Poor performance of strength, assistance with walking, rising from a chair, climbing stairs and falls for sarcopenia screening in cirrhosis: A pilot study

Abstract

BACKGROUND

Hepatic cirrhosis is a chronic condition often associated with malnutrition and sarcopenia, both of which negatively affect patient prognosis. Early identification of sarcopenia is essential for effective interventions.

AIM

To evaluate the strength, assistance with walking, rising from a chair, climbing stairs and falls (SARC-F) questionnaire as an indirect predictor of sarcopenia risk in patients with chronic liver disease (CLD).

METHODS

This was a pilot, prospective, cross-sectional study including 45 patients with hepatic cirrhosis undergoing clinical follow-up at the Gastroenterology Outpatient Clinic of the Hospital Complex of the Irmandade Santa Casa de Misericórdia de Porto Alegre. The following tools were used: Phase angle, five times sit-to-stand test, handgrip strength (HGS), and the SARC-F questionnaire.

RESULTS

Among the 45 patients evaluated (mean age: 61 years, slight male predominance), the SARC-F questionnaire identified only eight suspected cases of sarcopenia. In contrast, objective strength tests identified 15 cases by HGS and 21 by the sit-to-stand test. Cross-tabulation analysis showed that SARC-F did not identify any true positives and demonstrated low specificity and negative predictive value, compromising its effectiveness as a screening tool.

CONCLUSION

Despite its ease of application and low cost, the SARC-F demonstrated limited sensitivity and a high rate of false-positive results, compromising its accuracy as a standalone screening tool for sarcopenia in patients with hepatic cirrhosis.

Key Words: Liver cirrhosis; Sarcopenia; Nutritional status; Screening instruments; Hand strength

Core Tip: Sarcopenia is common in cirrhosis and negatively affects prognosis. Early detection is essential for effective management. We evaluated the strength, assistance with walking, rising from a chair, climbing stairs and falls (SARC-F) questionnaire as a screening tool in 45 cirrhotic patients. We compared its performance with objective functional tests, including handgrip strength and the five times sit-to-stand test. Our main finding is that SARC-F significantly underperformed, missing all true positive cases and showing low sensitivity. In contrast, functional tests detected more patients at risk and proved more reliable. This indicates that SARC-F should not be used alone in cirrhotic patients. Functional assessments provide better guidance and should be integrated into clinical screening protocols.

INTRODUCTION

Cirrhosis is a chronic condition characterized by progressive liver injury, inflammation, and irreversible fibrosis, leading to impaired hepatic function. The liver plays a central role in metabolism, detoxification, bile production, vitamin storage, and hormonal regulation, among other vital processes[1].

Malnutrition is a frequent and clinically relevant complication in cirrhosis. It contributes to increased morbidity and mortality and requires early nutritional and therapeutic management[2,3]. Sarcopenia, the most prevalent phenotypic manifestation of malnutrition in cirrhotic patients, is characterized by reduced muscle mass and/or strength and is recognized as an independent prognostic marker in this population[4].

Despite its importance, the diagnosis of sarcopenia in cirrhosis remains challenging. Gold-standard methods, such as imaging or bioimpedance analysis (BIA), are often expensive or time-consuming. In addition, their accuracy may be affected by common complications in cirrhotic patients, such as ascites and fluid retention, limiting their clinical applicability[5]. Therefore, there is a need for simple, low-cost, and reliable screening tools that can be implemented in routine care and public health settings.

The strength, assistance with walking, rise from a chair, climb stairs, and falls questionnaire (SARC-F) has been proposed as an accessible alternative for sarcopenia screening[6-8]. However, its performance in patients with hepatic cirrhosis remains unclear, and validation studies in this specific context are scarce.

Thus, this study aimed to evaluate the accuracy of the SARC-F questionnaire as an indirect predictor of sarcopenia risk in cirrhotic patients, contributing to the understanding of its clinical utility in this population.

MATERIALS AND METHODS

Design

This was a cross-sectional prospective study, conducted in accordance with the STROBE recommendations[7].

Population and sample

Patients diagnosed with hepatic cirrhosis undergoing clinical treatment at the Gastroenterology Outpatient Clinic of the Hospital Complex of the Irmandade Santa Casa de Misericórdia de Porto Alegre were evaluated. The sample included 45 patients, recruited by convenience, from March 2024 to February 2025. Patients were informed about the study during their nutritional consultation. Those who agreed to participate signed the informed consent form.

As this is a pilot study, no formal sample size calculation was performed. A convenience sample including all eligible patients followed at the outpatient clinic during the recruitment period was used, based on inclusion/exclusion criteria.

Inclusion criteria: Patients were included in the study based on clinical and laboratory criteria for cirrhosis, regardless of etiology, aged over 18 years, and of both sexes. Participants with sufficient psychological and cognitive conditions to participate in a scientific study were also included.

Exclusion criteria: Patients were excluded if they had any amputation interfering with body symmetry, were on enteral feeding, had chronic kidney failure, chronic pancreatitis, chronic diarrhea, or were human immunodeficiency virus positive. Patients with intestinal diseases leading to malabsorption, those participating in dietary programs for weight gain, with pacemakers or any metal implants, or with neuromuscular alterations in the upper limbs were not included in the study.

Anthropometric data

Weight was measured using a scale with 0.1 kg precision (Filizola, Brazil), and height using a stadiometer with 0.01 m precision (Cescorf, Brazil), with the patient standing, barefoot, and wearing minimal clothing. Weight and height were used to calculate the body mass index (BMI). Cut-off points followed World Health Organization recommendations: BMI < 18.5 normal weight; 18.6-29.9 overweight; > 30 obesity.

Phase angle

Phase angle (PA) was obtained through resistance and reactance values. Prognostic classification was based on previously defined cut-off points[5] by BIA.

Sarcopenia risk screening

Sarcopenia risk screening was conducted using the SARC-F tool in its translated and validated Portuguese version[6]. The SARC-F questionnaire was applied using the original scoring system, proposed by European working group on sarcopenia in older people 2 (EWGSOP2), with a total score ≥ 4 considered indicative of risk for sarcopenia, as previously validated. No adaptations or modifications were made for this study.

Handgrip strength assessment: To assess handgrip strength (HGS), the cut-off points proposed by the EWGSOP2 guidelines according to sex were used (men: < 27 kg/f; women: < 16 kg/f)[8].

Five times sit-to-stand test: To assess functionality, the five times sit-to-stand test (5xSTS) was used. The cut-off point was 15 seconds[8]. All assessments were conducted by trained team professionals.

Ethical aspects

The study was reviewed and approved by the Research Ethics Committee of the Irmandade Santa Casa de Misericórdia de Porto Alegre (No. 6.637.252). Volunteers read and signed the informed consent form. The entire study was conducted in accordance with resolution 196/96 of the National Health Council (Brazil) and the principles of the Declaration of Helsinki for research involving human beings. Data were processed in accordance with the General Data Protection Law.

Statistical analysis

Means and standard deviations were used for continuous variables, and absolute and relative values for categorical variables. For comparisons of mean SARC-F scores and BIA, PA, HGS, and 5xSTS according to sociodemographic, clinical variables, and sarcopenia phenotype, the Student’s t-test was used for simple comparisons between genders. Sensitivity and specificity analyses, positive and negative predictive values, were performed using receiver operating characteristic curve analysis. Given the small sample size, the study may be underpowered to detect smaller differences, and the findings should be interpreted with caution. Data analysis was conducted using SPSS Statistics (v.22, SPSS, IBM Company, Chicago, IL, United States), with a significance level of 5% (P < 0.05) for all tests.

RESULTS

Table 1 presents the general sample data, categorized by sex. The comparison between sarcopenia screening methods and their diagnostic performance is presented in Tables 2 and 3. The sample consisted of 45 patients, with a slight male majority. The average age was 61 years. There were no statistically significant differences between sexes.

Table 1 Sample characteristics, n (%)/mean ± SD.

Continuous variables	Total sample	Women	Men	P value
	n = 45 (100%)	n = 22 (48.9%)	n = 23 (51.1%)
Age (years)	61.09 ± 8.77	62.09 ± 9.13	60.1 3 ± 8.51	0.460
SARC-F (points)	1.89 ± 2.08	2.23 ± 2.27	1.57 ± 1.88	0.291
Handgrip strength (kg)	31.60 ± 15.12	25.45 ±13.04	37.48 ± 14.87	0.006
5x sit-to-stand test (second)	17.05 ± 6.87	16.30 ± 4.62	17.76 ± 8.55	0.482
Weight (kg)	81.31 ± 15.54	76.49 ± 13.30	85.92 ± 16.39	0.040
Height (m)	1.65 ± 0.08	1.60 ± 0.06	1.71 ± 0.07	< 0.001
BMI (kg/m²)	29.75 ± 5.29	29.95 ± 4.82	29.55 ± 5.81	0.805
Phase angle	5.46 ± 1.83	5.07 ± 2.06	5.82 ± 1.56	0.323
Categoric variables
Screening by SARC-F¹	8 (17.8)	4 (18.2)	4 (17.4)	0.893
Screening by JAMAR¹	15 (33.3)	8 (36.4)	7 (30.4)	0.419
Screening by TSL¹	21 (46.7)	11 (50)	10 (43.5)	0.550
SARC-F 1: Strength				0.354
Able	32 (71.1)	14 (63.6)	18 (78.3)
Partially unable/some difficulty	9 (20)	6 (27.3)	3 (13)
Unable/severe difficulty	4 (8.9)	2 (9.1)	2 (8.7)
SARC-F 2: Assisted walking				0.495
Able	39 (86.7)	19 (86.4)	20 (87)
Partially unable/some difficulty	5 (11.1)	3 (13.6)	2 (8.7)
Unable/severe difficulty	1 (2.2)	0 (-)	1 (4.3)
SARC-F 3: Rise from a chair				0.418
Able	27 (60)	11 (50)	16 (69.6)
Partially unable/some difficulty	16 (35.6)	10 (45.5)	6 (26.1)
Unable/severe difficulty	2 (4.4)	1 (4.5)	1 (4.3)
SARC-F 4: Climbing stairs				0.841
Able	22 (48.9)	8 (36.4)	14 (60.9)
Partially unable/some difficulty	18 (40)	11 (50)	7 (30.4)
Unable/severe difficulty	5 (11.1)	3 (13.6)	2 (8.7)
SARC-F 5: Falls				0.514
None	37 (82.2)	18 (81.8)	19 (82.6)
1-3	3 (6.7)	1 (4.5)	2 (8.7)
> 3	5 (11.1)	3 (13.6)	2 (8.7)

¹Screening was performed in patients with suspected sarcopenia, defined as those below the cutoff points for the indicators according to the European working group on sarcopenia in older people 2. In cross-tabulations, strength, assistance with walking, rising from a chair, climbing stairs and falls showed no true positives when compared with handgrip strength (HGS) and five-times sit-to-stand test (5xSTS). The proportion of true negatives was 48% for HGS and 35% for 5xSTS.

BMI: Body mass index; SARC-F: Strength, assistance with walking, rising from a chair, climbing stairs and falls; JAMAR: Jamar dynamometer; TSL: Total skeletal lean mass.

Table 2 Cross tables comparing strength, assistance with walking, rising from a chair, climbing stairs and falls with other tools for screening sarcopenia in cirrhotic patients, n (%).

Crossing SARC-F and HGS		Screening HGS1
		Negative	Positive
Screening SARC-F1	Negative	22 (48.5)	15 (33.3)
	Positive	8 (17.2)	0 (-)
Answers
Sensibility (%)		73.3
Specificity (%)		0
PPV (%)		59.5
NPV (%)		0

¹The screening is referred to patients with suspected sarcopenia, it means, those below the cutoff points for the indicators, according to European working group on sarcopenia in older people 2.

SARC-F: Strength, assistance with walking, rising from a chair, climbing stairs and falls; PPV: Positive predictive value; NPV: Negative predictive value; HGS: Handgrip strength.

Table 3 Cross tables comparing strength, assistance with walking, rising from a chair, climbing stairs and falls with other tools for screening sarcopenia in cirrhotic patients, n (%).

Crossing SARC-F and 5xSTS		Screening 5xSTS
		Negative	Positive
Screening SARC-F	Negative	16 (35.6)	21 (46.7)
	Positive	8 (17.2)	0 (-)
Answers
Sensibility (%)		66.7
Specificity (%)		0
PPV (%)		43.2
NPV (%)		0

The screening is referred to patients with suspected sarcopenia, it means, those below the cutoff points for the indicators, according to European working group on sarcopenia in older people 2. SARC-F: Strength, assistance with walking, rising from a chair, climbing stairs and falls; PPV: Positive predictive value; NPV: Negative predictive value; 5xSTS: Five-times sit-to-stand test.

According to the SARC-F assessment, eight patients (four men and four women) were suspected of having sarcopenia. Based on HGS, 15 patients met the criteria for probable sarcopenia, while 21 did so according to the 5xSTS (Table 2).

In the cross-tabulations, SARC-F showed no true positives when compared with HGS and 5xSTS. The proportion of true negatives was 48% for HGS and 35% for 5xSTS (Table 3).

DISCUSSION

This pilot study demonstrates that SARC-F has low sensitivity for detecting sarcopenia in cirrhotic patients. Although widely used for its simplicity and low cost, SARC-F showed poor performance in this sample for identifying or excluding sarcopenia. HGS and sit-to-stand tests, considered more robust by EWGSOP2, performed better.

In this sample, none of the patients identified as having sarcopenia by objective measures (HGS or 5xSTS) were flagged as at risk by SARC-F. This finding indicates limited sensitivity for early detection in cirrhotic patients. It does not suggest a general ineffectiveness of the tool in other populations.

The SARC-F questionnaire was developed as a simple and easy-to-administer tool for clinical sarcopenia screening, based on self-reported functional limitations. Its main purpose is to identify individuals at increased risk of sarcopenia who should undergo more detailed diagnostic evaluations[8]. It covers five domains: Muscle strength, walking assistance, rising from a chair, stair climbing, and recurrent falls. To improve its sensitivity, modifications have been proposed, such as combining SARC-F with calf circumference measurements (SARC-CalF) or other anthropometric data. These adaptations have shown greater diagnostic accuracy and sensitivity[6].

However, in this study sample, the SARC-CalF was not used, as calf circumference is not appropriate for patients with cirrhosis. This is due to the fact that these patients often present anthropometric changes, such as lower limb edema, which may lead to underestimation of muscle mass and compromise assessment accuracy[9,10].

A cross-sectional study conducted in Brazil, with a sample similar to the present study, identified low muscle strength in 91.1% of patients using the sit-to-stand test, while HGS detected only 15.6%. These results indicate that the sit-to-stand test is a more effective sarcopenia screening tool than dynamometry, revealing almost six times more cases of reduced strength[11]. The sit-to-stand test stood out as a highly effective screening tool for identifying probable sarcopenia, as it detected the highest number of individuals with low muscle strength. Due to its ease of use-requiring only a chair and a stopwatch-it is more accessible than HGS and can be used in various healthcare settings[12].

According to Nishikawa et al[13], a retrospective study with 1624 patients with chronic liver disease revealed that 33.5% had muscle weakness and 13.9% had sarcopenia, with reduced HGS being an independent predictor of mortality. These findings align with those of a cross-sectional study with 64 cirrhotic patients, which showed that between 35.9% and 51.6% had reduced HGS, depending on the adopted cut-off. Additionally, strength reduction was associated with higher MELD scores, indicating a possible correlation with worse clinical outcomes[14].

A cross-sectional and prospective study found that patients with sarcopenia had significantly lower HGS (19.57 kg vs 30.55 kg) and PA (4.18° vs 5.39°) compared to non-sarcopenic patients. Moreover, PA values equal to or below 5.05° showed high sensitivity for identifying sarcopenia, indicating its potential as a clinical and prognostic marker in men with cirrhosis[15], corroborating the present study in which the PA was 5.4°.

The low mean PA (5.4°) observed in this cohort reflects reduced cellular integrity and correlates with the high prevalence of sarcopenia risk, supporting its potential as a clinical marker in cirrhotic patients[15].

It is important to note, however, that the limitation of SARC-F seems to be specific to the cirrhotic population, and not a reflection of its general inefficacy as a screening tool. A study that investigated the presence of sarcopenia in hospitalized adults and older people with various chronic diseases showed that sarcopenia risk was identified in approximately one-third of patients[6,9], both by SARC-F (41.1%) and SARC-CalF (31.1%). These findings indicate that, in non-cirrhotic populations, SARC-F and its modified version proved to be effective tools for sarcopenia screening.

This difference in performance may be explained by distinct pathophysiological characteristics among populations. In aging, loss of muscle strength is commonly associated with reduced ability to perform activities of daily living (ADLs), making SARC-F suitable for capturing these self-reported limitations[4,8]. On the other hand, in patients with hepatic cirrhosis, strength loss is often a direct effect of liver dysfunction, with a greater impact on strength and muscle power production, but not always reflected in ADLs[2,3]. This dissociation reduces SARC-F sensitivity for early sarcopenia detection in this population and suggests the need for adapted or complementary screening tools.

Despite the small sample size and cross-sectional design, which limit generalizability, the study consistently demonstrated the poor performance of SARC-F, especially when compared to functional tests such as HGS and sit-to-stand, which showed greater sensitivity. Future studies should consider longitudinal designs and more representative samples. Additionally, research exploring adaptations of SARC-F or the development of specific scales for patients with hepatic cirrhosis may offer more sensitive and appropriate alternatives for the particularities of this condition.

CONCLUSION

This pilot study contributes to understanding the limitations of SARC-F in patients with cirrhosis. Although simple and low-cost, SARC-F showed low accuracy as an indirect predictor of sarcopenia. The unique pathophysiology of cirrhotic patients, including ascites, chronic inflammation, and altered body composition, may affect self-reported functional perception. This reduces the reliability of the questionnaire and highlights the need for caution when it is used alone.

Compared to functional tests, such as the 5xSTS and HGS, higher sensitivity and clinical applicability were observed, with some differences according to sex. These findings indicate that more appropriate screening protocols should combine complementary instruments. Additionally, multicenter studies with larger samples are needed to validate sarcopenia screening strategies in cirrhotic patients.