Open access peer-reviewed chapter

Management of Sarcopenic Obesity for Older Adults with Lower-Extremity Osteoarthritis

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Tsan-Hon Liou, Chun-De Liao and Shih-Wei Huang

Submitted: 20 May 2020 Reviewed: 27 July 2020 Published: 24 August 2020

DOI: 10.5772/intechopen.93487

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Lower-extremity osteoarthritis (OA) is a prevalent musculoskeletal disease in elder population. The main symptom of OA is pain which leads to muscle weakness and physical disability. Recently, muscle weakness, function limitation, and severity of disease in OA are addressed to aging-related muscle attenuations. Therefore, elder individuals with OA are under potential sarcopenia risks. In addition, obesity, which exerts negative impacts on disease outcomes, has become a burden in OA population. Under multifactor risks of OA, it is important to identify effectiveness of multidisciplinary management for such elder population to prevent sarcopenic obesity and maintain physical function. Previous studies have indicated that diet intervention (DI) using protein supplement, dietary protein, or weight loss enhances exercise efficacy in terms of additional muscle mass and strength gains to exercise training (ET) for elder individuals with high sarcopenia and frailty risks. However, it remains unclear whether DI in combination with ET augments any benefit for older adults with lower-extremity OA. This chapter aimed to review the effects of DI plus ET on muscle mass, strength, and physical function outcomes in older individuals with lower-extremity OA.


  • sarcopenia
  • osteoarthritis
  • protein supplement
  • exercise training
  • muscle mass
  • function outcome

1. Introduction

Elderly population aged 65 and over is a substantially growing population which is estimated to exceed 16% of global population worldwide in the year of 2050 [1]. Elongation of life expectancy is accompanied with an increase of chronic diseases leading to restricted physical function and disabilities in daily life [2, 3], among which musculoskeletal disorder is a significant public health issue with 7.5–35.2% of the elder people having mild to moderate musculoskeletal conditions [3, 4] and has become the second cause of global burden worldwide compared with other causes of morbidity-mortality [5].

Among the age-related musculoskeletal disorders, osteoarthritis (OA) is one of the most prevalent musculoskeletal diseases from the sixth to the ninth decade of lifespan, especially the OA in lower extremities is closely associated with limitations of functional activities and participation [6]. In addition, sarcopenia, obesity, or in combination of both called sarcopenic obesity have great impacts on physical function in older adults [7, 8]. The impacts of sarcopenia on musculoskeletal system are accounted to the risks of physical limitation in elder individuals, especially those with hip or knee OA [9, 10]. The age-related muscle dysfunction can be addressed to impairments in musculoskeletal system as well as neuromuscular system [11, 12]. With respective to the underlying mechanisms of sarcopenia in older population, muscle atrophy (i.e., decline in muscle size) plays a key role in muscle attenuation [11], especially the type II myofiber [13]. The loss of muscle mass occurs progressively from middle-age by a rate of 0.47% per year in men and 0.37% per year in women [14]; in people aged 75 years, muscle mass is decreased at a rapid rate of 0.64–0.70% per year in women and 0.80–0.98% per year in men and in severe diseases can lead to a loss of approximate 50% by the 8–9th decade of life [15]. Loss of skeletal muscle mass is commonly accompanied with deficits in muscle function such as muscle weakness, which is relevant to clinical presentation of sarcopenia as well as OA. Reid et al. indicated that leg lean mass is strongly associated with muscle strength (r = 0.78, p < 0.01) [16]. Liu et al. further indicated that low handgrip strength is strongly associated with decreased skeletal muscle mass in elder individuals [17]. Because of that loss of muscle strength may lead to physical difficulty and disability, low muscle mass has been identified as a crucial factor of functional limitation of physical mobility such as walk capability and chair rise [8, 17, 18].

Recently, the disease progression of knee and hip OA has been attributed to age-related decline in muscle mass (i.e., sarcopenia). Toda et al. reported that older women with knee OA experienced significantly lower leg lean mass relative to body weight (%) by a mean ± standard deviation of 19.2 ± 2.7%, compared with the healthy control (21.0 ± 2.9%; P < 0.0001) [19]; Lee et al. observed similar results which indicated that older adults with knee OA had a mean appendicular skeletal muscle mass of 15.6 kg which is significant lower than that of healthy control (17.3 kg, P < 0.001) [20]. Additionally, Jeon et al. reported that lower skeletal muscle mass independently associated with knee radiographic OA [odds ratio (OR) 1.34; 95% confidence interval (CI) 1.04, 1.75] [21]. Therefore, older people with knee OA are considered at high risk of sarcopenia [22]. Grimaldi et al. observed muscle mass decreased in patients with hip OA in terms of 2.6–14.4% muscle atrophy of gluteal muscle group in the affected side compared to those in the uninvolved side, whereas such asymmetry in muscle volume ranged from 0.4 to 3.7% in control peers [23]; in addition, the muscle volume asymmetry is positively associated with disease progression of hip OA, indicating that patients with moderate to severe OA may experience greater muscle mass loss than mild-severity or asymptomatic patients [24]. Therefore, the OA population faces not only age-related muscle attenuation (i.e., sarcopenia) but also the disease-induced muscle loss.

The sarcopenia, obesity, and OA are becoming major threats to aging society and have been recognized as important health issues [8, 25, 26, 27]. The relationships among sarcopenia, obesity (i.e., sarcopenic obesity), and OA have been discussed. Kemmler et al. conducted an observational study to investigate the prevalence of sarcopenia in community-dwelled women who aged 70 years and older; the results indicated that elder women with lower-extremity OA exhibited a significantly higher rate of sarcopenia (9.1%) than nonarthritic peers (3.5%) [28]. Jin et al. reported that elder men and women with sarcopenic obesity showed significantly higher risks of exhibiting knee OA (OR = 1.92–2.43) compared with the healthy control groups [29]. Misra et al. conducted a longitudinal study of the risk of radiographic OA in relation to sarcopenic obesity; the result showed that elder people with sarcopenic obesity (RR = 1.91) had increased risks of exhibiting knee OA within a 5-year interval of follow up [30]. Therefore, preventive efforts for the obese elder individuals may need to focus not only on reducing sarcopenia but also on improving sarcopenic obesity to reduce the growing incidence and prevalence of knee OA.


2. Treatments and management for sarcopenia in elderly

Sarcopenic obesity originates from a multifactorial consequence of aging and its related physical inactivity [31], which especially exerts negative impacts to obese elderly populations [32]. Several approaches for management of sarcopenic obesity have been recommended including pharmacological interventions, exercise interventions, and nutrition interventions to counteract muscle loss and physical declines in obese older adults [33]. According to the recommendations from the European Society for Clinical Nutrition and Metabolism Expert Group [34], there are urgent needs for elder people with a risk of sarcopenic obesity to incorporate nutrition intervention and muscle strengthening exercise to prevent the functional decline.

2.1 Protein supplement plus exercise training for sarcopenic obesity

Obesity has become epidemic burden in elderly population [25]. Sarcopenic obesity, a recently identified phenotype of obese elderly population, is developed based on an underling additive effect of sarcopenia and obesity and is referred by the coexistence of diminished muscle mass and increased fat mass. Sarcopenia has been characterized by age-related muscle degeneration [35], and obesity with an increased body fat exerts negative impacts on the skeletal muscle turnover and its homeostasis [31]. Such deteriorations of muscle mass loss originated from aging process result in muscle dysfunction which may further lead to physical deficits in frail elderly [36]. Furthermore, older adults who are identified as overweight or obesity have been observed suffering high risks of physical disability [37, 38]. Accordingly, sarcopenic obesity had been identified to be associated with more physical limit than either pure sarcopenia or obesity and was served as a risk to disability and frail life style [8, 39]. Therefore, the preservation of muscle mass and strength are vital for obese older adults to yield physical activities in daily life.

Aging-related attenuation of skeletal muscle mass had been addressed to a smaller muscle fiber size rather than loss of fiber number and characterized of type II myofiber phenotype dominant [13, 40]. In addition, sarcopenic muscles remain in a state of failing compensatory effort in an attempt to stave off muscular degeneration and atrophy [41]. Given the facts that myofiber hypertrophy activated by satellite cells is largely dependent on both net muscle protein synthesis and satellite cell recruitment through serious cellular processing mechanism [42, 43], and that both age-associated sarcopenia and obesity are associated with an over expression of myostatin which functions as a protein inhibitor negatively regulating the skeletal muscle growth and homeostasis with inhibiting the myoblasts proliferation and differentiation [44, 45, 46], it is important to identify whether resistance exercises exert any effect on the myofiber type-specific muscle mass loss in obese aged people. In such scenarios, previous trials claimed that age-related Type II myofiber phenotype atrophy would be improved following resistance exercise training by means of satellite cell proliferation and an increase in the rate of muscle contractile and mitochondrial protein synthesis, which further contributed to myofiber hypertrophy [40, 42, 47, 48, 49, 50, 51].

Progressive resistance exercise training (RET) has been used as an effective way of improving muscle function and increasing muscle mass by stimulating muscle protein synthesis in elder people [31, 49, 52, 53]. Liao et al. further indicate that elastic RET exerts benefits on lean mass and physical mobility in older women with sarcopenic obesity [54]. With respective to multidisciplinary interventions for prevention of sarcopenia in elder populations, an additional protein supplements (PS) has also been believed to augment the effects of resistance training on muscle mass gain in older adults [55, 56]. For obese elderly individuals with energy restricted diet, PS has its effect on reduction of losing muscle mass during caloric restriction-induced weight loss [57]. However, the effects of PS plus RET on muscle mass and strength gains for obese elder people remain controversy. While several studies identified the effects of PS on muscle mass accretion and strength gain during resistance training in sarcopenic or obese elderly individuals [58], some concluded that PS provides no additional benefit in resistance-trained obese elder individuals [59, 60]. Furthermore, few systemic review studies have summarized these results in obese elder individuals. Whether PS during RET exerts any benefit on augmentation of muscular and functional performance in obese elder people remains unclear.

Liao et al. conducted a systemic review and meta-analysis study to investigate effects of PS plus RET for obese elder people [61]. Main results of Liao’s study showed an overall effect on lean body mass (LBM) and fat mass with significant standardized mean differences (SMDs) of 0.58 (95% CI = 0.32, 0.84, P < 0.0001) and − 0.61 (95% CI = −0.93, −0.29; P = 0.0002) favoring PS plus RET, respectively; similar results were observed in leg strength (SMD = 0.69, 95% CI = 0.39, 0.98; P < 0.00001) and short physical performance battery test (SMD = 0.44, 95% CI = 0.11, 0.78, P = 0.009). The results indicate that PS during RET intervention may potentially positively contribute to changes in the body composition of overweight and obese older people. However, based on the lower body mass index (BMI) subgroup (mean BMI < 30 kg/m2) exhibited greater changes in muscle volume and handgrip strength whereas the subgroup with mean BMI ≥ 30 kg/m2 did not after PS, obese older individuals may be resistant to PS to some degree [61].

2.2 Associations of muscle mass changes with intervention effects on muscle strength and physical capability after protein supplement plus exercise training

Multidisciplinary approaches are recommended for elderly individuals who have high sarcopenia or frailty risks, including nutrient intervention alone, exercise training alone, or combination of both [62, 63, 64, 65, 66], and among which protein supplement combined with exercise training (PS + ET) has been widely employed to augment lean mass gain, strength gain, and physical function enhancement in elderly individuals, irrespective of PS types and exercise protocols [65, 67, 68, 69]. However, whether intervention-induced changes in muscle mass contribute to strength gain and physical mobility improvement after PS + ET remains unclear. Several previous meta-analysis studies have reported that an increase in lean mass is accompanied by significant increases in strength gain [61, 68, 70, 71, 72] as well as physical mobility [68, 72] following PS + ET; however, such simultaneous increases in lean mass with strength [67, 73] (or physical function [61, 71]) were not observed by other researchers. Low muscle mass strongly predicts strength loss and mobility limitations in older adults [17, 74]; in addition, sarcopenia has been addressed to suppressed muscle protein turnover and homeostasis [75, 76]; therefore, identification of relationship between the muscle mass changes and physical improvements in response to PS + ET can facilitate clinical practitioners to efficiently make optimal decisions and set appropriate intervention strategies for elderly patients who are diagnosed as sarcopenia or frailty.

Liao et al. conducted a systemic review and meta-regression study to determine the associations of lean mass changes with treatment effects on strength and physical mobility after PS + ET [77]. Main results of Liao’s study showed an overall effect on LBM and appendicular lean mass (ALM) with significant SMDs of 0.66 (95%CI: 0.41–0.91, P < 0.00001) and 0.40 (95%CI: 0.15–0.66, P = 0.002) favoring PS + ET, respectively; similar results were observed in leg strength (SMD = 0.65, 95% CI: 0.39–0.90; P < 0.00001) and walking capability (SMD = 0.33, 95% CI: 0.14–0.52; P = 0.0006). Meta-regression analysis results of Liao’s study showed that significant associations were observed between changes in ALM (β = 0.08, P = 0.003) and SMDs of leg strength; the results further indicated that elderly individuals who achieved an increase in ALM of >2.5% in response to PS + ET may have obtained a positive effect size of leg strength. In addition, changes in ALM were significantly associated with effect sizes of walking capability (β = 0.17, P = 0.04). According to the Liao’s results, intervention-induced muscle mass gains have contributions in strength gain and function recovery after PS + ET, particularly the elderly who have sarcopenia and frailty risks.


3. Management of muscle deficits for mild to moderate severity of osteoarthritis

Since OA has been recognized as a serious musculoskeletal disease [78], managements of OA comprise multidisciplinary interventions including pain medications and nonpharmacological treatments for those patients who exhibit mild to moderate symptoms. However, surgical treatments such as total joint arthroplasty that could help to relief pain and improve joint function (e.g., range of motion and strength) [79] are commonly recommended at the end stage of OA.

Evidences regarding the effects of ET alone or PS plus ET on muscle mass, strength, and physical mobility have been well established in elderly populations with sarcopenia (Figure 1). However, whether ET alone or PS plus ET exert any benefit on muscle mass and function outcomes remains unclear. Based on that low muscle mass is closely associated with OA and elder individuals with OA have high sarcopenia risk [10, 28], it is urgent to generate effective strategy to manage this condition for the rapidly growing OA population. In addition, it is necessary to identify evidence of intervention effects on muscle mass and strength gains for elder people with OA.

Figure 1.

Summary of evidences regarding effects of exercise and diet interventions on sarcopenia, sarcopenic obesity, and osteoarthritis. Black, green, and red arrow lines indicate exercise alone, protein supplement plus exercise, and diet interventions plus exercise, respectively. (+): significant intervention effect; (++): significantly additional effect; (?) unclear additional effect. RET, resistance exercise training; MET, multicomponent exercise training; PS, protein supplement; DP, dietary protein; WL, weight loss.

3.1 Exercise training

Among the interventions of OA, exercise therapy is recommended as one of the first-line treatments [80]. Exercise exerts benefits on pain reduction, muscle strength, and physical function in elder individuals with OA, regardless of exercise types [81]. Especially, the muscle strength-based exercise training (MSE) has been encouraged to minimize degenerative muscular function associated with aging [82, 83], because of that elder individuals experience well muscular adaptations in terms of muscle morphological and architectural changes responding to MSE [84]. Therefore, MSE has been recommended for elder people with OA to augment muscle volume and enhance muscle hypertrophy [80].

Previous results have shown that MSE exerts benefits on muscle mass gain in elderly people. Churchward-Venne et al. indicated that older individuals achieved significantly temporal changes in whole body lean mass at 12-week and 24-week follow up by 0.9 ± 0.1 kg (P < 0.001) and 1.1 ± 0.2 kg (P < 0.001), respectively, responding to prolonged resistance-type MSE with an intensity of 60–80% 1RM and an intervention duration of 24 weeks [85]. In a meta-analysis, Peterson et al. indicated that resistance exercise exerts significant effects on increasing LBM with a pooled mean difference of 1.1 kg (95% CI: 0.9–1.2 kg) compared to the controls in older people [53].

The MSE has been served as the most promising intervention for sarcopenic elderly [62, 86] as well as those with OA [87, 88, 89, 90] to increase strength and improve mobility. Due to that MSE enables older adults to yield increased muscle anabolic resistance occurring with advancing age [91, 92], resistance-type exercise training (RET) as well as multicomponent exercise training (MET) have been considered beneficial for preserving lean muscle mass in older populations, even in those with sarcopenia [53, 93]. In addition, muscle protein synthesis and myofiber proliferation can be effectively activated through MSE [94], which further contribute to skeletal muscle hypertrophy and muscle mass gains even in elder population [42, 43]. Therefore, MSE is recommend to be employed for management of OA since elder individuals with OA has been considered having low muscle mass [10].

However, it remains unclear that whether MSE has any effect on muscle mass gain and morphological changes in older individuals with lower extremities of OA. Studies have reported that patients with OA exhibited increased changes in the muscle cross-sectional area or muscle thickness after MSE [95, 96, 97], whereas other authors have reported conflicting conclusions that MSE exerted no beneficial effects on fat-free mass or muscle remodeling [98, 99, 100]. In addition, both sarcopenia and OA are associated with decreased muscle protein synthesis and homeostasis [75, 76], and exercise-induced muscular hypertrophy contributes to the increase of muscle strength [101]. Moreover, most of previous systematic reviews investigating the treatment efficacy of MSE for individuals with OA have focused on muscular strength and physical outcomes rather than the muscle mass or volume measures [87, 88, 89, 90]. Therefore, identifying the effects of MSE on increasing muscle mass and volume helps clinical practitioners to develop appropriate treatment strategies for older people with OA.

Liao et al. conducted a systemic review and meta-analysis study to investigate effects of MSE for elder people with lower extremity OA [77]. Main results of systemic review and meta-analyses showed MSE has effects on changes in muscle mass gain (SMD = 0.49, 95% CI: 0.28, 0.71; P < 0.00001), muscle thickness (SMD = 0.82, 95% CI: 0.20, 1.43; P = 0.009), and muscle cross-sectional area (SMD = 0.80, 95% CI: 0.25, 1.35; P = 0.004) compared with nonexercise controls. Liao’s study demonstrated that MSE exerts effects on lean mass gain as well as muscle morphological changes in older adults with knee or hip OA. In addition, the subgroup analysis results suggested that older men experienced greater MSE effects on muscle thickness than did women peers and those who received MSE after arthroplasty may achieve greater changes in muscle volume compared to those who received preoperative an MSE intervention or those who did not undergo arthroplasty. According to the results in Liao’s meta-analysis, MSE may aid in offsetting muscle attenuation or prevent sarcopenia in older individuals with knee or hip OA, particularly in older men and in those undergoing knee or hip arthroplasty.

3.2 Protein supplement

Diet intervention such as dietary protein or protein supplementation (PS) has been incorporated to multidisciplinary managements for OA [102], since elder patients with OA have potential risks of age-related sarcopenia. In addition, alternative and complementary therapeutic approaches, such as the use of a wide array of nutritional and physical manipulations, are becoming popular for relieving symptoms of OA. Several previous studies had investigated clinical efficacy of protein supplementation (PS) for elder individuals with knee OA [103, 104, 105, 106]. Colker et al. employed a 6-week milk PS for elder individuals with OA and the results showed that PS achieved significant improved changes of daily activity and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) per week compared with the placebo group (P < 0.001) [104]; Zenk et al. conducted a similar study for older adults with OA and demonstrated that compared with the placebo supplement, a 6-week milk PS obtained significant effects on WOMAC and reduction of medication use as well as the glucosamine-supplement group did [106]. Arjmandi et al. further indicated that a 3-month soy-protein supplement achieved greater changes in pain, physical difficulty, and medical requirement than milk PS did, particularly for elder men with OA [103]. Regarding other types of PS, Miller et al. used an alternative PS of leucine enriched herbal and indicated that WOMAC and pain score were significantly reduced in PS group by 45% (P < 0.05) and 21.8% (P < 0.002), respectively, compared to the placebo group (reduced 25.4% in WOMAC and 21.8% in pain) [105].

3.3 Protein supplement combined with exercise training

Nutritional intervention, especially the protein supplementation (PS), can influence outcomes for elder individuals undergoing exercise interventions such as resistance-based exercise training (RET) or multicomponent exercise training (MET). Several systematic review studies had identified benefits of PS plus exercise training for elder population. For healthy elder individuals, Morton et al. reported that prolonged PS plus RET has effects on fat free mass, mid-thigh cross-sectional area, and one-repetition maximum strength by significant pooled mean differences of 0.30 kg (95%CI: 0.09–0.52 kg; P = 0.007), 7.2 mm2 (95%CI: 0.20–14.30 mm2; P = 0.04), and 2.49 kg (95%CI: 0.64–4.33 kg; P = 0.01), respectively [67]. For overweight or obese elder individuals, Liao et al. indicated that PS plus RET exerts significant effects on LBM and muscle volume with the corresponding effect sizes being 0.58 (95% CI: 0.32–0.84; P < 0.0001) and 1.23 (95% CI: 0.50–1.96; P = 0.001), respectively, irrespective of the intervention period [61]. For frail elderly, Liao et al. demonstrated that PS plus either RET or MET exerts significant effects on LBM and leg strength with the corresponding effect sizes being 0.52 (95% CI: 0.33–0.71; P < 0.00001) and 0.37 (95% CI: 0.23–0.51; P < 0.00001), respectively [68]. According to the previous established evidence regarding efficacy of PS plus exercise training, additional PS employed during exercise training may exert benefits for elder population with OA. However, most of the previous systematic review and meta-analysis studies investigated effects of PS plus exercise training for sarcopenic or frail elderly people, few studies focusing on OA population who are potentially with a high risk of sarcopenia. Further studies are necessary to investigate treatment effects of PS plus exercise on elderly population with OA.

3.4 Weight loss plus exercise for sarcopenic obesity in osteoarthritis

Given that obesity has become a burden in OA population [25], weight loss (WL) should be considered as an option while setting the treatment goals and planning rehabilitation strategies for elder people with OA. Previous studies had shown that maintaining or lowering BMI to the normal range (usually within 20.0–24.9, regardless of ethic) may reduce risks or improve symptoms of OA [107, 108]. Felson et al. indicated that a decrease of over 50% in odds of developing OA (odds ratio = 0.46; P = 0.02) occurred in older women along with a 2-unit decrease in BMI or a 5.1-kg reduction in weight over a 10-year period, especially for those who had a baseline BMI > 25 kg/m2 (odds ratio = 0.41; P = 0.02) [108]. Coggon et al. concluded similar results that proportion of knee OA patients can be reduced from 10.9 to 57.1% while overweight and obese populations reduced their weight by 2–5 kg or until reaching the normal-range BMI [107]. Weight loss is also efficacious in relieving symptoms of knee OA, most importantly alleviating the pain. Riddle et al. observed a significant dose-response relationship (P < 0.003) exists between percentage changes in body weight and the corresponding changes in WOMAC pain, as well as WOMAC physical function; Riddle further indicated that weight changes (gain or loss) of ≥10% potentially leads to clinical important changes in pain and function for older individuals with OA [109]. Messier et al. also identified a dose response to WL for pain (P = 0.01), 6-minute walk distance (P < 0.0001), and function (P = 0.0006) [110]. Accordingly, WL should be incorporated to the management for elder individuals with OA, especially those who are overweight or obese.

An WL intervention may exert negative impacts on lean mass since obesity often masks the age-associated loss of muscle mass. Recently, WL in combination with exercise has been recommended as the optimal approach to managing obese patients with OA. Several previous trials had targeted weight management for obese older adults with OA including the Intensive Diet and Exercise for Arthritis Trial [111], the Arthritis, Diet and Activity Promotion Trial [112], and the Physical Activity, Inflammation, and Body Composition Trial [113]. These registered clinical trials employed weight-loss protocols which targeted 5–10% reduction of body weight over 6–18 months and incorporated partial meal replacements, nutrition class, and behavior therapy for diet habit changes and lifestyle modifications. Results from such previous trials showed that exercise training in combination with a weight-loss program in obese adults with knee OA achieved significantly greater changes in pain and function compared to the control groups. In addition, several systemic reviews regarding WL with or without exercise for elder OA populations also provide evidences for treatment efficacy on pain relief and function recovery [114, 115, 116, 117]. However, the effects of WL plus exercise on lean mass remain inconsistency among the results of previous trials and few systemic review and meta-analysis studies focused on the treatment efficacy on muscle mass outcome in obese elder individuals with OA who received WL plus exercise. Future studies should be warranted to investigate effects of WL plus exercise on muscle mass in order to prevent sarcopenia in such elder population with OA.

Liao et al. conducted a systemic review and meta-analysis study to investigate effects of diet intervention plus ET for elder people with mild to moderate OA [118]. Among the included trials in Liao’s study, all of the included trials which reported muscle mass outcomes conducted a WL plus ET intervention for obese elder patients with knee OA [118] and the results showed that during an overall follow-up duration, the WL plus ET group achieved significant effects on muscle mass gains (SMD = 0.61; 95%CI: 0.30–0.91, P = 0.0001) compared to the control groups, regardless of methodological design. The results indicated that WL plus ET exhibited significant effects on muscle mass for obese older individuals with OA.


4. Management of muscle dysfunction after total joint replacement for patients with end-stage osteoarthritis

4.1 Postoperative rehabilitation for muscle recovery after total joint replacement

Total joint replacement has been recommended for patients with end-stage of OA who experience poor response to pharmacological medication or conventional therapy [119, 120, 121]. Total knee replacement (TKR) as well as total hip replacement (THR) has profound benefits for pain relief, which is the main determinant of functional recovery following surgery.

Enhanced recovery programs after a TKR or THR surgery, which require a multidisciplinary team of dedicated professionals, have been well-established [122]. Among the perioperative interventions producing better surgery outcome, rehabilitation plays an important role in physical reconditioning and functional recovery [123]. As mentioned in the Section 2.1, muscle strengthening exercise (MSE) exerts benefits on muscle mass and strength gains in elder people with OA, and an MSE has been effectively employed following TKR or THR surgery as well to improve postoperative muscle and joint function [124]. However, it remains unclear that whether MSE exerts any effect on muscle mass after total joint replacement. It is important to identify the effects of MSE on muscle mass outcome following total joint replacement since patient who were undergoing TKR or THR may experience acute sarcopenia immediately after surgery [125, 126]. Due to that sarcopenia may have impacts on function outcome after TKR or THR, further studies should be conducted to warrant effective interventions for preserve muscle mass for elderly population with OA who recently underwent total joint replacement.

Liao et al. conducted a randomized control trial to investigate effects of post-TKR MSE for elder women with OA [127]. Liao’s study demonstrated that an intervention of 12-week elastic RET following TKR surgery exerted benefits for muscle mass gain and physical recovery among elderly women with KOA. The results of this study suggest that elastic RET should be incorporated to post-TKR rehabilitation for patients with KOA to achieve well postoperative outcomes, especially muscle mass gains and physical mobility improvements. Liao further stated that the elastic RET is relatively safe and easily performed at home. The elastic RET protocol used in Liao’s study will help clinical practitioners and physiotherapists and to establish prompt treatment strategies for elderly people with KOA, especially those who have undergone a recent TKR and are considered to have high sarcopenia risk. The findings of this study indicated post-TKR elastic RET exerted benefits on muscle mass and function and can potentially assist clinician decision-making concerning the optimal treatment strategy for elderly women who are undergoing a primary TKR.

4.2 Protein supplement plus exercise training after surgery

The previous observational study has indicated that low protein intake occurring in patients with OA may place themselves at high risks of sarcopenia [128]. Therefore, perioperative interventions including protein supplement may prevent elder patients from suffering acute sarcopenia and poor surgical outcome at early stage after total joint replacement (i.e., TKR or THR) [129, 130, 131]. Alito et al. employed 5-day protein-contained (23%) supplements (PS) before surgery for patients who were undergoing THR and the results demonstrated that comparing with the non-supplement control group, the PS group experienced significantly a lower level of C-reactive protein (mean 80.6 vs. 66.5 mg/L, P < 0.01) and a shorter length of hospital stay (median 6 vs. 3 days, P < 0.01) after THR [129]. Yang et al. used high-dose PS on the day before and after THR surgery and the results showed that, comparing to the standard-care group, the PS group had less proportion of patients who required an intravenous albumin (45.1% vs. 26.8%, P = 0.023) and experienced a shorter length of hospital stay (mean 5.1 vs. 3.9 days, P < 0.001) [130]. Bai et al. used an oral ingestion of hydrolyzed PS for 5 postoperative days after TKR and the results indicated that PS enhanced postoperative nutrition status in terms of greater changes in blood prealbumin (P < 0.03) compared to the regular-nutrition group [131]. The previous results had indicated that diet interventions, especially the PS, before or after total joint replacement can enhance postoperative nutrient status and shorten length of acute inpatient stay which further prevent elder patients from experiencing acute sarcopenia.

On the basis that either perioperative diet interventions or early rehabilitation programs exerts benefits on surgical outcome, combination of both may provide additional effects on function recovery after TKR or THR. The evidences regarding effects of PS plus exercise for healthy, sarcopenic, and frail elder populations have been well established by previous systemic review and meta-analysis studies [61, 68, 132]. However, the elder population with OA as well as those who underwent total joint replacement are less targeted by previous systemic reviews investigating efficacy of PS plus exercise. Future studies are necessary to be warranted in order to identify whether PS plus exercise following TKR or THR exerts any effect on postoperative function outcomes.

Liao et al. conducted a systemic review and meta-analysis study to investigate effects of diet intervention plus ET for elder people with OA [118]. Among the included trials in Liao’s study, all of the included trials which reported muscle mass outcomes conducted a PS plus ET intervention for older patients who recently received a TKR or THR [118] and the results showed that during an overall follow-up duration, the PS plus ET group achieved significant effects on muscle mass gains (SMD = 0.81; 95%CI: 0.45–1.17, P < 0.0001) compared to the ET control groups, regardless of PS type. The results indicated that PS plus ET exhibited significant effects on muscle mass for older individuals with OA, especially for those who recently received a total joint arthroplasty.


5. Conclusions

This review provides evidence that DI incorporated with ET is effective for promoting gains in muscle mass and strength and enhancing performance in physical mobility for the elder adults with lower-extremity OA, compared to placebo, DI-alone or ET-alone controls. In addition, muscle mass gains have effects on strength gain and global function recovery. Furthermore, the results of this study showed that PS plus ET appears to be the optimal treatment strategy for those who were undergoing total joint replacement whereas WL plus ET is most preferred for those who experienced mild to moderate severity of OA disease. Therefore, we concluded that DI additional to ET may have extra effects to prevent or offset muscle loss and function decline for elder individuals with OA who have high sarcopenia risks.


6. Implications for clinical practice

This review adds current evidences of interdisciplinary approach practices which comprise effective nutrient and exercise intervention strategies for KOA populations who have potential risks of sarcopenic obesity. This review also provides references for clinical practitioners to develop efficient and effective interventions for such population to prevent sarcopenic obesity.



This study was funded by grants from the Taipei Medical University-Shuang Ho Hospital, Ministry of Health and Welfare, Taiwan (grant no. 109TMU-SHH-13) and Taipei Medical University (grant no. IIT-1072-3).


Conflict of interest

The authors declare that they have no conflict of interest to the publication of this review.


  1. 1. United Nations, D.o.E.a.S.A., Population Division. World Population Prospects 2019: Ten Key Findings. 2019. 25 October 2019. Available from:
  2. 2. Guzman-Castillo M et al. Forecasted trends in disability and life expectancy in England and Wales up to 2025: A modelling study. The Lancet Public Health. 2017;2(7):e307-e313
  3. 3. Palazzo C et al. Respective contribution of chronic conditions to disability in France: Results from the national disability-health survey. PLoS One. 2012;7(9):e44994
  4. 4. Prince MJ et al. The burden of disease in older people and implications for health policy and practice. The Lancet. 2015;385(9967):549-562
  5. 5. Sebbag E et al. The world-wide burden of musculoskeletal diseases: A systematic analysis of the World Health Organization burden of diseases database. Annals of the Rheumatic Diseases. 2019;78(6):844-848
  6. 6. Palazzo C et al. The burden of musculoskeletal conditions. PLoS One. 2014;9(3):e90633
  7. 7. Cruz-Jentoft AJ et al. Sarcopenia: Revised European consensus on definition and diagnosis. Age and Ageing. 2019;48(1):16-31
  8. 8. Rolland Y et al. Difficulties with physical function associated with obesity, sarcopenia, and sarcopenic-obesity in community-dwelling elderly women: The EPIDOS (EPIDemiologie de l’OSteoporose) study. The American Journal of Clinical Nutrition. 2009;89(6):1895-1900
  9. 9. Kim SR et al. Associations between fat mass, lean mass, and knee osteoarthritis: The fifth Korean National Health and nutrition examination survey (KNHANES V). Calcified Tissue International. 2016;99(6):598-607
  10. 10. Kim HT et al. An analysis of age-related loss of skeletal muscle mass and its significance on osteoarthritis in a Korean population. The Korean Journal of Internal Medicine. 2016;31(3):585-593
  11. 11. Tieland M, Trouwborst I, Clark BC. Skeletal muscle performance and ageing. Journal of Cachexia, Sarcopenia and Muscle. 2018;9(1):3-19
  12. 12. Kwan P. Sarcopenia, a neurogenic syndrome? Journal of Aging Research. 2013;2013:791679
  13. 13. Nilwik R et al. The decline in skeletal muscle mass with aging is mainly attributed to a reduction in type II muscle fiber size. Experimental Gerontology. 2013;48(5):492-498
  14. 14. Mitchell WK et al. Sarcopenia, dynapenia, and the impact of advancing age on human skeletal muscle size and strength; a quantitative review. Frontiers in Physiology. 2012;3:260
  15. 15. Wilkinson DJ, Piasecki M, Atherton PJ. The age-related loss of skeletal muscle mass and function: Measurement and physiology of muscle fibre atrophy and muscle fibre loss in humans. Ageing Research Reviews. 2018;47:123-132
  16. 16. Reid KF et al. Lower extremity muscle mass predicts functional performance in mobility-limited elders. The Journal of Nutrition, Health & Aging. 2008;12(7):493-498
  17. 17. Liu LK et al. Age-related skeletal muscle mass loss and physical performance in Taiwan: Implications to diagnostic strategy of sarcopenia in Asia. Geriatrics & Gerontology International. 2013;13(4):964-971
  18. 18. Malmstrom TK et al. Low appendicular skeletal muscle mass (ASM) with limited mobility and poor health outcomes in middle-aged African Americans. Journal of Cachexia, Sarcopenia and Muscle. 2013;4(3):179-186
  19. 19. Toda Y et al. A decline in lower extremity lean body mass per body weight is characteristic of women with early phase osteoarthritis of the knee. The Journal of Rheumatology. 2000;27(10):2449-2454
  20. 20. Lee SY et al. Low skeletal muscle mass in the lower limbs is independently associated to knee osteoarthritis. PLoS One. 2016;11(11):e0166385
  21. 21. Jeon H et al. Low skeletal muscle mass and radiographic osteoarthritis in knee, hip, and lumbar spine: A cross-sectional study. Aging Clinical and Experimental Research. 2019;31(11):1557-1562
  22. 22. Shorter E et al. Skeletal muscle wasting and its relationship with osteoarthritis: A mini-review of mechanisms and current interventions. Current Rheumatology Reports. 2019;21(8):40
  23. 23. Grimaldi A et al. The association between degenerative hip joint pathology and size of the gluteus medius, gluteus minimus and piriformis muscles. Manual Therapy. 2009;14(6):605-610
  24. 24. Zacharias A et al. Atrophy of hip abductor muscles is related to clinical severity in a hip osteoarthritis population. Clinical Anatomy. 2018;31(4):507-513
  25. 25. Lechleitner M. The elderly as a target for obesity treatment. Expert Review of Endocrinology and Metabolism. 2015;10(4):375-380
  26. 26. Batsis JA et al. Impact of obesity on disability, function, and physical activity: Data from the osteoarthritis initiative. Scandinavian Journal of Rheumatology. 2015;44(6):495-502
  27. 27. Ackerman IN, Osborne RH. Obesity and increased burden of hip and knee joint disease in Australia: Results from a national survey. BMC Musculoskeletal Disorders. 2012;13:254
  28. 28. Kemmler W et al. Prevalence of sarcopenia in Germany and the corresponding effect of osteoarthritis in females 70 years and older living in the community: Results of the FORMoSA study. Clinical Interventions in Aging. 2015;10:1565-1573
  29. 29. Jin C et al. The clinical research of rehabilitation method based on virtual reality technology for early functional exercise after total knee arthroplasty. Chinese Journal of Control of Endemic Diseases. 2017;32(7):779-780
  30. 30. Misra D et al. Risk of knee osteoarthritis with obesity, sarcopenic obesity, and sarcopenia. Arthritis & Rhematology. 2019;71(2):232-237
  31. 31. Vincent HK, Raiser SN, Vincent KR. The aging musculoskeletal system and obesity-related considerations with exercise. Ageing Research Reviews. 2012;11(3):361-373
  32. 32. Choi KM. Sarcopenia and sarcopenic obesity. Endocrinology and Metabolism. 2013;28(2):86-89
  33. 33. Molino S et al. Sarcopenic obesity: An appraisal of the current status of knowledge and management in elderly people. The Journal of Nutrition, Health & Aging. 2016;20(7):780-788
  34. 34. Deutz NE et al. Protein intake and exercise for optimal muscle function with aging: Recommendations from the ESPEN expert group. Clinical Nutrition. 2014;33(6):929-936
  35. 35. von Haehling S, Morley JE, Anker SD. From muscle wasting to sarcopenia and myopenia: Update 2012. Journal of Cachexia, Sarcopenia and Muscle. 2012;3(4):213-217
  36. 36. Visser M et al. Leg muscle mass and composition in relation to lower extremity performance in men and women aged 70 to 79: The health, aging and body composition study. Journal of the American Geriatrics Society. 2002;50(5):897-904
  37. 37. Zoico E et al. Physical disability and muscular strength in relation to obesity and different body composition indexes in a sample of healthy elderly women. International Journal of Obesity and Related Metabolic Disorders. 2004;28(2):234-241
  38. 38. Vincent HK, Vincent KR, Lamb KM. Obesity and mobility disability in the older adult. Obesity Reviews. 2010;11(8):568-579
  39. 39. Lee S, Kim TN, Kim SH. Sarcopenic obesity is more closely associated with knee osteoarthritis than is nonsarcopenic obesity: A cross-sectional study. Arthritis and Rheumatism. 2012;64(12):3947-3954
  40. 40. Verdijk LB et al. Skeletal muscle hypertrophy following resistance training is accompanied by a fiber type-specific increase in satellite cell content in elderly men. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences. 2009;64(3):332-339
  41. 41. Calvani R et al. Mitochondrial pathways in sarcopenia of aging and disuse muscle atrophy. Biological Chemistry. 2013;394(3):393-414
  42. 42. Damas F et al. A review of resistance training-induced changes in skeletal muscle protein synthesis and their contribution to hypertrophy. Sports Medicine. 2015;45(6):801-807
  43. 43. Zammit PS, Partridge TA, Yablonka-Reuveni Z. The skeletal muscle satellite cell: The stem cell that came in from the cold. The Journal of Histochemistry and Cytochemistry. 2006;54(11):1177-1191
  44. 44. Elliott B et al. The central role of myostatin in skeletal muscle and whole body homeostasis. Acta Physiologica (Oxford, England). 2012;205(3):324-440
  45. 45. Allen DL, Hittel DS, McPherron AC. Expression and function of myostatin in obesity, diabetes, and exercise adaptation. Medicine and Science in Sports and Exercise. 2011;43(10):1828-1835
  46. 46. Yarasheski KE et al. Serum myostatin-immunoreactive protein is increased in 60-92 year old women and men with muscle wasting. The Journal of Nutrition, Health & Aging. 2002;6(5):343-348
  47. 47. Farup J, Sorensen H, Kjolhede T. Similar changes in muscle fiber phenotype with differentiated consequences for rate of force development: Endurance versus resistance training. Human Movement Science. 2014;34:109-119
  48. 48. Kosek DJ et al. Efficacy of 3 days/wk resistance training on myofiber hypertrophy and myogenic mechanisms in young vs. older adults. Journal of Applied Physiology. 1985;101(2):531-544
  49. 49. Yarasheski KE. Exercise, aging, and muscle protein metabolism. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences. 2003;58(10):M918-M922
  50. 50. Melov S et al. Resistance exercise reverses aging in human skeletal muscle. PLoS One. 2007;2(5):e465
  51. 51. Johnston AP, De Lisio M, Parise G. Resistance training, sarcopenia, and the mitochondrial theory of aging. Applied Physiology, Nutrition, and Metabolism. 2008;33(1):191-199
  52. 52. Liu CJ, Latham NK. Progressive resistance strength training for improving physical function in older adults. Cochrane Database of Systematic Reviews. 2009;3:CD002759
  53. 53. Peterson MD, Sen A, Gordon PM. Influence of resistance exercise on lean body mass in aging adults: A meta-analysis. Medicine and Science in Sports and Exercise. 2011;43(2):249-258
  54. 54. Liao CD et al. Effects of elastic band exercise on lean mass and physical capacity in older women with sarcopenic obesity: A randomized controlled trial. Scientific Reports. 2018;8(1):2317
  55. 55. Cermak NM et al. Protein supplementation augments the adaptive response of skeletal muscle to resistance-type exercise training: A meta-analysis. The American Journal of Clinical Nutrition. 2012;96(6):1454-1464
  56. 56. Tieland M et al. Protein supplementation increases muscle mass gain during prolonged resistance-type exercise training in frail elderly people: A randomized, double-blind, placebo-controlled trial. Journal of the American Medical Directors Association. 2012;13(8):713-719
  57. 57. Coker RH et al. Whey protein and essential amino acids promote the reduction of adipose tissue and increased muscle protein synthesis during caloric restriction-induced weight loss in elderly, obese individuals. Nutrition Journal. 2012;11(1):105-111
  58. 58. Zdzieblik D et al. Collagen peptide supplementation in combination with resistance training improves body composition and increases muscle strength in elderly sarcopenic men: A randomised controlled trial. The British Journal of Nutrition. 2015;114(8):1237-1245
  59. 59. Villanueva MG, He J, Schroeder ET. Periodized resistance training with and without supplementation improve body composition and performance in older men. European Journal of Applied Physiology. 2014;114(5):891-905
  60. 60. Verreijen AM et al. A high whey protein-, leucine-, and vitamin D-enriched supplement preserves muscle mass during intentional weight loss in obese older adults: A double-blind randomized controlled trial. American Journal of Clinical Nutrition. 2015;101(2):279-286
  61. 61. Liao CD et al. Effects of protein supplementation combined with resistance exercise on body composition and physical function in older adults: A systematic review and meta-analysis. The American Journal of Clinical Nutrition. 2017;106(4):1078-1091
  62. 62. Trethewey SP et al. Interventions for the management and prevention of sarcopenia in the critically ill: A systematic review. Journal of Critical Care. 2019;50:287-295
  63. 63. Jadczak AD et al. Effectiveness of exercise interventions on physical function in community-dwelling frail older people: An umbrella review of systematic reviews. JBI Database of Systematic Reviews and Implementation Reports. 2018;16(3):752-775
  64. 64. Tessier AJ, Chevalier S. An update on protein, leucine, omega-3 fatty acids, and vitamin D in the prevention and treatment of sarcopenia and functional decline. Nutrients. 2018;10(8):1099
  65. 65. Phillips SM. Nutritional supplements in support of resistance exercise to counter age-related sarcopenia. Advances in Nutrition. 2015;6(4):452-460
  66. 66. Denison HJ et al. Prevention and optimal management of sarcopenia: A review of combined exercise and nutrition interventions to improve muscle outcomes in older people. Clinical Interventions in Aging. 2015;10:859-869
  67. 67. Morton RW et al. A systematic review, meta-analysis and meta-regression of the effect of protein supplementation on resistance training-induced gains in muscle mass and strength in healthy adults. British Journal of Sports Medicine. 2018;52(6):376-384
  68. 68. Liao CD et al. Effects of protein supplementation combined with exercise intervention on frailty indices, body composition, and physical function in frail older adults. Nutrients. 2018;10(12):1916
  69. 69. Hidayat K et al. Effects of milk proteins supplementation in older adults undergoing resistance training: A meta-analysis of randomized control trials. The Journal of Nutrition, Health & Aging. 2018;22(2):237-245
  70. 70. Naclerio F, Larumbe-Zabala E. Effects of whey protein alone or as part of a multi-ingredient formulation on strength, fat-free mass, or lean body mass in resistance-trained individuals: A meta-analysis. Sports Medicine. 2016;46(1):125-137
  71. 71. Luo D et al. Effect of nutritional supplement combined with exercise intervention on sarcopenia in the elderly: A meta-analysis. International Journal of Nursing Sciences. 2017;4(4):389-401
  72. 72. Cheng H et al. Systematic review and meta-analysis of the effect of protein and amino acid supplements in older adults with acute or chronic conditions. The British Journal of Nutrition. 2018;119(5):527-542
  73. 73. Finger D et al. Effects of protein supplementation in older adults undergoing resistance training: A systematic review and meta-analysis. Sports Medicine. 2015;45(2):245-255
  74. 74. Janssen I, Heymsfield SB, Ross R. Low relative skeletal muscle mass (sarcopenia) in older persons is associated with functional impairment and physical disability. Journal of the American Geriatrics Society. 2002;50(5):889-896
  75. 75. Santos ML et al. Muscle strength, muscle balance, physical function and plasma interleukin-6 (IL-6) levels in elderly women with knee osteoarthritis (OA). Archives of Gerontology and Geriatrics. 2011;52(3):322-326
  76. 76. Wilson D et al. Frailty and sarcopenia: The potential role of an aged immune system. Ageing Research Reviews. 2017;36:1-10
  77. 77. Liao CD et al. Effects of Muscle Strength Training on Muscle Mass Gain and Hypertrophy in Older Adults with Osteoarthritis: A Systematic Review and Meta-Analysis. Hoboken: Arthritis Care & Research; 2019. DOI: 10.1002/acr.24097 [Online ahead of print]
  78. 78. Hawker GA. Osteoarthritis is a serious disease. Clinical and Experimental Rheumatology. 2019;120(5):3-6
  79. 79. Price AJ et al. Knee replacement. Lancet. 2018;392(10158):1672-1682
  80. 80. Skou ST, Roos EM. Physical therapy for patients with knee and hip osteoarthritis: Supervised, active treatment is current best practice. Clinical and Experimental Rheumatology. 2019;37(5):112-117
  81. 81. Juhl C et al. Impact of exercise type and dose on pain and disability in knee osteoarthritis: A systematic review and meta-regression analysis of randomized controlled trials. Arthritis & Rhematology. 2014;66(3):622-636
  82. 82. Peterson MD, Gordon PM. Resistance exercise for the aging adult: Clinical implications and prescription guidelines. The American Journal of Medicine. 2011;124(3):194-198
  83. 83. Giallauria F et al. Resistance training and sarcopenia. Monaldi Archives for Chest Disease. 2016;84(1-2):738
  84. 84. Narici MV et al. Muscular adaptations to resistance exercise in the elderly. Journal of Musculoskeletal & Neuronal Interactions. 2004;4(2):161-164
  85. 85. Churchward-Venne TA et al. There are no nonresponders to resistance-type exercise training in older men and women. Journal of the American Medical Directors Association. 2015;16(5):400-411
  86. 86. Vikberg S et al. Effects of resistance training on functional strength and muscle mass in 70-year-old individuals with pre-sarcopenia: A randomized controlled trial. Journal of the American Medical Directors Association. 2019;20(1):28-34
  87. 87. Zacharias A et al. Efficacy of rehabilitation programs for improving muscle strength in people with hip or knee osteoarthritis: A systematic review with meta-analysis. Osteoarthritis and Cartilage. 2014;22(11):1752-1773
  88. 88. Jansen MJ et al. Strength training alone, exercise therapy alone, and exercise therapy with passive manual mobilisation each reduce pain and disability in people with knee osteoarthritis: A systematic review. Journal of Physiotherapy. 2011;57(1):11-20
  89. 89. Bartholdy C et al. The role of muscle strengthening in exercise therapy for knee osteoarthritis: A systematic review and meta-regression analysis of randomized trials. Seminars in Arthritis and Rheumatism. 2017;47(1):9-21
  90. 90. Li Y et al. The effects of resistance exercise in patients with knee osteoarthritis: A systematic review and meta-analysis. Clinical Rehabilitation. 2016;30(10):947-959
  91. 91. Agergaard J et al. Light-load resistance exercise increases muscle protein synthesis and hypertrophy signaling in elderly men. American Journal of Physiology. Endocrinology and Metabolism. 2017;312(4):E326-E338
  92. 92. Rennie MJ. Anabolic resistance: The effects of aging, sexual dimorphism, and immobilization on human muscle protein turnover. Applied Physiology, Nutrition, and Metabolism. 2009;34(3):377-381
  93. 93. Vlietstra L, Hendrickx W, Waters DL. Exercise interventions in healthy older adults with sarcopenia: A systematic review and meta-analysis. Australasian Journal on Ageing. 2018;37(3):169-183
  94. 94. Marimuthu K, Murton AJ, Greenhaff PL. Mechanisms regulating muscle mass during disuse atrophy and rehabilitation in humans. Journal of Applied Physiology. 2011;110(2):555-560
  95. 95. Ferraz RB et al. Benefits of resistance training with blood flow restriction in knee osteoarthritis. Medicine and Science in Sports and Exercise. 2018;50(5):897-905
  96. 96. Mahmoud WS, Elnaggar RK, Ahmed AS. Influence of isometric exercise training on quadriceps muscle architecture and strength in obese subjects with knee osteoarthritis. International Journal of Medical Research & Health Sciences. 2017;6(3):1-9
  97. 97. Valtonen A et al. Maintenance of aquatic training-induced benefits on mobility and lower-extremity muscles among persons with unilateral knee replacement. Archives of Physical Medicine and Rehabilitation. 2011;92(12):1944-1950
  98. 98. Lim JY, Tchai E, Jang SN. Effectiveness of aquatic exercise for obese patients with knee osteoarthritis: A randomized controlled trial. PM & R :The Journal of Injury, Function, and Rehabilitation. 2010;2(8):723-731
  99. 99. Aguiar GC et al. Effects of resistance training in individuals with knee osteoarthritis. Journal of Physical Therapy Science. 2016;29(3):589-596
  100. 100. Waller B et al. Effects of high intensity resistance aquatic training on body composition and walking speed in women with mild knee osteoarthritis: A 4-month RCT with 12-month follow-up. Osteoarthritis and Cartilage. 2017;25(8):1238-1246
  101. 101. Balshaw TG et al. Changes in agonist neural drive, hypertrophy and pre-training strength all contribute to the individual strength gains after resistance training. European Journal of Applied Physiology. 2017;117(4):631-640
  102. 102. Finney A et al. Multidisciplinary approaches to managing osteoarthritis in multiple joint sites: A systematic review. BMC Musculoskeletal Disorders. 2016;17:266
  103. 103. Arjmandi BH et al. Soy protein may alleviate osteoarthritis symptoms. Phytomedicine. 2004;11(7-8):567-575
  104. 104. Colker CM et al. Effects of a milk-based bioactive micronutrient beverage on pain symptoms and activity of adults with osteoarthritis: A double-blind, placebo-controlled clinical evaluation. Nutrition. 2002;18(5):388-392
  105. 105. Miller MJS, Butler R. Relief of osteoarthritis with an herbal-amino acid supplement: A randomized double-blind placebo controlled trial. Advances in Bioscience and Biotechnology. 2012;3:504
  106. 106. Zenk JL, Helmer TR, Kuskowski MA. The effects of milk protein concentrate on the symptoms of osteoarthritis in adults: An exploratory, randomized, double-blind, placebo-controlled trial. Current Therapeutic Research. 2002;63(7):430-442
  107. 107. Coggon D et al. Knee osteoarthritis and obesity. International Journal of Obesity and Related Metabolic Disorders. 2001;25(5):622-627
  108. 108. Felson DT et al. Weight loss reduces the risk for symptomatic knee osteoarthritis in women. The Framingham study. Annals of Internal Medicine. 1992;116(7):535-539
  109. 109. Riddle DL, Stratford PW. Body weight changes and corresponding changes in pain and function in persons with symptomatic knee osteoarthritis: A cohort study. Arthritis Care & Research (Hoboken). 2013;65(1):15-22
  110. 110. Messier SP et al. Intentional weight loss in overweight and obese patients with knee osteoarthritis: Is more better? Arthritis Care & Research (Hoboken). 2018;70(11):1569-1575
  111. 111. Messier SP et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: The IDEA randomized clinical trial. JAMA. 2013;310(12):1263-1273
  112. 112. Miller GD et al. The arthritis, diet and activity promotion trial (ADAPT): Design, rationale, and baseline results. Controlled Clinical Trials. 2003;24(4):462-480
  113. 113. Miller GD et al. Intensive weight loss program improves physical function in older obese adults with knee osteoarthritis. Obesity (Silver Spring). 2006;14(7):1219-1230
  114. 114. Alrushud AS et al. Effect of physical activity and dietary restriction interventions on weight loss and the musculoskeletal function of overweight and obese older adults with knee osteoarthritis: A systematic review and mixed method data synthesis. BMJ Open. 2017;7(6):e014537
  115. 115. Christensen R et al. Effect of weight reduction in obese patients diagnosed with knee osteoarthritis: A systematic review and meta-analysis. Annals of the Rheumatic Diseases. 2007;66(4):433-439
  116. 116. Chu IJH, Lim AYT, Ng CLW. Effects of meaningful weight loss beyond symptomatic relief in adults with knee osteoarthritis and obesity: A systematic review and meta-analysis. Obesity Reviews. 2018;19(11):1597-1607
  117. 117. Robson EK et al. Effectiveness of weight loss interventions for reducing pain and disability in people with common musculoskeletal disorders: A systematic review with meta-analysis. The Journal of Orthopaedic and Sports Physical Therapy. 2020;50(6):319-333
  118. 118. Liao CD. Effects of Exercise Training Combined with Diet Intervention for Older Adults with Lower Extremity Osteoarthritis [thesis]. Taipei: National Taiwan University; 2020. DOI: 10.6342/NTU202000990
  119. 119. Liddle AD, Pegg EC, Pandit H. Knee replacement for osteoarthritis. Maturitas. 2013;75(2):131-136
  120. 120. Statements NCSS. NIH consensus statement on total knee replacement. NIH Consensus and State-of-the-Science Statements. 2003;20(1):1-34
  121. 121. Peters CL. Mild to moderate hip OA: Joint preservation or total hip arthroplasty? The Journal of Arthroplasty. 2015;30(7):1109-1112
  122. 122. Ibrahim MS et al. An evidence-based review of enhanced recovery interventions in knee replacement surgery. Annals of the Royal College of Surgeons of England. 2013;95(6):386-389
  123. 123. Ebert JR, Munsie C, Joss B. Guidelines for the early restoration of active knee flexion following total knee arthroplasty: implications for rehabilitation and early intervention. Archives of Physical Medicine and Rehabilitation. 2014;95(6):1135-1140
  124. 124. Pozzi F, Snyder-Mackler L, Zeni J. Physical exercise after knee arthroplasty: A systematic review of controlled trials. European Journal of Physical and Rehabilitation Medicine. 2013;49(6):877-892
  125. 125. Petterson SC et al. Time course of quad strength, area, and activation after knee arthroplasty and strength training. Medicine and Science in Sports and Exercise. 2011;43(2):225-231
  126. 126. Kouw IWK et al. One week of hospitalization following elective hip surgery induces substantial muscle atrophy in older patients. Journal of the American Medical Directors Association. 2019;20(1):35-42
  127. 127. Liao CD et al. Effects of elastic resistance exercise after total knee replacement on muscle mass and physical function in elderly women with osteoarthritis: A randomized controlled trial. American Journal of Physical Medicine & Rehabilitation. 2020;99(5):381-389
  128. 128. de Zwart AH et al. Dietary protein intake and upper leg muscle strength in subjects with knee osteoarthritis: Data from the osteoarthritis initiative. Rheumatology International. 2019;39(2):277-284
  129. 129. Alito MA, de Aguilar-Nascimento JE. Multimodal perioperative care plus immunonutrition versus traditional care in total hip arthroplasty: A randomized pilot study. Nutrition Journal. 2016;15:34
  130. 130. Yang L et al. A novel perioperative nutritional management model for primary unilateral total hip arthroplasty. Chinese Journal of Orthopaedics. 2019;27(11):1005-1009
  131. 131. Bai ZW et al. Nutritional status improvement in patients undergoing total knee arthroplasty by oral hydrolyzed protein. Beijing Medical Journal. 2018;40(1):30-33
  132. 132. Liao CD et al. The role of muscle mass gain following protein supplementation plus exercise therapy in older adults with sarcopenia and frailty risks: A systematic review and meta-regression analysis of randomized trials. Nutrients. 2019;11(8):1713

Written By

Tsan-Hon Liou, Chun-De Liao and Shih-Wei Huang

Submitted: 20 May 2020 Reviewed: 27 July 2020 Published: 24 August 2020