Lower Limb Physical Function Research Articles

Are sarcopenia and its individual components linked to all-cause mortality in heart failure? A systematic review and meta-analysis

Abstract Objective The objective of this systematic review and meta-analysis was to assess sarcopenia and its components as prognostic factors in patients with heart failure (HF). Methods From inception to December 2022, a systematic literature search was carried out utilizing PubMed, Web of Science, Scopus, and Cochrane Library databases. A meta-analysis employing a random-effects model was performed to assess the pooled effects. Results The systematic review and meta-analysis included 32 and 18 longitudinal studies, respectively. The prediction of 1- to 2-year all-cause mortality in sarcopenia was not statistically significant (hazard ratio (HR): 1.35, 95% CI 0.76–2.38, I2 = 54%, P = 0.31). The lowest combined quartile and quantile of the population were used to define low handgrip strength that showed identical results (HR: 1.24, 95% CI 0.94–1.62, I2 = 0%, P = 0.13). Low L3-L4 psoas muscle mass (HR: 2.20, 95% CI 1.26–3.83, I2 = 87%, P < 0.01) and slow gait speed (HR: 1.45, 95% CI 1.20–1.74, I2 = 0%, P < 0.01) were significant contributors to all-cause mortality risk. Additionally, a 0.1 m/s increase in gait speed demonstrated a significant reduction of all-cause mortality (HR: 0.77, 95% CI 0.66–0.90, I2 = 60%, P < 0.01). Our narrative synthesis also described appendicular lean mass (ALM) and short physical performance battery (SPPB) scores as significant prognostic factors. Conclusions Compared to patients with higher overall functional performance, those with HF and low ALM, low psoas muscle mass, low SPPB, and slow gait speed are at an increased risk of all-cause mortality. Early prevention and/or treatment of lower limb physical function deterioration may be an essential strategy to reduce the risk of premature death in HF. Graphical abstract

Convergent validity and inter-rater reliability of a lower-limb multimodal physical function assessment in community-dwelling older adults.

Introduction: Lower-limb physical function declines with age and contributes to a greater difficulty in performing activities of daily living. Existing assessments of lower-limb function assess one dimension of movement in isolation or are not time-efficient, which discourages their use in community and clinical settings. We aimed to address these limitations by assessing the inter-rater reliability and convergent validity of a new multimodal functional lower-limb assessment (FLA). Methods: FLA consists of five major functional movement tasks (rising from a chair, walking gait, stair ascending/descending, obstacle avoidance, and descending to a chair) performed consecutively. A total of 48 community-dwelling older adults (32 female participants; age: 71 ± 6years) completed the FLA as well as timed up-and-go, 30-s sit-to-stand, and 6-min walk tests. Results: Slower FLA time was correlated with a slower timed up-and-go test (ρ = 0.70), less sit-to-stand repetitions (ρ = -0.65), and a shorter distance in the 6-min walk test (ρ = -0.69; all, p < 0.001). Assessments by two raters were not different (12.28 ± 3.86s versus 12.29 ± 3.83s, p = 0.98; inter-rater reliability ρ = 0.993, p < 0.001) and were statistically equivalent (via equivalence testing). Multiple regression and relative weights analyses demonstrated that FLA times were most predicted by the timed up-and-go performance [adjusted R 2 = 0.75; p < 0.001; raw weight 0.42 (95% CI: 0.27, 0.53)]. Discussion: Our findings document the high inter-rater reliability and moderate-strong convergent validity of the FLA. These findings warrant further investigation into the predictive validity of the FLA for its use as an assessment of lower-limb physical function among community-dwelling older adults.

A group-based exercise and behavioural maintenance intervention for adults over 65 years with mobility limitations: the REACT RCT

Background Mobility limitation in older age reduces quality of life, generates substantial health- and social-care costs, and increases mortality. Objective The REtirement in ACTion (REACT) trial aimed to establish whether or not a community-based active ageing intervention could prevent decline in physical functioning in older adults already at increased risk of mobility limitation. Design A multicentre, pragmatic, two-arm, parallel-group randomised controlled trial with parallel process and health economic evaluations. Setting Urban and semi-rural locations across three sites in England. Participants Physically frail or pre-frail older adults (aged ≥ 65 years; Short Physical Performance Battery score of 4–9). Recruitment was primarily via 35 primary care practices. Interventions Participants were randomly assigned to receive brief advice (three healthy ageing education sessions) or a 12-month, group-based, multimodal exercise and behavioural maintenance programme delivered in fitness and community centres. Randomisation was stratified by site and used a minimisation algorithm to balance age, sex and Short Physical Performance Battery score. Data collection and analyses were blinded. Main outcome measures The primary outcome was change in lower limb physical function (Short Physical Performance Battery score) at 24 months, analysed using an intention-to-treat analysis. The economic evaluation adopted the NHS and Personal Social Services perspective. Results Between June 2016 and October 2017, 777 participants (mean age 77.6 years, standard deviation 6.8 years; 66% female; mean Short Physical Performance Battery score 7.37, standard deviation 1.56) were randomised to the intervention arm (n = 410) or the control arm (n = 367). Data collection was completed in October 2019. Primary outcome data at 24 months were provided by 628 (80.8%) participants. At the 24-month follow-up, the Short Physical Performance Battery score was significantly greater in the intervention arm (mean 8.08, standard deviation 2.87) than in the control arm (mean 7.59, standard deviation 2.61), with an adjusted mean difference of 0.49 (95% confidence interval 0.06 to 0.92). The difference in lower limb function between intervention and control participants was clinically meaningful at both 12 and 24 months. Self-reported physical activity significantly increased in the intervention arm compared with the control arm, but this change was not observed in device-based physical activity data collected during the trial. One adverse event was related to the intervention. Attrition rates were low (19% at 24 months) and adherence was high. Engagement with the REACT intervention was associated with positive changes in exercise competence, relatedness and enjoyment and perceived physical, social and mental well-being benefits. The intervention plus usual care was cost-effective compared with care alone over the 2 years of REACT; the price year was 2019. In the base-case scenario, the intervention saved £103 per participant, with a quality-adjusted life-year gain of 0.04 (95% confidence interval 0.006 to 0.074) within the 2-year trial window. Lifetime horizon modelling estimated that further cost savings and quality-adjusted life-year gains were accrued up to 15 years post randomisation. Conclusion A relatively low-resource, 1-year multimodal exercise and behavioural maintenance intervention can help older adults to retain physical functioning over a 24-month period. The results indicate that the well-established trajectory of declining physical functioning in older age is modifiable. Limitations Participants were not blinded to study arm allocation. However, the primary outcome was independently assessed by blinded data collectors. The secondary outcome analyses were exploratory, with no adjustment for multiple testing, and should be interpreted accordingly. Future work Following refinements guided by the process evaluation findings, the REACT intervention is suitable for large-scale implementation. Further research will optimise implementation of REACT at scale. Trial registration This trial is registered as ISRCTN45627165. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 14. See the NIHR Journals Library website for further project information.

Gait, Function, and Strength Following Lower Limb Salvage Surgery for a Primary Malignant Bone Tumor: A Systematic Review

Background: Primary malignant bone tumors are a rare form of cancer, treated with limb salvage surgery (LSS), which includes sacrifices of muscle and bone. Purpose: To systematically appraise outcomes of gait, physical function (including dynamic balance, transfers, sit-to-stand, and stair climbing) and muscle performance related to the trunk and lower limb in current literature for individuals who have undergone LSS due to a primary bone tumor. Data Sources: Medline, Cochrane, and PEDro databases were searched from inception to June 2020. Study Selection: Following PRISMA guidelines, articles were screened by 2 reviewers independently (J.N. and C.H.) to determine eligibility based on population of interest (adults who have had LSS) and outcomes (gait, trunk, and lower limb physical function or muscle performance). Discrepancies were resolved with a third reviewer until a mutual consensus was reached (S.H.). Data Extraction: Data on gait, function, and muscle strength were extracted and grouped based on the surgical location (ankle, proximal tibia, distal femur, proximal femur/hip, or pelvic region). Data Synthesis: Data were extracted into tables and grouped first based on participants' surgical site and then based on a domain of outcomes (individual or mean group results for gait measures, strength, balance, use of walking aids, or ability to complete a task such as balance or stairs). Results: One thousand four hundred and forty-five abstracts were screened with 32 studies (354 participants) included in the review. Gait speed was reported in 16 studies and use of walking aids reported in 14 studies; these were the most reported outcomes in the review. Knee extensor strength was reported in 6 studies. Following internal hemipelvectomy surgery, 42% of participants ambulated without a walking aid and gait speed was reported as 0.61 to 1.6 m/s. For those who underwent surgery at the hip, 71% ambulated independently with an average gait speed of 0.94 to 1.20 m/s. Of participants who underwent surgery at the knee, 89% ambulated independently with an average gait speed of 0.36 to 1.32 m/s. Following knee LSS, knee extensor strength of the operated limb varied from 2% to 84% compared with the nonoperated side. Physical function outcome measures that were reported in the studies included the Timed Up and Go (TUG), single-leg balance and stair climbing. Two studies reported the TUG for participants who underwent LSS at the knee and 1 study for participants who underwent LSS at mixed locations on the lower limb. Single-leg balance and stair climbing were both reported in the same study on participants who had undergone LSS at the ankle. Discussion: Approximately 50% of people following hemipelvectomy surgery required a walking aid, with majority of the participants (58%) displaying a gait speed less than 1.1 m/s. Conversely, few people who underwent LSS at the knee and ankle required the use of walking aids. Knee and ankle-related LSS may more likely lead to independent ambulation when compared with surgical procedures at more proximal locations on the lower limb or pelvis. Gait speed is a relevant outcome and was most commonly reported in these participants. Muscle strength in participants varied widely, and physical function was not often measured, limiting insights into these domains. Limitations: Large variability in age, time since surgery, and surgical techniques across patients as well understanding of participants' comorbidities were limitations. Conclusions: Following internal hemipelvectomy surgery, individuals generally have greater functional limitations in gait independence and speed when compared with more distal surgical locations. Further investigation of other functional activities such as sit-to-stand and stair climbing in subacute timeframes is required.

Replacing Sedentary Behavior With Physical Activity of Different Intensities: Implications for Physical Function, Muscle Function, and Disability in Octogenarians Living in Long-Term Care Facilities.

We investigated the associations of replacing sedentary behavior (SB) with physical activity of different intensities on the physical function of octogenarians living in long-term care facilities. This pooled study recruited 427 older adults aged 80 years and older (69.1% female; body mass index: 27.53). For 345 participants who provided valid data, we assessed device-measured time spent in SB, light-intensity physical activity (LIPA), and moderate to vigorous physical activity (MVPA). We assessed lower limb physical function, strength, mobility, and disability. We used compositional data analysis to investigate the associations of replacing SB with physical activity on the outcomes. Reallocation of SB to LIPA and MVPA was associated with a higher number of 30-second Chair Stand cycles (LIPA: +0.21, MVPA: +1.81; P < .001), greater peak force (LIPA: +11.96N, MVPA: +27.68N; P < .001), peak power (LIPA: +35.82W, MVPA: +92.73W; P < .001), peak velocity (LIPA: +0.03m/s, MVPA: +0.12m/s; P < .001), higher levels of grip strength (LIPA: +0.68kg, MVPA: +2.49kg; P < .001), and less time in the Time Up and Go (LIPA: -7.63s, MVPA: -12.43s; P < .001). Replacing SB with LIPA or MVPA is associated with physical function and disability of older adults living in long-term care facilities.

Immediate Effects of a Telerehabilitation Program Based on Aerobic Exercise in Women with Fibromyalgia.

Background: We analyzed the immediate effects of a Telerehabilitation Program (TP) based on aerobic exercise in women with fibromyalgia (FM) syndrome during the lockdown declared in Spain due to the COVID-19 pandemic. Methods: A single-blind randomized controlled trial was designed. Thirty-four women with FM were randomized into two groups: TP group and Control group. The intervention lasted 15 weeks, with 2 sessions per week. The TP based on aerobic exercise was guided by video and the intensity of each session was monitored using the Borg scale. Pain intensity (Visual Analogue Scale), mechanical pain sensitivity (algometer), number of tender points, FM impact (Revised Fibromyalgia Impact Questionnaire), pain catastrophizing (Pain Catastrophizing Scale), physiological distress (Hospital Anxiety and Depression Scale), upper (Arm Curl Test) and lower-limb physical function (6-min Walk Test) were measured at baseline and after the intervention. Results: The TP group improved pain intensity (p = 0.022), mechanical pain sensitivity (p < 0.05), and psychological distress (p = 0.005), compared to the Control group. The Control group showed no statistically significant changes in any variable (p > 0.05). Conclusions: A TP based on aerobic exercise achieved improvements on pain intensity, mechanical pain sensitivity, and psychological distress compared to a Control group during the lockdown declared in Spain due to COVID-19 pandemic.

The Effects of Tai Chi on Markers of Atherosclerosis, Lower-limb Physical Function, and Cognitive Ability in Adults Aged Over 60: A Randomized Controlled Trial.

Objective: The purpose of this study was to investigate the effects of Tai Chi (TC) on arterial stiffness, physical function of lower-limb, and cognitive ability in adults aged over 60. Methods: This study was a prospective and randomized 12-week intervention trial with three repeated measurements (baseline, 6, and 12 weeks). Sixty healthy adults who met the inclusion criteria were randomly allocated into three training conditions (TC-24, TC-42, and TC-56) matched by gender, with 20 participants (10 males, 10 females) in each of the three groups. We measured the following health outcomes, including markers of atherosclerosis, physical function (leg power, and static and dynamic balance) of lower-limb, and cognitive ability. Results: When all three TC groups (p < 0.05) have showed significant improvements on these outcomes but overall cognitive ability at 6 or 12 weeks training period, TC-56 appears to have superior effects on arterial stiffness and static/dynamic balance in the present study. Conclusions: Study results of the present study add to growing body of evidence regarding therapeutic TC for health promotion and disease prevention in aging population. Future studies should further determine whether TC-42 and TC-56 are beneficial for other non-Chinese populations, with rigorous research design and follow-up assessment.

Hypertension Treatment and Control and Risk of Falls in Older Women.

A lower risk of falls is commonly cited as a reason to treat hypertension conservatively in older individuals. We examined the effect of hypertension treatment and control status and measured blood pressure (BP) level on the risk of falls in older women. Prospective cohort study. A total of 5971 women (mean age 79 years; 50.4% white, 33.1% black, 16.5% Hispanic/Latina) enrolled in the Women's Health Initiative and Objective Physical Activity and Cardiovascular Health study. BP was measured by trained nurses, and hypertension treatment was assessed by medication inventory. Participants mailed in monthly calendars to self-report falls for 1 year. Overall, 70% of women had hypertension at baseline (53% treated and controlled, 12% treated and uncontrolled, 5% untreated). There were 2582 women (43%) who reported falls in the 1 year of surveillance. Compared with nonhypertensive women, when adjusted for fall risk factors and lower limb physical function, the incidence rate ratio (IRR) for falls was 0.82 (confidence interval [CI] = 0.74-0.92) in women with treated controlled hypertension (p = .0008) and 0.73 (CI = 0.62-0.87) in women with treated uncontrolled hypertension (p = .0004). Neither measured systolic nor diastolic BP was associated with falls in the overall cohort. In women treated with antihypertensive medication, higher diastolic BP was associated with a lower risk of falls in a model adjusted for fall risk factors (IRR = 0.993 per mm Hg; 95% CI = 0.987-1.000; p = .04). The only class of antihypertensive medication associated with an increased risk of falls compared with all other types of antihypertensive drugs was β-blockers. Women in this long-term research study with treated hypertension had a lower risk of falls compared with nonhypertensive women. Diastolic BP (but not systolic BP) is weakly associated with fall risk in women on antihypertensive treatment (<1% decrease in risk per mm Hg increase). J Am Geriatr Soc, 2019. J Am Geriatr Soc 67:726-733, 2019.

Body composition and physical function in women with multiple sclerosis

Persons with multiple sclerosis (MS) have reduced physical activity (PA) and lower-limb physical function and potentially disordered body composition compared with their peers without MS. The aim of this study was to determine whether PA and body composition were differentially associated with lower-limb physical function in persons with MS compared with controls. Females with MS and age- and body mass index-matched female controls (n = 51; average age 48.1 +/- 9.7 yr) were measured for PA with daily step counts, relative fat mass (%Fat), and leg lean mass (LM-LEG) via dual energy X-ray absorptiometry and for lower-limb physical function with objective performance tests. Persons with MS had 12.5% to 53% poorer lower-limb physical function than controls (all p < 0.05). PA, %Fat, and LM-LEG to body mass ratio (LM-LEG/BM) were associated with lower-limb physical function in both persons with MS and controls (all p < 0.05). Based on median splits, higher %Fat, lower LM-LEG/BM, and MS conferred poorer lower-limb physical function (all p < 0.05). PA, %Fat, and LM-LEG/BM were associated with lower-limb physical function, suggesting that body composition, specifically reducing adiposity and increasing lean mass and/or increasing PA levels, may be a potential target for MS interventions.

Central Versus Lower Body Obesity Distribution and the Association With Lower Limb Physical Function and Disability

To determine whether fat distribution in obese adults is significantly associated with decreased function and increased disability. Cross-sectional epidemiologic analysis. Multicenter, community-based study. Multicenter Osteoarthritis Study participants included adults ages 50-79 years at high risk of developing or already possessing knee osteoarthritis. A total of 549 men and 892 women from the Multicenter Osteoarthritis Study who had a body mass index ≥ 30 kg/m² and who underwent dual energy x-ray absorptiometry (DEXA) scans were included in these analyses. Exclusion criteria included bilateral knee replacements, cancer, or other rheumatologic disease. Body fat distribution was determined using baseline DEXA scan data. A ratio of abdominal fat in grams compared with lower limb fat in grams (trunk:lower limb fat ratio) was calculated. Participants were divided into quartiles of trunk:lower limb fat ratio, with highest and lowest quartiles representing central and lower body obesity, respectively. Backward elimination linear regression models stratified by gender were used to analyze statistical differences in function and disability between central and lower body obesity groups. Lower limb physical function measures included 20-meter walk time, chair stand time, and peak knee flexion and extension strength. Disability was assessed using the Late Life Function and Disability Index. Trunk:lower limb fat ratio was not significantly associated with physical function or disability in women or men (P value .167-.972). Total percent body fat (standardized β = -0.1533 and -0.1970 in men and women, respectively) was a better predictor of disability when compared with trunk:lower limb fat ratio (standardized β = 0.0309 and 0.0072). Although fat distribution patterns may affect clinical outcomes in other areas, lower limb physical function and disability do not appear to be significantly influenced by the distribution of fat in obese older adults with, or at risk for, knee osteoarthritis. These data do not support differential treatment of functional limitations based on fat distribution.