Evaluating skeletal muscle mass with ultrasound in patients with systemic sclerosis

Is Myopenia or Myosteatosis Clinically Relevant in Systemic Sclerosis? Skeletal Muscle Assessment Using Computed Tomography

OBJECTIVES

Systemic sclerosis (SSc) is a chronic autoimmune disease characterized by fibrosis, vascular damage, and immune dysregulation, often leading to muscle abnormalities. This study aimed to evaluate the prevalence of myopenia and myosteatosis in SSc patients using computed tomography (CT) and their associations with clinical features, including lung disease and esophageal dilatation.

MATERIALS AND METHODS

SSc patients followed at Gazi University Rheumatology Clinic (2000-2024) who had thoracic CT imaging were included. Muscle mass and density were assessed at the L1 vertebral level. Skeletal muscle area (SMA) and skeletal muscle radiation attenuation (SMRA) were measured to identify myopenia and myosteatosis. Lung disease involvement and widest esophageal diameter (WED) were assessed via CT. Statistical analyses explored correlations between muscle metrics and clinical variables, with multiple linear regression identifying predictors.

RESULTS

Among 95 patients (54.7% diffuse SSc, 45.3% limited SSc; mean age 57.04 ± 13.65 years; female-to-male ratio 8.5:1), myopenia and myosteatosis prevalence were 27.3% and 41.1%, respectively. Myosteatosis was associated with female sex (p = 0.001), older age (p = 0.001), higher BMI (p = 0.043), and inflammation markers (CRP, ESR). Myopenia correlated with BMI (p = 0.001) but not clinical outcomes. Higher WED correlated with lower SMRA (p = 0.001). BMI predicted muscle mass (R² = 0.42), while age, gender, and BMI determined SMRA (R² = 0.67, p < 0.001).

CONCLUSIONS

Myosteatosis was more prevalent and strongly associated with clinical features, including lung disease and esophageal dilatation, than myopenia, underscoring the importance of muscle quality.

Assessment of Factors Related to Sarcopenia in Patients with Systemic Sclerosis

Objectives: Systemic sclerosis (SSc) patients exhibit a heightened vulnerability to sarcopenia, a condition characterized by the loss of muscle mass and strength. This study aims to determine the prevalence of sarcopenia in patients with SSc and to investigate the associated factors contributing to this condition. Methods: Eighty patients with SSc were included in the study, and their demographic and clinical characteristics, body composition by bioelectrical impedance analysis, SARC-F score, chair-stand test performance, and 4 m walking speed were recorded. Results: Among the 80 participants, 91.3% were female, with a median age of 56.5 years (range 45-65). The majority (70%) had limited SSc, and 71.3% reported at least one comorbidity. According to the International Physical Activity Questionnaire, only 12.5% of participants met the criteria for an active lifestyle. The SARC-F questionnaire indicated that 20% of patients were at risk for sarcopenia. The prevalence of sarcopenia among patients showed considerable variability: 5% (95% CI 0.1-9) were identified through the appendicular skeletal muscle index (ASMI), 8.8% (95% CI 2.4-15) via the fat-free mass index (FFMI), and a concerning 20% (95% CI 11-29) according to the skeletal muscle mass index (SSMI). A multivariate logistic regression analysis identified age as the only factor significantly influencing the SARC-F score, with an odds ratio of 1.081 (95% CI 1.012-1.154, p = 0.020). Additionally, the older age group demonstrated a lower level of physical activity, poorer chair-stand test outcome, and slower 4 m gait speeds (p = 0.013, p = 0.008, p = 0.001, respectively), as well as a higher reported frequency of falls (p = 0.039). Conclusions: Sarcopenia is a prevalent issue among individuals with SSc, particularly in the older population. This study did not identify a direct correlation between sarcopenia and SSc subtype, disease activity, or other clinical parameters. However, the need for an improved cut-off value for diagnosing sarcopenia in this specific cohort is evident.

Imaging findings of scleroderma-associated myopathy: A systematic literature review

AIMS

Systemic sclerosis (SSc) affects skeletal muscle directly, with SSc-associated myopathy (SSc-myopathy) increasingly recognised as a distinct immune-mediated myopathy. Manual muscle testing and creatine kinase (CK) are insensitive diagnostic tools for SSc-myopathy. We aimed to evaluate the role of imaging in SSc-myopathy diagnosis.

METHODS

A systematic search of MEDLINE(Ovid), Pubmed, and EMBASE databases was performed to identify studies of ≥10 SSc patients that reported skeletal muscle imaging results. Eligibility criteria were defined a priori. Risk of bias assessment was performed using the National Heart, Lung and Blood Institute (NHLBI) quality assessment tool. Descriptive summaries were used to present data owing to inter-study heterogeneity.

RESULTS

Of 2426 studies identified, 17 articles met the inclusion criteria. Imaging modalities varied, but magnetic resonance imaging (MRI) was the most commonly applied imaging technique (n = 9 studies). Abnormalities on MRI were reported in 38-100 % of patients and included muscle oedema, atrophy, and fatty infiltration. Changes were observed in skeletal muscles (n = 14 studies), axial muscles (n = 1), masseter muscle (n = 1), and accessory respiratory muscles (n = 2). Blood oxygenation level-dependent MRI, dynamic contrast-enhanced ultrasound, and scintigraphic evaluation have each been used to assess skeletal muscle perfusion. A lack of correlation between creatine kinase, clinical weakness, and imaging findings was consistently reported. We were unable to identify any distinct imaging patterns or relationship between imaging and histopathological skeletal muscle abnormalities owing to limited data available.

CONCLUSION

Imaging detects inflammatory, atrophic, and vasculopathic changes in the skeletal musculature of SSc patients. The discordance between clinical assessment and imaging findings underscores the potential role for muscle imaging to both screen and diagnose SSc-myopathy.

Nutritional disorders and nutrition-related conditions: an underestimated clinical problem in systemic sclerosis

Nutritional disorders are significant but often underestimated complications in patients with systemic sclerosis (SSc). The most prevalent nutritional disorders in SSc are malnutrition, affecting up to 62.5% of patients, and sarcopenia, with a frequency of up to 42%. Thus, clinical vigilance is recommended for the detection of eating disorders in SSc patients, particularly those with gastrointestinal involvement, cardiopulmonary complications, an advanced disease stage, and high disease activity. Nutritional treatment should be carefully tailored to the patients' clinical condition to ensure that it effectively addresses their specific needs. Studies focusing on enteral nutrition in SSc patients demonstrate its effectiveness in stabilizing or improving nutritional status in malnourished patients. In severe cases, parenteral nutrition offers viable options to support patient health. The findings highlight the importance of early nutritional assessment and intervention in improving patient outcomes and suggest that individualized nutritional therapy can be a critical component of comprehensive care for SSc patients.

Ultrasound Cut-Off Values for Rectus Femoris for Detecting Sarcopenia in Patients with Nutritional Risk

BACKGROUND

A nationwide, prospective, multicenter, cohort study (the Disease-Related caloric-protein malnutrition EChOgraphy (DRECO) study) was designed to assess the usefulness of ultrasound of the rectus femoris for detecting sarcopenia in hospitalized patients at risk of malnutrition and to define cut-off values of ultrasound measures.

METHODS

Patients at risk of malnutrition according to the Malnutrition Universal Screening Tool (MUST) underwent handgrip dynamometry, bioelectrical impedance analysis (BIA), a Timed Up and Go (TUG) test, and rectus femoris ultrasound studies. European Working Group on Sarcopenia in Older People (EWGSOP2) criteria were used to define categories of sarcopenia (at risk, probable, confirmed, severe). Receiver operating characteristic (ROC) and area under the curve (AUC) analyses were used to determine the optimal diagnostic sensitivity, specificity, and predictive values of cut-off points of the ultrasound measures for the detection of risk of sarcopenia and probable, confirmed, and severe sarcopenia.

RESULTS

A total of 1000 subjects were included and 991 of them (58.9% men, mean age 58.5 years) were evaluated. Risk of sarcopenia was detected in 9.6% patients, probable sarcopenia in 14%, confirmed sarcopenia in 9.7%, and severe sarcopenia in 3.9%, with significant differences in the distribution of groups between men and women (p < 0.0001). The cross-sectional area (CSA) of the rectus femoris showed a significantly positive correlation with body cell mass of BIA and handgrip strength, and a significant negative correlation with TUG. Cut-off values were similar within each category of sarcopenia, ranging between 2.40 cm2 and 3.66 cm2 for CSA, 32.57 mm and 40.21 mm for the X-axis, and 7.85 mm and 10.4 mm for the Y-axis. In general, these cut-off values showed high sensitivities, particularly for the categories of confirmed and severe sarcopenia, with male patients also showing better sensitivities than women.

CONCLUSIONS

Sarcopenia in hospitalized patients at risk of malnutrition was high. Cut-off values for the better sensitivities and specificities of ultrasound measures of the rectus femoris are established. The use of ultrasound of the rectus femoris could be used for the prediction of sarcopenia and be useful to integrate nutritional study into real clinical practice.

Sarcopenia in systemic sclerosis: prevalence and impact-a systematic review and meta-analysis

OBJECTIVE

This review aims to provide an estimate of sarcopenia prevalence and its impact on clinical characteristics in patients with systemic sclerosis (SSc).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Embase, Medline, Web of Science and the Cochrane Central Register of Controlled Trials were systemically searched from inception to 24 May 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included observational studies that reported the prevalence of sarcopenia in patients with SSc.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently performed study selection and data extraction using standardised methods. Risk of bias was assessed using the Agency for Healthcare Research and Quality Scale and the Newcastle-Ottawa Scale. Meta-analysis was conducted using random effects models.

RESULTS

A total of 4583 articles were screened and 9 studies with data from 815 patients were included in the analysis (8 cross-sectional studies and 1 retrospective cohort study). The overall prevalence of sarcopenia in patients with SSc was 22% (95% CI 17% to 28%). Patients with SSc with sarcopenia had a poorer quality of life (mean difference -12.02; 95% CI -19.11 to -4.93) and higher C reactive protein (CRP) levels (standardised mean difference 0.67; 95% CI 0.35 to 1.00).

CONCLUSIONS

Sarcopenia is common in patients with SSc. Patients with SSc with sarcopenia had a worse quality of life and higher CRP levels, based on our findings. Given the detrimental impact of sarcopenia on quality of life, future efforts aimed at early identification of sarcopenia in the clinical assessment of patients with SSc may have significance.

PROSPERO REGISTRATION NUMBER

CRD42022368326.

Ultrasound assessment of diaphragm and quadriceps muscles and its relationship with handgrip and respiratory muscle strength in patients with systemic sclerosis: a cross-sectional study

BACKGROUND

Muscle dysfunction may cause disability and reduce the quality of life of patients with systemic sclerosis (SSc) when compared to healthy individuals. However, the literature on the topic is scarce and uses several criteria for assessing muscle dysfunction in this population.

OBJECTIVES

To compare diaphragm and quadriceps muscle thickness, diaphragm mobility, and handgrip strength between patients with SSc and healthy individuals.

METHOD

This cross-sectional study included 16 patients with SSc and 16 self-reported healthy individuals matched for age. We assessed quadriceps and diaphragm thickness and diaphragmatic mobility (ultrasound), handgrip strength (hand-held dynamometer), and respiratory muscle strength (manovacuometer). Patients also responded to the Health Assessment Questionnaire Disability Index and the International Physical Activity Questionnaire.

RESULTS

Patients with SSc presented lower quadriceps thickness (p < 0.0001), diaphragmatic mobility (p = 0.01), handgrip (p < 0.0001), and respiratory muscle strength (p < 0.0001) than healthy individuals. A moderate positive correlation was observed between handgrip strength and quadriceps thickness in patients with SSc (rho = 0.576; p = 0.02).

CONCLUSIONS

Patients with SSc presented reduced quadriceps thickness, diaphragmatic mobility, handgrip, and respiratory muscle strength when compared to healthy individuals Also, handgrip strength was correlated with quadriceps thickness in patients with SSc, suggesting that loss of muscle mass accompanies loss of peripheral muscle strength group of patients. Key Points • SSc patients presented reduced quadriceps thickness and diaphragmatic mobility • SSc patients have reduced handgrip and respiratory muscle strength • Lower handgrip muscle strength correlated with lower quadriceps thickness.

Diagnostic test accuracy of ultrasound for sarcopenia diagnosis: A systematic review and meta-analysis

Muscle ultrasound is an emerging tool for diagnosing sarcopenia. This review aims to summarize the current knowledge on the diagnostic test accuracy of ultrasound for the diagnosis of sarcopenia. We collected data from Ovid Medline, Embase and the Cochrane Central Register of Controlled Trials. Diagnostic test accuracy studies using muscle ultrasound to detect sarcopenia were included. Bivariate random-effects models based on sensitivity and specificity pairs were used to calculate the pooled estimates of sensitivity, specificity and the area under the curves (AUCs) of summary receiver operating characteristic (SROC), if possible. We screened 7332 publications and included 17 studies with 2143 participants (mean age range: 52.6-82.8 years). All included studies had a high risk of bias. The study populations, reference standards and ultrasound measurement methods varied across the studies. Lower extremity muscles were commonly studied, whereas muscle thickness (MT) was the most widely measured parameter, followed by the cross-sectional area (CSA). The MTs of the gastrocnemius, rectus femoris, tibialis anterior, soleus, rectus abdominis and geniohyoid muscles showed a moderate diagnostic accuracy for sarcopenia (SROC-AUC 0.83, 8 studies; SROC-AUC 0.78, 5 studies; AUC 0.82, 1 study; AUC 0.76-0.78, 2 studies; AUC 0.76, 1 study; and AUC 0.79, 1 study, respectively), whereas the MTs of vastus intermedius, quadriceps femoris and transversus abdominis muscles showed a low diagnostic accuracy (AUC 0.67-0.71, 3 studies; SROC-AUC 0.64, 4 studies; and AUC 0.68, 1 study, respectively). The CSA of rectus femoris, biceps brachii muscles and gastrocnemius fascicle length also showed a moderate diagnostic accuracy (AUC 0.70-0.90, 3 studies; 0.81, 1 study; and 0.78-0.80, 1 study, respectively), whereas the echo intensity (EI) of rectus femoris, vastus intermedius, quadriceps femoris and biceps brachii muscles showed a low diagnostic accuracy (AUC 0.52-0.67, 2 studies; 0.48-0.50, 1 study; 0.43-0.49, 1 study; and 0.69, 1 study, respectively). The combination of CSA and EI of biceps brachii or rectus femoris muscles was better than either CSA or EI alone for diagnosing sarcopenia. Muscle ultrasound shows a low-to-moderate diagnostic test accuracy for sarcopenia diagnosis depending on different ultrasound parameters, measured muscles, reference standards and study populations. The combination of muscle quality indicators (e.g., EI) and muscle quantity indicators (e.g., MT) might provide better diagnostic test accuracy.

Reliability assessment of ultrasound muscle echogenicity in patients with rheumatic diseases: Results of a multicenter international web-based study

Objectives

To investigate the inter/intra-reliability of ultrasound (US) muscle echogenicity in patients with rheumatic diseases.

Methods

Forty-two rheumatologists and 2 radiologists from 13 countries were asked to assess US muscle echogenicity of quadriceps muscle in 80 static images and 20 clips from 64 patients with different rheumatic diseases and 8 healthy subjects. Two visual scales were evaluated, a visual semi-quantitative scale (0-3) and a continuous quantitative measurement ("VAS echogenicity," 0-100). The same assessment was repeated to calculate intra-observer reliability. US muscle echogenicity was also calculated by an independent research assistant using a software for the analysis of scientific images (ImageJ). Inter and intra reliabilities were assessed by means of prevalence-adjusted bias-adjusted Kappa (PABAK), intraclass correlation coefficient (ICC) and correlations through Kendall's Tau and Pearson's Rho coefficients.

Results

The semi-quantitative scale showed a moderate inter-reliability [PABAK = 0.58 (0.57-0.59)] and a substantial intra-reliability [PABAK = 0.71 (0.68-0.73)]. The lowest inter and intra-reliability results were obtained for the intermediate grades (i.e., grade 1 and 2) of the semi-quantitative scale. "VAS echogenicity" showed a high reliability both in the inter-observer [ICC = 0.80 (0.75-0.85)] and intra-observer [ICC = 0.88 (0.88-0.89)] evaluations. A substantial association was found between the participants assessment of the semi-quantitative scale and "VAS echogenicity" [ICC = 0.52 (0.50-0.54)]. The correlation between these two visual scales and ImageJ analysis was high (tau = 0.76 and rho = 0.89, respectively).

Conclusion

The results of this large, multicenter study highlighted the overall good inter and intra-reliability of the US assessment of muscle echogenicity in patients with different rheumatic diseases.

The Diagnostic Value of Ultrasound of the Rectus Femoris for the diagnosis of Sarcopenia in adults: A systematic review

BACKGROUND & AIM

Sarcopenia is defined as a loss of muscle mass and function, which can be caused by normal ageing or factors such as physical inactivity. Severe health consequences caused by sarcopenia highlight the need for early identification. Computed Tomography (CT) imaging, often mentioned as the gold standard due to its accuracy, is costly and not routinely performed in daily clinical care. Ultrasound of the rectus femoris, however, is low in costs and easily accessible. The aim is to present the current and most recent literature regarding the diagnostic value of ultrasound measurements of the rectus femoris for the diagnosis of sarcopenia in adults.

METHODS

The databases PubMed and Web of Science were used to search for studies comparing ultrasound of the rectus femoris with a reference test to diagnose sarcopenia in adults. The quality of the final eligible studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies, version 2, tool (QUADAS-2).

RESULTS

Six studies were included in this systematic review. The muscle thickness and cross-sectional area of the rectus femoris were assessed and compared with the reference tests CT, Dual-Energy X-ray Absorptiometry (DXA), and Bioelectrical Impedance Analysis (BIA). Half of the studies had a low risk of bias on all QUADAS-2 domains. Three studies reported statistical significant outcomes and diagnostic values ranging from 60 to 81% sensitivity and 51 to 94% specificity.

CONCLUSIONS

Ultrasound of the rectus femoris muscle to diagnose sarcopenia has been shown to be a promising method in multiple clinical populations. However, there were some limitations such as a high methodological heterogeneity. Future research should develop standardized protocols and determine clear cut-off values to allow for a better implementation of ultrasound in clinical practice.

Prevalence and clinical associations with primary hypogonadism in male systemic sclerosis

Background

Systemic sclerosis may affect male and female fertility. Premature ovarian failure has been reported in female systemic sclerosis patients, but the effects on male fertility in systemic sclerosis have not been studied.

Objectives

We aimed to determine the prevalence and clinical associations with primary hypogonadism among male systemic sclerosis patients.

Methods

This was a cross-sectional pilot study, including 30 adult male systemic sclerosis patients attending the Scleroderma Clinic, Khon Kaen University. Testosterone deficiency symptoms were assessed using the Aging Males' Symptoms Rating Scale, urological examination, and blood testing (for total testosterone, free testosterone, follicle-stimulating hormone, and luteinizing hormone). We excluded patients with congenital hypogonadism and any acquired disorders of the testes and genitalia. The definition of primary hypogonadism was based on the International Society for the Study of the Aging Male 2015 diagnostic criteria for hypogonadism.

Results

Seven patients met the definition of primary hypogonadism-a prevalence of 23.3% (95% confidence interval: 9.9-42.3). The respective mean age and mean systemic sclerosis duration was 59.4 ± 11.9 and 5.5 ± 4.7 years. Older age at onset, high triglyceride level, and older age starting corticosteroid treatment were significantly associated with primary hypogonadism (p = 0.02, 0.02, and 0.03, respectively). Systemic sclerosis subset, disease severity, and immunosuppressant use were not associated with primary hypogonadism among Thai male systemic sclerosis patients.

Conclusion

Around one-quarter of male systemic sclerosis patients had primary hypogonadism. Elderly onset of systemic sclerosis, hypertriglyceridemia, and late corticosteroid treatment were risk factors for developing primary hypogonadism.

Ultrasound and magnetic resonance imaging as diagnostic tools for sarcopenia in immune-mediated rheumatic diseases (IMRDs)

Sarcopenia is characterized by loss of muscle mass, altered muscle composition, fat and fibrous tissue infiltration, and abnormal innervation, especially in older individuals with immune-mediated rheumatic diseases (IMRDs). Several techniques for measuring muscle mass, strength, and performance have emerged in recent decades. The portable dynamometer and gait speed represent the most frequently used tools for the evaluation of muscle strength and physical efficiency, respectively. Aside from dual-energy, X-ray, absorptiometry, and bioelectrical impedance analysis, ultrasound (US) and magnetic resonance imaging (MRI) techniques appear to have a potential role in evaluating muscle mass and composition. US and MRI have been shown to accurately identify sarcopenic biomarkers such as inflammation (edema), fatty infiltration (myosteatosis), alterations in muscle fibers, and muscular atrophy in patients with IMRDs. US is a low-cost, easy-to-use, and safe imaging method for assessing muscle mass, quality, architecture, and biomechanical function. This review summarizes the evidence for using US and MRI to assess sarcopenia.

Prediction Model including Gastrocnemius Thickness for the Skeletal Muscle Mass Index in Japanese Older Adults

Non-invasive and easy alternative methods to indicate skeletal muscle mass index (SMI) have not been established when dual energy X-ray absorptiometry (DXA) or bioelectrical impedance analysis (BIA) cannot be performed. This study aims to construct a prediction model including gastrocnemius thickness using ultrasonography for skeletal muscle mass index (SMI). Total of 193 Japanese aged ≥65 years participated. SMI was measured by BIA, and subcutaneous fat thickness and gastrocnemius thickness in the medial gastrocnemius were measured by using ultrasonography, and age, gender and body mass index (BMI), grip strength, and gait speed were collected. The stepwise multiple regression analysis was conducted, which incorporated SMI as a dependent variable and age, gender, BMI, gastrocnemius thickness, and other factors as independent variables. Gender, BMI, and gastrocnemius thickness were included as significant factors, and the formula: SMI = 1.27 × gender (men: 1, women: 0) + 0.18 × BMI + 0.09 × gastrocnemius thickness (mm) + 1.3 was shown as the prediction model for SMI (R = 0.89, R2 = 0.8, adjusted R2 = 0.8, p < 0.001). The prediction model for SMI had high accuracy and could be a non-invasive and easy alternative method to predict SMI in Japanese older adults.

Sarcopenia in rheumatic disorders: what the radiologist and rheumatologist should know

Sarcopenia is defined as the loss of muscle mass, strength, and function. Increasing evidence shows that sarcopenia is common in patients with rheumatic disorders. Although sarcopenia can be diagnosed using bioelectrical impedance analysis or DXA, increasingly it is diagnosed using CT, MRI, and ultrasound. In rheumatic patients, CT and MRI allow "opportunistic" measurement of body composition, including surrogate markers of sarcopenia, from studies obtained during routine patient care. Recognition of sarcopenia is important in rheumatic patients because sarcopenia can be associated with disease progression and poor outcomes. This article reviews how opportunistic evaluation of sarcopenia in rheumatic patients can be accomplished and potentially contribute to improved patient care.