Haemi Jee*
Department of Sports and Health Care, Namseoul University, 91 Daehak-ro Seonghwan-eup Sebuk-gu Cheonan-si Chungcheongnam-do, 31020, South Korea
*Corresponding Author E-mail: amyjee@nsu.ac.kr
ABSTRACT:
Background/Objectives: Various factors influence sarcopenia including neurological disorders such as stroke. However, little is known about the denervative influence of stroke in limb composition. Therefore, this study aims to compare upper and lower limb imbalances in Korean post-stroke females.
Methods/Statistical analysis: The Fourth and Fifth Korea National Health and Nutrition Examination Surveys (KNHANES) with body composition results obtained from DXA (dual-energy X-ray absorptiometry) were used for this study. Muscle and fat masses were utilized to compare composition imbalances and changes between the left and right upper and lower limbs of post-stroke group with reported limb paralysis and healthy. Furthermore, effects of physical activity were observed by comparing muscle and fat masses of regular walkers (≥3 days/week) and non-walkers (<3 days/week).
Findings: First, the left and right limb muscle and fat mass differences were compared. Although significances were not observed, greater tendency for fat contents were observed in both upper and lower limbs of the post-stroke patients. Significantly greater muscle mass ratios were shown in the body upper and lower limbs of two groups. In order to further clarify influence of stroke in body composition, strong influential factor of physical activity was observed in post-stroke group. Significantly greater amount of muscle mass in both the upper and lower limbs were shown in the post-stroke group who performed regular physical activity. The results suggested that stroke may expatiate muscle and fat imbalances in both the upper and lower limbs. Moreover, fat accumulation seemed more prominent in post-stroke patients. However, regularly performed physical activity seemed to deter muscle atrophy.
Improvements/Applications: Results of this study may be utilized to further inform the stroke patients of the deterring effects of stroke and provide a guideline to prevent atrophic imbalance by regularly participating in physical activity.
KEYWORD: stroke, atrophy, sarcopenia, denervation, physical activity.
1. INTRODUCTION:
Sarcopenia is one of the age-related diseases for the elderly with muscle wasting or decline in lean body mass, muscle mass, and function as primary characteristics of the disease 1.In general, continual reduction in lean body mass occurs with senescence. Rapid reduction in muscle mass has been reported after the age of 50. Muscle mass and strength decrease at an annual rate of 1 to 2% and 1.5%, respectively. Moreover, about 3% annual reduction of muscle strength has been reported after the age of 60 2. It has been estimated that about 5 to 13% of the population between 60 to 70, and 11 to 50% of the population above 80 have been affected by sarcopenia2. However, age is not the only determinant factor for promoting sarcopenia. Multifactorial factors or conditions such as altered endocrine function, immobilization, malnutrition, insulin resistance, inflammation, and denervation have been reported to be related to sarcopenia 3,4.
Stroke has been reported to be one of the major causes for sarcopenia 1,5,6. Stroke is one of the leading causes of disability which lead to apparent socioeconomical burden on both stroke patients and guardians1. Even with optimal therapeutic intervention, majority of the patients are unable to fully recover after stroke 7. More than 60% of the patients remain incompletely recovered, 15 to 30% remain permanently disabled, and about 20% require institutional care after the onset of stroke 8. Although stroke related sarcopenia is poorly elucidated, factors such as malnutrition, loss of cortical control, and hemiparesis have been reported to promote muscle atrophy in stroke patients9. Furthermore, immobility after a stroke event has been known to rapidly decrease muscular function and physiology6.
Despite a considerable amount of stroke related researches reported up to date, studies on post-stroke patients and sarcopenia have rarely been conducted, especially in Korean females. In addition, possible muscular imbalances with hemispheric dennervation have not been previously observed by comparing left and right sides, especially between physical active and inactive females. Physical activity has been reported to be one of the major deterring factors in sarcopenia. Influence of regularly performed physical activity on muscle atrophy and muscular imbalance in the upper and lower extremities has also not been elucidated in Korean females. Therefore, this study aimed to compare body composition muscle and fat masses in the left and right upper and lower limbs between physically active and inactive females to elucidate the influencing effects of partial hemispheric dennervation and physical activity.
2. MATERIALS AND METHODS:
The Fourth and Fifth Korea National Health and Nutrition Examination Surveys (KNHANES) which included the health behavior questionnaires, anthropometric, and other health-related measurements were utilized for the study. The KNHANE surveys are cross-sectional and nationally representative surveys conducted by the Division of Chronic Disease Surveillance, Korea Centers for Disease Control and Prevention, from 2008 to 2011. Written consents were obtained from the examinees by the participating clinical specialists prior to the assessment and survey. Written consents were obtained from the examinees by the participating clinical specialists prior to the examinations. The second and third year KNHANES III and first and second year KNHANES IV assessment data conducted between 2008 and 2011were approved by the ethics committee of the Korea Centers for Disease Control and Prevention (2008-04EXP-01-C, 2009-01CON-03-2C, 2010-02CON-21-C, and 2011-02CON-06C).
2.1. Variable Assessment:
Following variables were used for the study: body mass index (BMI), left and right legmuscle mass (g), left and right armmuscle mass (g), left and right legfat mass (g), left and right arm fat mass (g), and whole body weight (g) measured by dual-energy X-ray absorptiometry (DXA) (Hologic Discovery, Hologic Inc., Bedford, MA, USA). Muscle mass and fat mass variables were compared between the left and right lower and upper limbs in the post-stroke female subjects in comparative to the healthy controls with similar anthropometric measurements. Based on the definition proposed in previous studies, the body weight–adjusted appendicular skeletal muscle mass and body fat was used in this study6.
2.2. Subjects:
To select healthy subjects, those who had any history of movement disorders such as stroke, orthopedic disorder, or neurological disorder were excluded. Among a total of 4,682 participants aged 45 years or older female subjects, 4,573subjects who did not have information on stroke history were excluded. Among 61 post-stroke patients and 46 healthy subjects, subjects who did not conduct body composition measurements via DXA nor responded to the stroke related questionnaires were excluded. After exclusion of 26 post-stroke patients and 20 healthy subjects, final 35 post-stroke patients and 26 healthy subjects were included for the post-stroke and control comparisons. Furthermore, 4 subjects were excluded for the comparison of the physically active and inactive comparison in post-stroke patients. In order to focus on the influence of physical activity in post-stroke patients, those who reported post-stroke sequelae were included instead of limiting to post-stroke patients with reported limb paralysis.
2.3. Statistical analysis:
Descriptive statistics were used to calculate the subjects’ characteristics. The equality or homogeneity assessment of variances was performed with the Levene’s test prior initiating the comparative assessment. One-way ANOVA was performed between the body composition variables of muscle and fat masses between the right and left upper and lower extremities. Additional comparative analysis via one-way ANOVA was performed between the physically active (walkers) and non-active (non-walkers) post-stroke subjects. The results were considered significant when the probability was less than 0.05 (p< 0.05). The statistical analyses were performed using the SPSS 18.0 statistical analysis program.
3. RESULTS AND DISCUSSION:
35 post-stroke patients with mean age of 66.46 (±9.81) years and BMI (body mass index) of 24.51 (±3.22) kg/m2 and 22 healthy subjects with mean age of 66.44 (±7.63) years and BMI of 25.51 (±3.49) kg/m2 were observed for the differences in the upper and lower appendicular muscle and fat masses as the post-stroke and control groups. Statistically significant differences in age and BMI were not observed between groups. Furthermore, 55 post-stroke patients were grouped as the walker (≥3 days per week) and non-walker groups (<3 days per week) based on the amount of physical activity or walking performed per week to compared for the upper and lower appendicular fat and muscle masses. The mean ages and BMI of the walker group (n = 22) and the non-walker group (n = 33) were 69.68 (±7.91) years and 65.97 (±9.42) years (p = 0.13), and 25.24 (±3.77) kg/m2 and 24.55 (±3.48) kg/m2 (p = .49), respectively. Statistically significant differences in age and BMI were not observed between groups.
First, the fat and muscle mass (g) differences of the arms and legs of the patient and control groups were compared as in Figure 1. The fat and muscle mass differences were calculated by subtracting the right limb mass from the left limb and averaging the absolute values. Although significant differences were not observed, greater differences in arm fat, arm muscle, and leg fat masses were observed in the post-stroke patients in comparison to the controls.
The groups were further compared for the fat and muscle ratios between the right and left legs (Figure 2A).The fat and muscle ratios were calculated by subtracting the right limb mass from the left limb mass and dividing the difference by the whole body weight and multiplying the result by one hundred. Significant differences were shown in the muscle and fat ratios of the post-stroke patients and the muscle ratio of the controls. The muscle ratios of the right and left legs of the control group the post-stroke group were 11.84% and 11.56% (p<0.01) and 12.03% and 11.80% (p<0.01), respectively. The fat ratios of the right and left legs of the control group the post-stroke group were 4.12% and 4.01% (p=0.16) and 4.25% and 4.15% (p<0.05), respectively.
The left and right arm fat and muscle were also compared for the fat and muscle ratios in two groups (Figure 2B). The fat and muscle ratios were also calculated by subtracting the right limb mass from the left limb mass and dividing the difference by the whole body weight and multiplying the result by one hundred. Significant differences in the muscle and fat ratios between the right and left arms were shown in the post-stroke group and significant difference in the muscle ratio between the right and left arms was shown in the control group. The muscle ratios of the right and left arms of the control group the post-stroke group were 3.90 (±0.76) % and 3.62 (±0.76) % (p<0.00) and 4.01(±0.70) % and 3.70 (±0.76) % (p<0.00), respectively. The fat ratios of the right and left arms of the control group and the post-stroke group were 1.48 (±0.74) % and 1.46 (±0.70) % (p=0.60) and 1.60 (±0.62) % and 1.54 (±0.62) % (p<0.01), respectively.
Finally, the differences in the left and right limb masses were compared by the amount of physical activity in the post-stroke patients. The post-stroke patients who regularly walked equal to or more than 3 days a week were grouped into the walker group and the post-stroke patients who walked less than 3 days a week were grouped into the non-walker group. Significantly greater amount of arm muscle mass was shown in the walker group in comparison to the non-walker group. Arm muscle mass differences for the walker and non-walker groups were 946.20 (±1,068.32)g and 448.45 (±630.53)g (p<0.04), respectively.
Although significance was not shown in the leg muscle mass, comparatively greater tendency for leg mass was shown in the walker group in comparison to the non-walker group. Leg muscle mass differences for the walker and non-walker groups were 579.38 (±1,503.89)g and 243.35 (±1,005.80)g, (p=0.36), respectively. Muscle mass wasting or sarcopenia is strongly related to senescence or aging. Changes such as denervation of motor units, muscle fiber type conversion from type II to type I, and lipid deposition are often observed in aging muscle. Such compositional changes in the body lead to loss of muscular strength necessary to maintain daily living. Sarcopenia is frequently seen in post-stroke patients10.
Obstruction or aneurysm of blood vessels to brain during a stroke event may lead to brain lesion and subsequent impediment of the motoneuron pathways. Palsy of the contralateral limbs may result through disruption of the motoneuron pathways. Neurological deficits and motor function limitations may initiate structural degradation of the skeletal muscle11. As a vicious cycle, such initial degradation may lead to further functional limitation and accelerate atrophy of the muscular system11,12.
This study compared the differences in muscle and fat masses between the right and left legs and the right and left arms of the post-stroke and healthy female adults. Imbalance in the musculoskeletal system has been known to impede proper functional movement and further promote musculoskeletal dysfunction. Although significant differences were not observed between the left and right upper and lower limbs in terms of muscle and fat contents in the post-stroke patients with reported limb paralysis, trend for greater amount of fat in the lower limb and upper limbs were observed as shown in figure 1. The muscle and fat imbalances were more prominently shown in the post-stroke group in both upper and lower limbs as shown in Figure 2A and 2B. The muscle mass imbalances between the left and right limbs were significant in both post-stroke and control groups. On the other hand, the fat ratios between the left and right limbs were only significant in the upper and lower limbs of the post-stroke group. Such results indicated that although mixed results of muscle masses were shown in both the upper and lower limbs, fat masses were prominent in those with stroke experiences. Mixed results in lean mass changes have been reportedin paretic limbsin previous studies10,13.
A study by Mean et al (2006) measured muscle mass at different time point after stroke and reportedof significant muscle massonly in the parentic limbs at 3 weeks 10. Such rapid reduction followed by slight regain in muscle mass was explained alteration of the amount of physical activity and neurological recovery 10. A study by Jorgensen and Jacobsen (2001) reported that walking rehabilitation lead to regain in muscle mass in both paretic and non-paretic limbs13. However, the degree of muscle mass recovery was more significant in the paretic side 13. Mixed results in fat mass change also have been reported in paretic and non-paretic limbs in previous studies10,14,15.
A systematic review by Bernhardt et al. reported that 5 out of 9 research studies (n=305) showed more fat in the paretic leg (mean difference ranges from 560.00 to -146.00g) and 3 out of 5 research studies (n=160) showed more fat in the paretic arm (mean difference ranges from 66.42 to -125.17g)13. There may be several explanatory reasons for such disparity in observations.
Changes in body composition after stroke may be highly variable between individuals. Life style habits such as nutritional status, hormonal and inflammatory factors, and degree of physical activity have been known to strongly influence stroke severity 16,17. In order to further observe alteration of the body composition after stroke experience, influence of physical activity was observed by comparing between physically active post-stroke patients and non-active post-stroke patients. Post-stroke patients who regularly walked 3 days or more per week were grouped as walkers and less than 3 days per week were grouped as non-walkers.
Figure 3 showed that physically active subjects or walkers had greater amount of arm muscle mass in comparison to the non-walkers. Although significance was not shown, greater amount of leg muscle mass was shown in the walker group. Such results indicated that physical activity may impede the sarcopenic effects of stroke.
Influence of physical activity on post-stroke recovery has been observed by various studies 18-21. Endurance, resistance, and balance exercise have been recommended to prevent and recover from deterring effects of stroke. Although strength training may provide significant improvements body composition, older females with stroke experiences usually performed equal to or less than moderate intensity physical activity. However, since walking, a weight-bearing physical activity, may promote muscle mass maintenance, positive influences on sarcopenia have been previously reported 21,22.
Stroke is one of the most disabling diseases in adults. With increase in the elderly population and age related problems, pathology and mechanism of stroke should be fully studied and understood to understand stroke related changes. Further studies should include sex differences and differences in lower and upper extremities.
This study had several limitations. First, the sample size for analysis was small considering the amount of people participated in KNHANE surveys composed of 4 years. A significant amount of subjects was excluded due to limited amount of subjects with previous history of stroke, DXA assessments, and responses to proper questions on the stroke related questionnaires. Second, information on the stroke event, degree of complication, and involved side was not included in the KNHANE survey. Such information could have provided valuable information for better elucidation of post-stroke sarcopenia. However, body composition imbalance and muscular atrophy with fat content increase could be acknowledged through given data. Third, quality of muscle was not analyzed in this study. Previous studies reported muscle type II fiber atrophy, fiber type transition, and muscle strength reduction23. Muscle quality assessment may have further elucidated sarcopenia in post-stroke females. Finally, the amount of muscle and fat masses and body composition prior to a stroke event could not be assessed. The amount of muscle and fat changes before and after a neurological event may have provided vital information on the degree of stroke influenced compositional changes. A cohort study for observations on more specific body segments should be conducted to understand the magnitude of body composition changes in function of degree of stroke, aging, and physical activity.
4. CONCLUSION
Body compositions of muscle and fat mass in the upper and lower extremities may be prevalent in post-stroke Korean females. Regularly performed physical activity such as walking seems to deter the neurological and prolonged bed rest effects on muscular atrophy. It is recommended that awareness for sarcopenia with changes in muscle and fat contents, especially on the parietal limb, should be given to post stroke patients for early prevention through lifestyle medication including regularly performed physical activity.
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Received on 23.06.2017 Modified on 27.07.2017
Accepted on 29.08.2017 © RJPT All right reserved
Research J. Pharm. and Tech. 2017; 10(9): 3074-3080.
DOI: 10.5958/0974-360X.2017.00545.5