Experimental Gerontology 152 (2021) 111448

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Experimental Gerontology
journal homepage: www.elsevier.com/locate/expgero

Assessment of functional sit-to-stand muscle power: Cross-sectional

trajectories across the lifespan
Julian Alcazar a, b, c, Per Aagaard d, Bryan Haddock e, Rikke S. Kamper c, Sofie K. Hansen c,
Eva Prescott f, g, Ignacio Ara a, b, Luis M. Alegre a, b, Ulrik Frandsen d, Charlotte Suetta c, e, h, *
a
GENUD Toledo Research Group, Universidad de Castilla-La Mancha, Toledo, Spain
b
CIBER of Frailty and Healthy Aging (CIBERFES), Madrid, Spain
c
Geriatric Research Unit, Geriatric Department, Bispebjerg University Hospital, Copenhagen, Denmark
d
Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
e
Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet-Glostrup University Hospital, Copenhagen, Denmark
f
Department of Cardiology, Bispebjerg-Frederiksberg University Hospital, Copenhagen, Denmark
g
Copenhagen City Heart Study, Frederiksberg University Hospital, Copenhagen, Denmark
h
Geriatric Research Unit, Department of Internal Medicine, Herlev-Gentofte University Hospital, Copenhagen, Denmark

A R T I C L E I N F O A B S T R A C T

Section Editor: Li-Ning Peng Background: The 30-s sit-to-stand (STS) muscle power test is a valid test to assess muscle power in older people;
however, whether it may be used to assess trajectories of lower-limb muscle power through the adult lifespan is
Keywords: not known. This study evaluated the pattern and time course of variations in relative, allometric and specific STS
Chair rising muscle power throughout the lifespan.
Chair stand
Methods: Subjects participating in the Copenhagen Sarcopenia Study (729 women and 576 men; aged 20 to
Leg extension power
93 years) were included. Lower-limb muscle power was assessed with the 30-s version of the STS muscle power
Sarcopenia
Functional capacity test. Allometric, relative and specific STS power were calculated as absolute STS power normalized to height
squared, body mass and leg lean mass as assessed by DXA, respectively.
Results: Relative STS muscle power tended to increase in women (0.08 ± 0.05 W⋅kg− 1⋅yr− 1; p = 0.082) and
increased in men (0.14 ± 0.07 W⋅kg− 1⋅yr− 1; p = 0.046) between 20 and 30 years, followed by a slow decline
(− 0.05 ± 0.05 W⋅kg− 1⋅yr− 1 and − 0.06 ± 0.08 W⋅kg− 1⋅yr− 1, respectively; both p > 0.05) between 30 and
50 years. Then, relative STS power declined at an accelerated rate up to oldest age in men
(− 0.09 ± 0.02 W⋅kg− 1⋅yr− 1) and in women until the age of 75 (− 0.09 ± 0.01 W⋅kg− 1⋅yr− 1) (both p < 0.001). A
lower rate of decline was observed in women aged 75 and older (− 0.04 ± 0.02 W⋅kg− 1⋅yr− 1; p = 0.039). Similar
age-related patterns were noted for allometric and specific STS power.
Conclusions: The STS muscle power test appears to provide a feasible and inexpensive tool to monitor cross-
sectional trajectories of muscle power throughout the lifespan.

1. Introduction structure and/or function (WHO, 2013). Specifically, lower-limb skel­

The amount of people ≥70 years old experiencing limitations in
various activities of daily living has recently increased (Lin et al., 2012).
Mobility limitations have been found to predict future disability in ac­
tivities of daily living independently of morbidity and cognitive status
among older people (Heiland et al., 2016). Even in mid-life, when the
prevalence of disability is relatively low, mobility limitations have been
found to predict the incidence of disability at old age (Dodds et al.,
2018). Mobility limitations can be caused by an impairment in a body
etal muscle power has been demonstrated to be one of the strongest
contributors to mobility limitations among older individuals (Bean et al.,
2003; Foldvari et al., 2000; Martinikorena et al., 2016). A decrease of
one standard deviation in maximal muscle power has been associated to
a 27–42% increased likelihood of disability among older people (Kuo
et al., 2006). In this sense, lower-limb relative muscle power (i.e. ab­
solute muscle power normalized to body mass) has proven more rele­
vant for physical performance than muscle power per se (Alcazar et al.,
2018a; Alcazar et al., 2018b; Skelton et al., 1994), since several

* Corresponding author at: Geriatric Research Unit, Geriatric Department Bispebjerg/Frederiksberg & Herlev/Gentofte Hospitals, Denmark.
E-mail address: charlotte.suetta@regionh.dk (C. Suetta).

https://doi.org/10.1016/j.exger.2021.111448
Received 13 December 2020; Received in revised form 11 May 2021; Accepted 7 June 2021
Available online 9 June 2021
0531-5565/© 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
J. Alcazar et al.
activities of daily living involve weight-bearing locomotion. Notably,
the decline in maximal muscle power is known to occur earlier and at a
faster rate during aging compared to the decline rates observed in
muscle size and strength (De Vito et al., 1998; Lauretani et al., 2003;
Macaluso and De Vito, 2003; Reid et al., 2014; Runge et al., 2004;
Siglinsky et al., 2015; Skelton et al., 1994). Consequently, regular
routine monitoring of relative muscle power with aging or during other
disease- (Pring et al., 2018) or disuse-related (Suetta and Kjaer, 2010)
situations associated with muscle power loss have been strongly rec­
ommended in the daily clinical practice (Alcazar et al., 2020a).
Traditional protocols and specific instruments to assess muscle
power (Alcazar et al., 2017; Bassey and Short, 1990; Edwen et al., 2014)
can be relatively expensive, difficult to transport, and typically require
periodic calibration or other technical issues. Overcoming these poten­
tial barriers, the sit-to-stand (STS) muscle power test (Alcazar et al.,
2020b, 2018a) has recently been proposed as a rapid, inexpensive,
reliable and feasible procedure to assess lower limb skeletal muscle
power in older people. The traditional STS test (Csuka and McCarty,
1985) is a functional performance measure that involves either
recording the time taken to stand and sit from a seated position for a
certain number of times or recording the number of repetitions per­
formed in a given time period. The STS muscle power test uses a simple
equation to calculate muscle power from either the time- (Alcazar et al.,
2018a) or the repetition-based (Alcazar et al., 2020b) measure obtained
from the traditional STS test. The STS muscle power test has been
thoroughly validated against other previously accepted instruments to
assess muscle power, such as a linear position transducer (Alcazar et al.,
2018a), a force plate (Baltasar-Fernandez et al., 2021) and the Not­
tingham power rig (Alcazar et al., 2020b). A previous study found STS
muscle power to be more strongly associated with physical function than
time-based STS performance (Alcazar et al., 2018a), repetition-based
STS performance, handgrip strength and leg extension power (Alcazar
et al., 2020b). However, no previous studies have assessed the ability of
STS muscle power assessment to monitor changes in lower limb muscle
power throughout the adult lifespan. As the STS muscle power test is
easier to implement in a clinical setting compared to leg extension
power assessed by the Nottingham power rig, the present study inves­
tigated whether the STS muscle power test provides similar muscle
power cross-sectional trajectories compared to previously used and
validated procedures (e.g. Nottingham power rig (Alcazar et al.,
2020b)). In addition, the identification of the specific age at which STS
muscle power starts to decline and whether it declines at different rates
during distinct periods in life would be of interest. Therefore, the present
study aimed to evaluate the pattern and time course of changes in
relative, allometric and specific STS muscle power throughout the adult
lifespan.
2. Material and methods
2.1. Study cohort
The Copenhagen Sarcopenia Study (Suetta et al., 2019) is a population-
based cross-sectional study conducted between 2013 and 2016, whose
participants were recruited from a random sample of 20,000 men and
women (aged 20 to 101 years) taking part in the Copenhagen City Heart
Study (Aguib and Al Suwaidi, 2015). Subjects from this cohort were
invited to participate in the present investigation using the following
exclusion criteria: pregnancy, acute medical illness, surgery within the
last three months, ongoing medication known to affect body composi­
tion, and any history of compromised ambulation or prolonged immo­
bilization. A total of 1305 subjects (729 women and 576 men; aged 20 to
93 years) accepted to participate in the present investigation. Other
aspects of muscle power and muscle strength from the same cohort have
previously been published (Alcazar et al., 2020a; Alcazar et al., 2020b;
Suetta et al., 2019). All subjects gave their written informed consent.
The study was performed in accordance with the Helsinki Declaration
2
Experimental Gerontology 152 (2021) 111448
and approved by the Ethical Committee of Copenhagen (H-3-2013-124).
2.2. Body composition
A stadiometer and scale device were used to record the height and
body mass of the participants without shoes and while wearing light
clothing. Height (m) was assessed to the nearest 0.1 cm and body mass
(kg) to the nearest 0.1 kg. Body mass index (BMI) was obtained from the
ratio between weight and height squared (kg⋅m− 2). Leg lean mass was
assessed by dual energy X-ray absorptiometry (iDXA, GE Lunar, Madi­
son, USA) and analyzed using commercially available software (Encore
software version 16.0). Due to the variation in lean mass is highly
influenced by body size, leg skeletal muscle index (SMI) was derived as
the ratio between leg lean mass and height squared (kg⋅m− 2).
2.3. Sit-to-stand testing
The 30-s STS test involves recording the number of STS repetitions
performed by the subjects in 30 s. After the cue “ready, set, go!”, par­
ticipants started to perform STS repetitions as rapidly as possible on a
standardized armless chair (0.45 m seat height) from the sitting position
with their buttocks touching the chair to the full standing position, and
with their arms crossed over the chest. A stopwatch was started simul­
taneously with the “go!” cue and it was stopped when the 30-s time limit
was reached. The total number of completed STS maneuvers during the
30-s period was recorded. Strong standardized verbal encouragement
was given throughout the test. The subjects were allowed to try 1–2
times with an adequate resting period (30–60 s) before the definitive
STS test was annotated. As described in detail elsewhere (Alcazar et al.,
2018a) (Alcazar et al., 2020b), STS mean muscle power (W) was
calculated through Eq. (1):
Body mass × 0.9 × g × [Height × 0.5 − Chair height]
[ ]
STS mean power =
Time
× 0.5
n of reps
(1)
where body mass is indicated in kg, body height and chair height in m,
and time in s (in the case of the current study 30 s). Briefly, 0.9 is a
coefficient to calculate the proportion of body mass that is lifted during
the STS maneuver, 0.5 in the numerator is a coefficient to calculate leg
length and 0.5 in the denominator is a coefficient to calculate the
duration of the concentric phase of one STS repetition. Then, allometric
STS power (W⋅m− 2) was calculated as the ratio of absolute STS power
and height squared; relative STS power (W⋅kg− 1) was calculated as the
ratio between allometric STS power and BMI; and specific STS power
(W⋅kg− 1) was calculated as the ratio between allometric STS power and
leg SMI.
2.4. Statistical analysis
Data are presented as mean ± standard deviation (SD) unless
otherwise stated for men and women separately. Two-way ANOVA with
two fixed effects (sex; and age group: 20–29, 30–39, 40–49, 50–59,
60–64, 65–69, 70–74, 75–79, 80–84 and ≥85 years). A Bonferroni’s
correction for multiple comparisons was applied. For comparisons, the
age group showing the highest power values was used as the reference
group. The association between age and the different study variables (i.
e. relative, allometric and specific STS muscle power) was assessed by
regression analyses. Firstly, linear, quadratic and cubic regression
models were compared based on the coefficient of determination (R2)
change in order to determine the most suitable regression model for each
study variable. A more complex model (i.e. quadratic or cubic) was
preferred over a simpler model (i.e. linear) when the change in the F-
value was significant. In all cases, curvilinear (i.e. quadratic or cubic)
regression models were significantly superior to linear regression
J. Alcazar et al. Experimental Gerontology 152 (2021) 111448

models. Then, segmented (piecewise) regression analyses were per­
formed to determine whether and at what boundary ages a change in the
slope (i.e. rate of change) of the relationship between age and the study
variables occurred. Using an iterative approach several age points were
evaluated (30, 35, 40, 45, 50, 55, 60, 65, 70, 75 and 80 years) at
different age intervals (20–45, 20–50, 25–55, 30–60, 35–65, 40–70,
45–75, 50–80, 55–85, 60–90 and 65–95 years, respectively). Subse­
quently, a single regression model was created for each study variable
considering the age points at which a statistically significant change in
slope was observed. Finally, R2 and standard error of the estimate values
obtained from the piecewise regression analysis were compared with
those obtained from the respective quadratic and cubic regression
models. No significant differences were observed between segmented
and quadratic or cubic fits, while higher R2 and lower standard error of
the estimate values were found for the piecewise compared with the
quadratic and cubic regression models, so only segmented regression
models are reported in the present study. The slopes obtained from the
regression analyses represent the annual rate of change for the different
study variables. These slopes were also reported for each 5-year age
interval relative to the average value at the beginning of the corre­
sponding 5-year age interval. Differences in regression slopes between
women and men were evaluated by comparison of 95% confidence in­
tervals. In addition, the association between age and relative STS power
observed in the present study was compared to that previously reported
between age and relative leg extension power (Nottingham power rig) in
the same participants (Alcazar et al., 2020a) using linear mixed effects
models. Statistical analyses were performed using SPSS v20 (SPSS Inc.,
Chicago, Illinois), and the level of significance was set at α = 0.05 using
two-tailed testing.
3. Results
The main anthropometric characteristics of the study participants
are showed in Table 1. There were main effects of sex and age for
allometric relative, allometric and specific power values (all p < 0.001).
No significant sex-by-age interactions were noted (all p > 0.05). Spe­
cifically, lower levels of STS muscle power (relative, allometric and
specific) were observed above the age of 50 in both women and men
compared with the young reference groups (30–39 years) (all p < 0.05)
(Table 2). In addition, men showed higher values of allometric and
relative STS muscle power than women at all age groups (all p < 0.001).
In contrast, while specific STS muscle power differed between women
and men aged 40–80 years (all p < 0.01), no sex differences were
observed between 20 and 40 years nor above 80 years (all p > 0.05).
3.1. Changes in allometric STS muscle power with age
Allometric STS power increased among women between 20 and
30 years (3.7 ± 1.2 W⋅m− 2 per year; p = 0.003), followed by a non-
significant decrease between 30 and 55 years (− 1.0 ± 1.4 W⋅m− 2 per
year; p > 0.05), then decreasing between 55 and 80 years
(− 2.2 ± 0.3 W⋅m− 2 per year; p < 0.001), followed by a non-significant
decrease from 80 years to oldest age (− 1.1 ± 0.8 W⋅m− 2 per year;
p > 0.05) (Fig. 1A). Likewise, male participants exhibited an increase
between 20 and 30 years (4.8 ± 2.0 W⋅m− 2 per year; p = 0.015), fol­
lowed by a non-significant decrease between 30 and 55 years
(− 1.1 ± 2.2 W⋅m− 2 per year; p > 0.05), which converged into a decline
from 55 years to oldest age (− 2.8 ± 0.4 W⋅m− 2 per year; p < 0.001)
(Fig. 1B).
3.2. Changes in relative STS muscle power with age
Women showed a trend for an increase in relative STS power during
the 20–30 age interval (0.09 ± 0.05 W⋅kg− 1 per year; p = 0.085) fol­
lowed by a non-significant decline between 30 and 55 years
(− 0.06 ± 0.06 W⋅kg− 1 per year; p > 0.05) (Fig. 1C). From 55 years and
above a gradually decreasing rate of decline was noted into oldest age
(− 0.10 ± 0.02 W⋅kg− 1 per year up to the age of 75 and
− 0.05 ± 0.02 W⋅kg− 1 per year into oldest age; both p < 0.05). Men
experienced an increase in relative STS power between 20 and 30 years
(0.16 ± 0.08 W⋅kg− 1 per year; p = 0.041), followed by a non-significant
decrease between 30 and 50 years (− 0.06 ± 0.09 W⋅kg− 1 per year;
p > 0.05), which converged into a statistically significant decline from
50 years and into oldest age (− 0.10 ± 0.02 W⋅kg− 1 per year; p < 0.001)
(Fig. 1D).
3.3. Changes in specific STS muscle power with age
Specific STS power increased in women from 20 to 30 years
(0.42 ± 0.22 W⋅kg− 1 per year; p = 0.049), followed by no change from
30 to 55 years (− 0.19 ± 0.24 W⋅kg− 1 per year; p > 0.05), decreasing
from 55 to 80 years (− 0.41 ± 0.06 W⋅kg− 1 per year; p < 0.001), and a
non-significant decrease from 80 years to oldest age
(− 0.13 ± 0.15 W⋅kg− 1 per year; p > 0.05) (Fig. 1E). Among men, specific
STS power tended to increase between 20 and 30 years
(0.55 ± 0.32 W⋅kg− 1 per year; p = 0.081), while remaining constant
between 30 and 50 years (− 0.13 ± 0.35 W⋅kg− 1 per year; p > 0.05), and
demonstrating a decline above the age of 50 into oldest age
(− 0.35 ± 0.07 W⋅kg− 1 per year; p < 0.001) (Fig. 1F).
Annual rates of change (expressed % per year) in allometric, relative
and specific STS muscle power are reported in Table 3.
3.4. Comparison of cross-sectional trajectories of relative STS power and
relative leg extension power throughout the adult lifespan
There were no significant differences between trajectories of relative
power observed with aging when assessed with the STS muscle power
test vs. the Nottingham power rig in women and men (both p > 0.05)
(Fig. 2).

Table 1
Main anthropometric characteristics of the participants (mean ± standard deviation).
Age Women Men
− 2
n Body mass (kg) Height (m) BMI (kg⋅m ) n Body mass (kg) Height (m) BMI (kg⋅m− 2)

20–29 y 98 62.9 ± 8.0 1.68 ± 0.07 22.3 ± 2.6 59 82.1 ± 10.9 1.85 ± 0.07 24.1 ± 2.7
30–39 y 74 66.2 ± 11.3 1.69 ± 0.07 23.3 ± 3.6 51 84.0 ± 14.0 1.81 ± 0.05 25.6 ± 4.0
40–49 y 96 68.7 ± 11.3 1.68 ± 0.05 24.3 ± 4.1 83 82.9 ± 10.3 1.83 ± 0.06 24.9 ± 2.9
50–59 y 109 70.8 ± 13.2 1.68 ± 0.07 25.2 ± 4.8 96 85.6 ± 13.1 1.80 ± 0.07 26.6 ± 4.0
60–64 y 56 69.0 ± 10.6 1.66 ± 0.06 25.2 ± 4.1 56 87.8 ± 12.1 1.80 ± 0.07 27.1 ± 3.2
65–69 y 74 70.9 ± 12.4 1.64 ± 0.07 26.3 ± 4.8 62 88.8 ± 17.3 1.79 ± 0.06 27.7 ± 4.7
70–74 y 72 68.5 ± 12.0 1.64 ± 0.06 25.6 ± 4.7 55 84.4 ± 13.0 1.77 ± 0.06 26.9 ± 4.1
75–79 y 79 68.4 ± 11.9 1.63 ± 0.06 25.8 ± 4.4 72 80.5 ± 14.5 1.76 ± 0.07 25.8 ± 4.3
80–84 y 35 64.8 ± 12.3 1.61 ± 0.05 24.9 ± 4.3 26 78.1 ± 9.9 1.75 ± 0.06 25.4 ± 2.9
≥ 85 y 36 60.1 ± 9.3 1.59 ± 0.08 23.8 ± 3.2 16 73.9 ± 11.3 1.73 ± 0.09 24.7 ± 3.3

BMI, body mass index; y, years.

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J. Alcazar et al. Experimental Gerontology 152 (2021) 111448

Table 2
Sit-to-stand muscle power measures for women and men by different age groups (displayed as mean ± standard deviation).
Age (n) Allometric STS power Relative STS power Specific STS power
(W⋅m− 2) (W⋅kg− 1) (W⋅kg− 1)

Women
20–29 y (98) 136.5 ± 34.0 6.20 ± 1.40 27.6 ± 5.9
30–39 y (74) 146.3 ± 37.3 6.30 ± 1.45 28.5 ± 6.0
40–49 y (96) 135.9 ± 34.0 5.64 ± 1.43 26.0 ± 5.9
50–59 y (109) 125.0 ± 34.7* 5.06 ± 1.45* 24.3 ± 6.3*
60–64 y (56) 104.7 ± 30.7* 4.24 ± 1.33* 20.7 ± 6.1*
65–69 y (74) 101.0 ± 28.9* 3.96 ± 1.29* 20.2 ± 5.4*
70–74 y (72) 89.9 ± 26.8* 3.54 ± 0.99* 18.1 ± 4.8*
75–79 y (79) 74.8 ± 19.3* 2.93 ± 0.72* 15.3 ± 3.4*
80–84 y (35) 69.2 ± 19.4* 2.79 ± 0.69* 14.5 ± 3.4*
≥ 85 y (36) 59.7 ± 17.3* 2.49 ± 0.59* 13.0 ± 3.0*
ANOVA p < 0.001 p < 0.001 p < 0.001

Men
20–29 y (59) 173.4 ± 38.1 7.30 ± 1.49 28.5 ± 5.5
30–39 y (51) 191.9 ± 43.4 7.55 ± 1.47 29.9 ± 5.7
40–49 y (83) 176.6 ± 36.7 7.12 ± 1.36 28.7 ± 5.0
50–59 y (96) 160.6 ± 40.9* 6.12 ± 1.55* 25.8 ± 6.7*
60–64 y (56) 138.7 ± 44.8* 5.16 ± 1.60* 22.7 ± 7.0*
65–69 y (62) 135.6 ± 39.4* 5.00 ± 1.60* 22.1 ± 6.6*
70–74 y (55) 117.8 ± 33.4* 4.43 ± 1.31* 20.5 ± 5.4*
75–79 y (72) 103.0 ± 32.3* 4.01 ± 1.22* 18.3 ± 5.0*
80–84 y (26) 90.2 ± 30.3* 3.55 ± 1.15* 16.2 ± 5.3*
≥ 85 y (16) 75.9 ± 27.2* 3.09 ± 1.13* 14.6 ± 4.1*
ANOVA p < 0.001 p < 0.001 p < 0.001

STS, sit-to-stand; y, years.

*
Statistically significant differences compared to the sex-specific reference group (bold) (p < 0.05).

4. Discussion
As one of the main findings of the present investigation, women and
men above the age of 50 demonstrated decreased levels of allometric,
relative and specific STS power when compared to their young reference
groups. The reduced STS power values were due to a steady decline
noted in all participants above 30 years that was accentuated after the
fifth decade of life in both women and men. Notably however, women,
but not men, exhibited a lower loss in STS muscle power after their
eighth decade of life. Also representing a main study finding, the relative
(percentage) decline rate in STS muscle power was generally found to
increase with age.
Though literature on the subject is sparse, changes in STS muscle
power with age has been studied using linear position transducer
methodology (Glenn et al., 2017) and force platform analysis (Dietzel
et al., 2013; Roberts et al., 2018; Zech et al., 2011). Absolute and relative
STS power have previously been reported to decline with age (Dietzel
et al., 2013; Glenn et al., 2017; Roberts et al., 2018), although with some
differences regarding the age interval at which decreased STS power
measures are detected. These discrepancies among studies are likely due
to different criteria for dividing the sample into separate age groups
and/or affected by low numbers of subjects included in specific age
intervals.
Nevertheless, the comparison between age groups does not provide
precise information about the onset of the decline in STS power nor on
the existence of critical periods in life in which STS power declines at an
accelerated rate. Dietzel et al. (2013) reported that STS muscle power
assessed with a force platform declines with age in a curvilinear fashion
at an increased rate of decline with advancing age. We have recently
reported that relative muscle power of the leg extensors assessed by the
Nottingham power rig began to decline in both women and men aged
40 years, with the rate of decline varying between 1.3 and 1.7% per year
from 40 to 60 years and between 1.7 and 2.3% per year from 60 to
80 years, while annual rates of decline above the age of 80 were
1.7–1.8% among women and 2.7–3.1% among men (Alcazar et al.,
2020a). To expand these observations, we wanted to identify the specific
age at which STS muscle power starts to decline and whether it declines
at different rates during distinct periods in life. A similar overall age-
related pattern of change in relative STS muscle power was observed
in the present study compared with that previously reported for relative
leg extension power (Alcazar et al., 2020a) (Fig. 2), with minor (statis­
tically non-significant) differences observed between 20 and 50 years.
While relative leg extension power remained constant from 20 to
40 years and began to decrease afterwards (Alcazar et al., 2020a),
relative STS muscle power tended to increase in women and increased
significantly in men between 20 and 30 years, followed by a steady
decline in both women and men up to their 50s, above which age the
declines observed in relative STS muscle power and relative leg exten­
sion power were almost identical. Interestingly, the rate of decline of
relative muscle power measured by STS and leg extension leveled off
after the age of 75 in women. At least in part, this pattern may arise due
to a possible survival effect bias. Lower muscle power represents an
independent predictor of all-cause mortality (Metter et al., 2004), and
older people below a certain critical threshold of lower-limb muscle
power may not have participated in the study because of severe mobility
limitations. Particularly, older women have a higher risk of falls (Martin
et al., 2013) and live a greater proportion of their life with disability
(Kyu et al., 2018) compared with older men, which is likely associated
with their lower relative muscle power.
The decline in relative muscle power with age is predominantly
caused by a decrease in allometric muscle power (Alcazar et al., 2020a).
However, age-related changes in body mass (and BMI) also exert an
influence on the observed cross-sectional trajectory of relative muscle
power. An increase in body mass has been reported to happen from 20 to
75 years in women and from 20 to 65 years men (Alcazar et al., 2020a)
likely because of a progressive accumulation of fat mass (Hughes et al.,
2002; Zamboni et al., 2003). This would explain the slightly larger
decline rate in relative STS muscle power observed after the third decade
of life compared with the decline in allometrically scaled STS muscle
power among women. On the other hand, since no changes in lower-
limb lean mass were reported in the present cohort before the age of
75 in women and 65 yrs in men (Alcazar et al., 2020a), the present
decrease in allometric STS muscle power appears to have been directly
caused by a decline in specific STS muscle power. The steep decline rate

4
J. Alcazar et al. Experimental Gerontology 152 (2021) 111448

Fig. 1. Cross-sectional trajectories of allometric, relative and specific sit-to-stand power values throughout the adult lifespan in women (open circles) and men (open
squares). a–b: allometric STS power; c–d: relative STS power; e–f: specific STS power; a-c-e: women; b–d–f: men. Regression lines (continuous lines), 95% confidence
intervals (dashed lines) and coefficient of determination (R2) values were obtained by piecewise regression analysis.

in specific STS muscle power presently noted in women above 55 years
and in men above 50 years possibly reflects the accelerated loss of motor
units observed after the fifth decade of life in humans (Campbell et al.,
1973; Tomlinson and Irving, 1977). Some of the denervated muscle fi­
bers will be re-innervated by nearby surviving motor units (Hepple and
Rice, 2016), with a likely loss of function that mainly affects those fibers
with a higher power-generating capacity (i.e. type II fibers) (Larsson
et al., 1979; McPhee et al., 2018). This fact, together with the accu­
mulation of non-contracting tissue within skeletal muscles (e.g. con­
nective and adipose tissue) (Csapo et al., 2014; Reid et al., 2014) and the
slowing of the neuromuscular system (Reid et al., 2014), may contribute
to the loss of specific muscle power while maintaining the amount of
muscle mass. Later in life, above the age of 75 years in women and
65 years in men, we recently documented a decline in lower-limb lean
mass (Alcazar et al., 2020a). The loss of muscle mass with age (i.e.
sarcopenia) may be due to the inability to reinnervate denervated fibers
in advanced stages of motor unit loss, leading to a simultaneous loss of
muscle fibers and atrophy of remaining myofibers (McPhee et al., 2018).
Actually, a failure to reinnervate denervated fibers has recently been
suggested to trigger the accelerated decrease in muscle mass among
sarcopenic older men, who showed smaller motor unit potentials than
non-sarcopenic older men (Piasecki et al., 2018). Consequently, after the

5
J. Alcazar et al. Experimental Gerontology 152 (2021) 111448

Table 3 et al., 2000; Kuo et al., 2006; Martinikorena et al., 2016) and physical
Annual rate of change (% year− 1) in sit-to-stand muscle power measures in training to increase lower-limb muscle power has been demonstrated to
women and men by different age groups (displayed as mean ± standard be able to revert frailty status (Losa-Reyna et al., 2019). Consequently,
deviation). the development of sensitive screening tools to detect the onset of
Allometric STS power Relative STS power Specific STS power muscle power decline or to identify critical periods in life in which
Women muscle power is lost at an accelerated rate will allow to implement
20–24 3.2 ± 1.1* 1.5 ± 0.9 1.7 ± 0.9* countermeasures that prevent the onset of frailty and disability, to ul­
25–29 2.8 ± 0.9* 1.4 ± 0.8 1.6 ± 0.8* timately improve individuals’ quality of life (Katula et al., 2008) and
30–34 − 0.7 ± 0.9 − 0.9 ± 0.8 − 0.6 ± 0.8 reduce the economic costs associated with skeletal muscle dysfunction
35–39 0.7 0.9 0.9 0.9 0.7 0.9
(Beaudart et al., 2014; Janssen et al., 2004). Notably, in the present
− ± − ± − ±
40–44 − 0.7 ± 1.0 − 1.0 ± 0.9 − 0.7 ± 0.9
45–49 − 0.8 ± 1.0 − 1.0 ± 1.0 − 0.7 ± 0.9 study we documented changes with age in lower-limb muscle power in a
50–54 − 0.8 ± 1.0 − 1.1 ± 1.0 − 0.7 ± 0.9 population-based cohort including 1305 subjects aged 20–93 years by
55–59 − 1.8 ± 0.3* − 2.0 ± 0.3* − 1.7 ± 0.2* means of a simple yet sensitive STS muscle power test that provides
60–64 2.0 0.3* 2.2 0.3* 1.8 0.3*
− ± − ± − ±
similar patterns as seen with validated and more sophisticated in­
65–69 − 2.2 ± 0.3* − 2.4 ± 0.4* − 2.0 ± 0.3*
70–74 − 2.5 ± 0.4* − 2.8 ± 0.4* − 2.2 ± 0.3* struments (Alcazar et al., 2020b; Alcazar et al., 2018a). Particularly, the
75–79 − 2.8 ± 0.4* − 1.5 ± 0.7* − 2.5 ± 0.4* information provided by the STS muscle power test has been found to be
80–84 − 1.5 ± 1.2 − 1.6 ± 0.8* − 0.9 ± 1.0 more strongly associated with physical function, cognitive function and
≥85 − 1.7 ± 1.3 − 1.8 ± 0.9* − 1.0 ± 1.1 sarcopenia than isolated STS time data per se and more strongly asso­
Men ciated with maximal gait speed than measures of maximal handgrip
20–24 3.4 ± 1.4* 2.5 ± 1.2* 2.2 ± 1.3 strength, 30-s STS performance or leg extension power when examined
25–29 2.9 1.2* 2.2 1.1* 2.0 1.1
± ± ±
in older people (Alcazar et al., 2020b, 2018a). Low relative STS power
30–34 − 0.6 ± 1.1 − 0.8 ± 1.1 − 0.4 ± 1.2
35–39 − 0.6 ± 1.2 − 0.8 ± 1.1 − 0.5 ± 1.2
has recently been reported to be more clinically relevant than probable
40–44 − 0.6 ± 1.2 − 0.8 ± 1.2 − 0.5 ± 1.2 (low handgrip strength) and confirmed (low handgrip strength plus low
45–49 − 0.6 ± 1.2 − 0.9 ± 1.2 − 0.5 ± 1.2 appendicular lean mass) sarcopenia in older adults (Losa-Reyna et al.,
50–54 − 0.7 ± 1.3 − 1.5 ± 0.3* − 1.3 ± 0.3* 2020). Further, STS power performance was positively associated with
55–59 1.7 0.3* 1.6 0.3* 1.4 0.3*
health-related quality of life after controlling for age, sex, comorbidity,
− ± − ± − ±
60–64 − 1.9 ± 0.3* − 1.8 ± 0.3* − 1.5 ± 0.3*
65–69 − 2.0 ± 0.3* − 2.0 ± 0.4* − 1.6 ± 0.3* hospitalization, depression and physical activity levels of the older
70–74 − 2.3 ± 0.4* − 2.2 ± 0.4* − 1.7 ± 0.4* participants (Alcazar et al., 2018a). Low relative STS power has recently
75–79 − 2.6 ± 0.4* − 2.4 ± 0.4* − 1.9 ± 0.4* been associated to increased all-cause mortality among older adults
80–84 − 3.0 ± 0.5* − 2.8 ± 0.5* − 2.1 ± 0.4* regardless of physical activity, obesity, hypertension and smoking
≥85 − 3.5 ± 0.5* − 3.2 ± 0.6* − 2.3 ± 0.5*
(Alcazar et al., 2021). Overall considered, the STS muscle power test
STS, sit-to-stand; y, years. seems to be valid, inexpensive and useful to assess lower-limb muscle
*
Significantly different compared with a slope equal to zero (p < 0.05). power throughout the adult lifespan, and an operational algorithm for
the detection and treatment of low relative STS power has been pro­
posed (Losa-Reyna et al., 2020).
sixth and seventh decades of life in men and women, respectively, the
decline in allometric STS muscle power observed in the present study
most likely was caused by both a loss in lower-limb lean mass (Alcazar 4.1. Strengths and limitations
et al., 2020a) and specific STS muscle power (cf. Fig. 1E–F), respectively.
The maintenance of functional ability during aging and the preven­ Cross-sectional study designs such as the present involve a number of
tion of frailty is a public health priority (Cesari et al., 2016; WHO, 2015). inherent limitations. Subjects in a poor health or with impaired muscle
Lower-limb muscle power represents a critical determinant of mobility function might be less likely to accept participation or survive to old age.
limitations and disability in older people (Bean et al., 2003; Foldvari However, similar refusal and/or survival effect bias has also been re­
ported in longitudinal studies (Desrosiers et al., 1998). One strength of

Fig. 2. Comparison of cross-sectional trajectories of relative muscle power between leg extension power (Nottingham power rig; grey lines) (data obtained from
Alcazar et al. (2020a)) and sit-to-stand muscle power (black lines) in women (a) and men (b) included in the same study cohort. Average (continuous lines) and 95%
confidence intervals (dashed lines) were obtained according to the procedures reported in the present study (piecewise regression analysis) and are expressed relative
to lower-limb relative muscle power values (W⋅kg− 1) observed in the young reference group.

6
J. Alcazar et al.
cross-sectional studies is that they enable the evaluation of muscle
function in a considerably large sample size and across a greater age
range. In any case, the present results are in close agreement with data
reported by longitudinal studies (Reid et al., 2014). On the other hand,
the present age-related changes in STS muscle power cannot be entirely
attributed to the effect of aging as such, since there might be other
relevant factors known to contribute to the loss of skeletal muscle power.
Most importantly, temporarily disuse can severely affect muscle func­
tion (Suetta and Kjaer, 2010). Notwithstanding, the present results
contribute to an improved understanding of the age-related changes in
STS muscle power, and their timing, in the general population aged
between 20 and 93 years, which may be of strong relevance to develop
and implement exercise-based intervention strategies that can make a
difference at a population level.
In conclusion, four stages of age-related change in STS muscle power
were observed among women: STS muscle power measures increased
from 20 to 30 years, decreased steadily from 30 to 55 years and more
pronouncedly above 55 years, with an attenuated decline rate after the
eight decade of life. By contrast, men experienced three stages of change
in various STS muscle power measures: there was an increase from 20 to
30 years followed by a steady decline during the fourth and fifth decades
of life, after which an accelerated loss in all STS muscle power was found
into oldest age. The present STS muscle power test appears to provide an
inexpensive and feasible tool to monitor changes in lower-limb muscle
power throughout the adult lifespan.
CRediT authorship contribution statement
C.S. conceived and designed the study; J.A., R.S.K. and S.K.H.
participated in data acquisition; J.A., P.A., B.H. and C.S. analyzed and
interpreted the data; J.A., P.A., B.H., R.S.K., S.K.H., E.P., I.A., L.M.A., U.
F. and C.S. wrote the manuscript; and all authors made a critical revision
of the manuscript and approved the final version of the manuscript.
Funding
This work was supported by the Ministerio de Educación, Cultura y
Deporte of the Government of Spain (Grants FPU014/05106 and EST17/
00868), the Biomedical Research Networking Center on Frailty and
Healthy Aging (CIBERFES) and FEDER funds from the European Union
(Grant CB16/10/00477).
Declaration of competing interest
The authors declare no conflicts of interest.
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