Introduction
Sarcopenia, the age-related loss of muscle mass and function, is recognized as an important geriatric syndrome leading to negative health outcomes such as falls, fractures, hospitalizations with increased medical costs, and mortality [
1‐
5]. Until recently, low muscle mass was required to diagnose sarcopenia as a core component, despite evidence suggesting muscle function as an independent and more sensitive indicator for aging and health outcomes [
3,
6‐
8]. Taking this into consideration, the European Working Group on Sarcopenia in Older People (EWGSOP) proposed a new algorithm with the emphasis on screening for sarcopenia in individuals with low muscle function rather than muscle mass [
3]. As a more comprehensive approach, dysmobility syndrome was previously proposed to identify older individuals with high risk of falls, fractures, and decreased mobility [
4,
9,
10]. Similar to metabolic syndrome, dysmobility syndrome is diagnosed when several components are present together including previous falls, low muscle function, poor physical performance, low appendicular lean mass, high fat mass, and low bone mass [
10,
11]. In Caucasian and Asian middle-aged to elderly cohorts, dysmobility syndrome is associated with decreased physical activity and increased risk for falls, fractures, and mortality [
12‐
16].
Establishing a diagnostic threshold for muscle function testing with good discriminatory ability is important for the identification of individuals with sarcopenia or dysmobility syndrome. Currently, the most commonly used muscle function tests in sarcopenia definitions are usual gait speed and grip strength [
3,
4,
6,
17,
18]. Both usual gait speed and grip strength have proven their usefulness in large epidemiologic studies but have limitations in a given individual including larger variability, not testing maximal effort (and therefore having a ceiling effect), being impacted by comorbidities and testing maximal force rather than power [
4,
6,
17,
19]. Muscle function tests that do not have these limitations may have the potential to improve diagnostic performance for identifying individuals with sarcopenia or dysmobility syndrome and also monitoring disease progression or response to treatment over time. Jump power, measured during a two-legged countermovement jump, has been utilized to assess muscle function in various populations including older adults with impaired function [
20‐
28]. The countermovement jump combines maximal effort during an explosive movement (i.e., high power output) with the requirement for good coordination of various muscle and joint groups, and organ systems required for balance [
4,
19,
20]. It combines features of classical muscle function tests like grip strength (maximal effort) with classical physical function tests like usual gait speed (requirement for a high degree of coordination of different organ systems), with good safety and reproducibility [
4,
20,
21,
28,
29]. Low jump power is associated with sarcopenia or dysmobility syndrome in older Caucasian or Asian adults [
24,
30,
31]. However, to our knowledge, international cut-offs for weight-corrected jump power to identify individuals with either sarcopenia or dysmobility syndrome across different ethnic groups have not been investigated. The aim of this study was to explore the cut-offs for weight-corrected jump power that could be used internationally to identify individuals with sarcopenia or dysmobility syndrome using a combined cohort of Caucasian and Asian older adults.
Discussion
This analysis of age- and sex-matched Asian and Caucasian older adults indicates that jump power values of < 19.0 W/kg in women and < 23.8 W/kg in men can be utilized as an international threshold for identifying individuals with sarcopenia or dysmobility syndrome. Low jump power defined by these cut-offs was an independent risk factor for the composite outcome with an odds ratio of 4.67, which improved the discrimination for individuals with sarcopenia or dysmobility syndrome when considered together with age, sex, height, and ethnicity.
These findings are well aligned with previous reports showing that jump power improves discrimination between those with or without dysmobility syndrome in the KURE cohort [
24]. In an analysis of US cohorts, Siglinsky and colleagues proposed jump power cut-offs to be in the range of 15–17 W/kg depending on which sarcopenia definition was used. Those without sarcopenia had values of approximately 20 W/kg [
30]. However, cut-offs were not separated by sex. Singh and colleagues also found that individuals with sarcopenia had lower jump power compared with those without, even though they used a different method for measuring jump power [
31]. Intriguingly, the distribution of jump power in these various cohorts was similar to the range of jump power in our study. [
19‐
21,
23‐
25,
28‐
31,
34,
35]. Although participants were not separated into those with sarcopenia or without in these studies, the similarity in the range of jump power suggests that our results might be transferable to other populations. However, the proposed cut-offs need to be validated in additional cohorts and ethnicities other than Asian and Caucasian.
As there is no agreement on one single sarcopenia definition and several cut-offs for various muscle and physical function tests exist, we deliberately chose the establishment of cut-offs for jump power that could be generalizable not only internationally to different populations but also for individuals with or without any sarcopenia or dysmobility syndrome as the primary aim of this study. To do so, we decided that our endpoint would combine different ways to define poor musculoskeletal health. First, the sarcopenia was defined according to EWGSOP2 algorithm. It is important to note that the recent 2018 EWGSOP2 definition differs significantly from the 2010 EWGSOP definition leading to different sarcopenia prevalence in the same population [
7]. In our view, the 2018 EWGSOP2 definition has clear advantages because “probable sarcopenia” can now be diagnosed without measuring lean mass, a clinically very important change. The previous limitation to depend on lean mass as a parameter to define poor musculoskeletal health but not on function was also one reason for the development of dysmobility syndrome. In dysmobility syndrome, low lean mass is only one of six equally weighted factors included in the definition. Dysmobility syndrome not only balances the importance of low lean mass but it also includes other organ systems that play a vital role in musculoskeletal health, namely, the bone, fat, and indirectly (through the prevalence of falls) the nervous system [
9‐
12,
42]. The criteria and cut-offs were chosen based on a thorough literature review but these need to be adjusted as more data becomes available [
9‐
12,
24,
42,
43]. Because dysmobility syndrome approaches musculoskeletal health differently, we felt that using a composite outcome of either dysmobility syndrome or sarcopenia in two cohorts with different ethnicities would increase the likelihood of finding cut-offs that can be applied to different populations and different definitions of musculoskeletal health. Using such a composite outcome is further supported by the fact that the association with decreased mobility and increased falls, fractures, and mortality is similar between the two entities [
1,
3,
5,
7,
12‐
16,
42,
44]. Other authors have used other terms and parameters to describe syndromes of impaired muscle, low bone mass, and obesity, including osteosarcopenic obesity or locomotive syndrome [
43‐
45]. Future studies are needed to examine whether the proposed jump power cut-offs can also be applied to these syndromes.
The jump power measurement has advantages as a test with good reproducibility, good correlation with other methods to measure physical function and muscle mass, little or no ceiling effect, and good safety [
4,
20,
21,
28,
29]. Relatively weak correlations between hand grip strength and jump power shown in prior studies may indicate that jump power has an advantage over hand grip strength as a parameter for lower extremity function, a clinically relevant region due to the association with falls and hip fractures in older adults [
46]. However, some limitations need to be pointed out. Jump power is measured on a force plate, which limits the portability of the method with additional cost. However, research is ongoing whether jump power can be assessed without using a force plate [
31,
47,
48]. Another limitation is the current scarcity of studies that have prospectively examined the direct relationship of low jump power with health outcomes such as falls, fractures, immobility, decreased daily activity, or mortality, although cross-sectional studies robustly support the association between lower jump power or inability to jump with worse ADLs and more falls [
23,
28]. Some large, well-established musculoskeletal cohorts, such as the MrOS study, have included jump power in their assessment recently, and prospective data should be available in the near future. Our hope is that the proposition of jump power cut-offs will encourage other groups to start using jump power in their research to validate our results and examine the relationship of jump power and health outcomes. In our prior work, we found that individuals who failed or refused to jump due to various reasons had elevated odds of dysmobility syndrome in community-dwelling Korean older adults [
24]. Based on these findings, it would be reasonable to consider groups who had jump power lower than the identified thresholds or those who failed (or refused) to jump as high risk groups. This needs to be validated in further studies.
Creating an age- and gender-matched dataset out of two cohorts of community-dwelling older adults from two different ethnic backgrounds enables us to reduce confounding from variables other than ethnicity but also led to a smaller sample size mainly due to the age gap between two cohorts. As already pointed out, this study did not include other ethnicities, and as such, further studies are necessary to show that these cut-offs are truly “international.” However, we feel that it is a clear strength to have examined individuals from the two large ethnic groups, Caucasian and Asian. Because there currently is no consensus of the optimal cut-off for low lean mass among different ethnicities and the methodology for measuring lean mass was different in two ethnic cohorts, regional definitions were applied per EWGSOP2 by race and the ALM acquisition methodology used to derive respective cut-offs [
3,
35,
39,
40]. We used the DXA-based EWGSOP 2018 appendicular lean mass cut-offs for the Caucasian (UW) cohorts and the BIA-based AWGS cut-offs to define low lean mass for the Asian cohort (KURE) based on Asian normative references [
3,
40]. Despite the differences in lean mass assessment between two cohorts, we observed similar prevalence of sarcopenia, dysmobility syndrome, and composite outcome between age-matched Caucasian and Asian cohorts in this study. Another point that needs to be noted is the differences in body composition between the Korean-Asian and US-Caucasian population. High fat mass was more prevalent in the Caucasian individuals, whereas low lean mass was more common in the Asian cohort. However, the distribution of their muscle function, particularly muscle power, was similar regardless of the differences in body composition. To us, this is an advantage of a score-based diagnosis rather than an approach where the diagnosis of sarcopenia solely relies on the presence of low lean mass. Which factors should be included in such a score-based approach to diagnose poor musculoskeletal health is still up for discussion. The dysmobility syndrome approach is a simple and powerful but can certainly be improved further. The results from this study suggest that one possibility would be the inclusion of jump power in the definition of dysmobility syndrome or sarcopenia, which merits further validation.
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