam, Amsterdam, Netherlands
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Department of Public Health, Epidemiology and Health Economics. University of Liège, Wallonia, Belgium
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MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, United Kingdom
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Academic Geriatric Medicine, University of Southampton, Southampton, United Kingdom
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Geriatrics and Geriatric Emergency Care, Italian National Research Center on Aging (IRCCSINRCA), Ancona, Italy
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Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
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Department of Medical Sciences, University of Ferrara, Ferrara, Italy Corresponding author Ben Fox
[email protected]
Review question/objective The objective of this review is to examine the use of grip strength analysis in well and unwell populations in adults 65 years and over as a tool to establish muscle strength in sarcopenia. More specifically, the main review question is: 1. What protocol, if any, is most commonly used among older adults with sarcopenia and does this match the standardized protocol suggested in 2011 by Roberts et al.1?
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Secondary review questions are: 2. What are the reported cut-off values being used to determine sarcopenia in older adults, with consideration for ethnic and gender variability? 3. Is grip strength, as a tool to measure muscle strength, suitable for people with common comorbidities and geriatric syndromes, such as osteoarthritis, often associated with sarcopenia?
Background Sarcopenia, a commonly used concept in geriatrics and gerontology, is characterized by a loss of 1
muscle mass, muscle strength and/or physical functioning. Prevalence rates vary between 1-39% in 2
community dwelling older populations and 14-33% in long-term care populations.
Several
epidemiological studies have shown the association of sarcopenia with adverse health outcomes such as falls, disability, hospitalization and mortality.
3-4
Originally, sarcopenia refers to the loss of muscle
5
mass with aging , which was later complemented with loss of muscle strength and physical functioning. In 2010, the European Working Group on Sarcopenia in Older People (EWGSOP) reported a consensus definition of sarcopenia, which included measurement of low muscle mass and low muscle 1
function (strength or physical performance). This consensus definition can be used
to identify
sarcopenia patients in clinical practice and to select individuals for clinical trials. Well-designed clinical trials could ultimately lead to effective treatment and prevention strategies for sarcopenia. Since the publication of the consensus report, many studies have adopted this definition, which could potentially lead to better comparison of results between studies. On the other hand, within this definition there still is wide variability in measurement tools and use of cut-off values, which could actually hamper comparability between studies. To assess muscle strength, the EWGSOP has recommended grip strength measurement which is easy and inexpensive. A recent systematic review on the measurement properties of tools to assess sarcopenia concluded that grip strength measurement is a valid and reliable method.
6
In a
comprehensive review of the measurement of grip strength in clinical and epidemiological studies by 7
Roberts et al., it was shown that there is wide variability in the choice of equipment and protocols for measuring grip strength. To enable comparison between studies, a standardized approach, incorporating more consistent measurement of grip strength is warranted. Based on the results of the 7
review, a standardized approach was described including the utilization of the widely used Jamar hydraulic hand dynamometer, as was a clear assessment protocol. So far, it is unknown whether this approach has been adopted in studies investigating grip strength for sarcopenia. The primary aim of this current review is to identify whether studies are adhering to the suggested protocol, or whether a more common method is prevalent. The EWGSOP has suggested multiple cut-off values to define sarcopenia regarding muscle strength: an absolute cut-off score of 20 kilograms (kg) for women and 8
9
30 kg for men, and Body Mass Index (BMI) specific cut-off values for men and women. Alternatively, the Foundation for the National Institutes of Health (FNIH) Sarcopenia Study suggested cut-off points of 26kg for males and 16kg for females, based on the likelihood of mobility impairment. 11
values have also been suggested by Dodds et al.,
10
Similar
who generated grip strength reference values
and calculated cut-off points 2.5 standard deviations below the mean from 12 United Kingdom (U.K) based epidemiology studies.
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Recently, Beaudart et al.
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showed that large differences in sarcopenia prevalence occur when both
cut-off values are compared, especially in women.
12
Additionally, prevalence has also shown to be
dependent upon the tool used to assess muscle strength.
13
Evidently, cut-off values are highly varied
and may be selected for statistical, theoretical or practical reasons, and/or are based on the type and magnitude of association with clinical endpoints such as hospitalization, falls or mobility. Difficulties arise in promoting a clear-cut definition of sarcopenia with no consistent recommendation for cut-off values of grip strength available. It is therefore important to identify which grip strength cut-off values should be used for the identification of sarcopenia patients and how comorbidities such as osteoarthritis may affect such values. This review will aim to report on the cut-off values used, the justification for and the considerations of comorbidities within the identified articles. Furthermore, a study has suggested that cut-off values may be different within Asian populations. Therefore, ethnicity will also be taken into account for variations in appropriate cut-off values.
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The overarching objective of this review is to provide insight into the current use of grip strength within the literature among older adults aged 65 and over and, subsequently, to provide commentary on the consistency of protocol and cut-off values reported for grip strength measures. This insight into current research practice will lead to well-considered recommendations concerning the measurement of grip strength in research and clinical practice. A preliminary search for sarcopenia revealed five systematic reviews in the Cochrane Library and two within the JBI Database of Systematic Reviews and Implementation Reports, but none that examine the protocol of grip strength measures. A single study was identified through a search of Medline [Via EBSCOhost] which examines the psychometric 6
properties of common measures of muscle mass, strength and physical performance in sarcopenia , but it was not specific to grip strength measures, nor did it examine the used protocol within studies. A lack of research into this area warrants further research and the need for the conduct of this proposed review.
Keywords ageing; EWGSOP; geriatrics; grip strength; muscle strength; protocol; sarcopenia
Inclusion criteria Types of participants Participants will be adults, aged 65 years and over living at home or in health or social care settings with sarcopenia as a prevailing pathology. The setting and whether the participants fulfil specific inclusion criteria or form part of an inclusive screening study will be recorded. Notes will be made for sarcopenia status, comorbidities, gender, ethnicity and other geriatric disorders. Studies across varied diseases and disabilities, including stroke,
and musculoskeletal, neuromuscular and cognitive
disease will be included in the interest of evaluating the suitability of hand grip assessment in these populations, with reference to the ability to complete protocol, free from pain or other relevant noted issues. While no specific exclusion criteria exist for this review, a comment on the exclusion criteria from included studies will be provided. Types of intervention(s)/phenomena of interest The phenomenon of interest is the stated protocol and cut-off values of grip strength as a measure of muscle strength, following any protocol and using any standard equipment for assessing grip strength. Expected instruments could include: the hydraulic Jamar, the pneumatic Martin Vigorimeter,
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the mechanical Harpenden hand dynamometers and the strain Isometric Strength Testing Unit. Use of grip strength to determine the success of hand surgical interventions will be excluded. Types of outcomes The primary outcome of interest is whether the stated protocol from included studies aligns with the 7
suggested protocol from Roberts et al., on the domains of: body, arm, wrist and feet posture, level of encouragement, number of trials (one, three or other), scoring procedures (nearest one unit of measurement), hand/s assessed (left, right, dominate or both), equipment used (hydraulic Jamar, etc.) and trial used (highest, mean of trials or other). Population characteristics will also be of interest to this study. Cut-off scores for low muscle strength will also be reported on. As multiple cut-off scores have been reported within the literature, this review will report on the stated cut-off scores for men and for women from included studies. Potential missing data from any of those domains will be reported on. Types of studies This review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies for inclusion, examining stated protocol and cut-off points. This review will also consider descriptive epidemiological study designs including case series, individual case reports and descriptive cross sectional studies for inclusion, examining stated protocol and cut-off points.
Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of PubMed, will be undertaken, followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified articles will be searched for additional studies. Due to resource implications, non-English studies will not be included. Only studies since 2010 will be included in this review to examine the protocol and cut-off values, as a follow-up to the previous research conducted by Roberts et al.
7
The databases to be searched are: MEDLINE, EMBASE, CINAHL and Scopus The search for unpublished, grey literature studies will include: Google Scholar and ProQuest (Dissertations and Theses Databases), Initial keywords will include: “grip strength”, OR “grip”, OR “hand strength*” OR “muscle strength” OR “dynamometer” AND “older adults” OR “frail” OR “frailty” OR “health status” OR “aged” OR “geriatric” AND “sarcopenia” OR “muscle atrophy” OR “muscular atrophy” Additionally, the ‘citation map’ function from ISI Web of Science will be used to generate a two 3
generation map of articles citing Roberts et al. The search strategy has been developed to capture literature that use grip strength in adults over the age of 65 years.
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Assessment of methodological quality Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBIMAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Data extraction Data will be extracted from papers included in the review using a modified version of the standardized 7
data extraction tool from JBI-MAStARI (Appendix II), based on domains listed by Roberts et al. The data extracted will include specific details about the populations, study methods and outcomes of significance to the review question and specific objectives. Attempts will be made to contact authors of primary studies to include any missing data for clarification.
Data synthesis Due to the nature of anticipated data, a quantitative meta-analysis will not be possible. Findings will be presented in narrative form including tables and figures to aid in data presentation, where 7
appropriate. Studies will be analyzed as adhering to the suggested protocol from Roberts et al. or using a different protocol. Cut-off values, and the justification of, within studies will also be presented 7
in narrative form. However, as no recommendation was made within Roberts et al. no comment on adherence to cut-off values will be made.
Conflicts of interest The authors have no conflicts of interest to declare.
Acknowledgements Authors would like to acknowledge the role of Alzheimer's Australia Dementia Research Foundation for providing a PhD scholarship for the primary author.
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References 1.
Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing. 2010;39(4):412-23.
2.
Cruz-Jentoft AJ, Landi F, Schneider SM, Zú-iga C, Arai H, Boirie Y, et al. Prevalence of and interventions for sarcopenia in ageing adults. Report of the International Sarcopenia Initiative (EWGSOP and IWGS). Age Ageing. 2014;43(6):748-759.
3.
Reid KF, Naumova EN, Carabello RJ, Phillips EM, Fielding RA. Lower extremity muscle mass predicts functional performance in mobility-limited elders. J Nutr Health Aging. 2008;12(7):493– 498.
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Janssen I, Baumgartner RN, Ross R, Rosenberg IH, Roubenoff R. Skeletal muscle cutpoints associated with elevated physical disability risk in older men and women. Am J Epidemiol. 2004;159(4):413–421.
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Rosenburg, IH. Sarcopenia: origins and clinical relevance. J. Nutr 1997;127(5): 990S-991S.
6.
Mijnarends DM, Meijers JMM, Halfens RJG, ter Borg S, Luiking YC, Verlaan S, et al. Validity and Reliability of Tools to Measure Muscle Mass, Strength, and Physical Performance in CommunityDwelling Older People: A Systematic Review. J Am Med Dir Assoc. 2013 3;14(3): 170-8.
7.
Roberts HC, Denison HJ, Martin HJ, Patel HP, Syddall H, Cooper C, et al. A review of the measurement of grip strength in clinical and epidemiological studies: towards a standardised approach. Age Ageing. 2011;40(4): 423-9.
8.
Lauretani F, Russo CR, Bandinelli S, Bartali B, Cavazzini C, Di Iorio A, et al. Age-associated changes in skeletal muscles and their effect on mobility: an operational diagnosis of sarcopenia. J Appl Physiol. 1985;95(5): 1851-60.
9.
Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in Older Adults: Evidence for a Phenotype. J Gerontol A Biol Sci Med Sci. 2001 March 1, 2001;56(3): M146-M57.
10. Alley DE, Shardell MD, Peters KW, McLean RR, Dam T-TL, Kenny AM, et al. Grip Strength Cutpoints for the Identification of Clinically Relevant Weakness. J Gerontol A Biol Sci Med Sci. 2014;69(5): 559-66. 11. Dodds RM, Syddall HE, Cooper R, Benzeval M, Deary IJ, Dennison EM, et al. Grip Strength across the Life Course: Normative Data from Twelve British Studies. PLoS ONE. 2014;9(12): e113637. 12. Beaudart C, Reginster J-Y, Slomian J, Buckinx F, Locquet M, Bruyère O. Prevalence of sarcopenia: the impact of different diagnostic cut-off limits. J Musculoskelet Neuronal Interact. 2012;14(4): 425-31. 13. Beaudart C, Reginster JY, Slomian J, Buckinx F, Dardenne N, Quabron A, et al. Estimation of sarcopenia prevalence using various assessment tools. Exp Geront. 2015 1;61(0): 31-7. 14. Chen L-K, Liu L-K, Woo J, Assantachai P, Auyeung T-W, Bahyah KS, et al. Sarcopenia in Asia: Consensus Report of the Asian Working Group for Sarcopenia. J Am Med Dir Assoc. 2014;15(2): 95-101.
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Appendix I: Appraisal instruments MAStARI appraisal instrument
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Appendix II: Data extraction instruments 1
Data extraction form for grip strength protocol studies (adapted from a study by Roberts et al. )
Reviewer____________________________________
Date________________________________
Author______________________________________
Year________________________________
Journal______________________________________ Record Number_______________________
Study Method RCT
Quasi-RCT
Longitudinal
Retrospective
Observational
Other
Participants Setting Population
Sample Size Group A ___________________
Group B_________________
Other__________________
Protocol for Grip Strength
Stated Protocol
Aligned to Roberts et al. (Y/N)
Posture Body Arm Wrist Feet Level of Encouragement Number of Trials Scoring Procedures Hand/s Assessed Equipment Used Trial Used
Other information of potential interest (e.g. any issues of suitability mentioned)
Reviewers Conclusions
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