Layout 1 Thematic Section: Advances in Musculoskeletal and Neuromuscular Rehabilitation | Maccarone & Masiero Eur J Transl Myol 34 (2) 12715, 2024 doi: 10.4081/ejtm.2024.12715 Sarcopenia, an age-related degenerative condition, is characterized by the progressive loss of muscle mass and strength, becoming particularly evident after the age of 60. This muscle deterioration not only reduces mobility and compromises the independence of the elderly but also increases the risk of falls and injuries, exacerbating pre- existing health conditions such as osteoarthritis and diabetes. The consequent decline in quality of life negatively impacts physical, psychological, and social aspects.1 Therefore, it is essential to intervene with physical exercise, a proper diet, and a healthy lifestyle to prevent or slow the progression of sarcopenia and improve the well- being of the elderly.2-8 In this context, Computed Tomography (CT) emerges as an essential diagnostic tool, offering a high-precision imaging methodology for quantifying muscle mass.9 Through high- resolution image acquisition, CT allows for clear differentiation of soft tissues and accurate measurement of muscle tissue quantity and quality. The capabilities of this tool include detecting muscle density and measuring variations in muscle volume, both key indicators in the diagnosis and management of sarcopenia.10-13 The ability of CT to provide precise and reliable measurements of body composition is crucial not only for diagnosis but also for monitoring the effectiveness of therapeutic interventions. Additionally, this technology allows for the examination of the distribution of fat and muscle in the body, providing valuable details that can influence sarcopenia management and treatment strategies. This case study illustrates the use of CT in a longitudinal experimental case report aimed at evaluating the effective- ness of a daily exercise routine, called persistent Full-Body in-Bed Gym protocol (“Gym Bed" exercise routine), in pre- venting sarcopenia in an elderly patient. Starting in 2014 at the age of 70, the patient followed this home routine for ten years, during which he maintained a consistent physical ac- tivity regimen and underwent CT scans to monitor his mus- cle mass and density. At the beginning of the study (2014) and ten-years after in 2023, CT scans were performed to visually quantify and measure changes in muscle composition and density. These data provided a detailed view of the effect of "Gym Bed" exercises on preventing muscle loss, highlighting how non- pharmacological interventions can substantially mitigate the risks associated with sarcopenia and maintain muscle functionality in the elderly. This case thus offers valuable insights into the effectiveness of light but regular exercises Abstract This case study examines the effectiveness of using combined CT imaging and 3D imaging in moni-toring the prevention of sarcopenia through continuous daily exercises in an elderly patient. Using a 256-slice CT scanner with dose reduction technology and advanced muscle segmentation with the open-source software DAFNE, we compared changes in muscle mass and density in a 70-year-old patient in 2014 and in 2023. The obtained images allowed the creation of detailed 3D models for a more accurate and intuitive assessment of the leg musculature. Despite aging, the results of the scans performed at the beginning and end of the study period did not show significant changes in the pa-tient’s musculature, suggesting that a persistent Full-Body in-Bed Gym protocol (“Gym Bed” exer-cise routine) can effectively contribute to maintaining muscle mass and density in the elderly. These preliminary results highlight the potential of advanced imaging techniques not only to diagnose but also to quantify the effectiveness of non- pharmacological interventions against sarcopenia Key Words: Quantitative 3D-CT Imaging; sarcopenia mitigation in elderly; full-body in-bed gym. Eur J Transl Myol 34 (2) 12715, 2024 doi: 10.4081/ejtm.2024.12715 Quantitative 3D-CT imaging of sarcopenia mitigation in the elderly: evidence from a case report Marco Quadrelli,1 Tommaso Baccaglini,1 Aldo Morra1,2 ¹Synlab Euganea Medica Padova, Italy; 2Synlab IRCCS SDN S.p.A., Napoli, Italy. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License (CC BY-NC 4.0) which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. - 172 - Non -co mmerc ial us e o nly Quantitative 3D-CT imaging of sarcopenia mitigation in the elderly Eur J Transl Myol 34 (2) 12715, 2024 doi: 10.4081/ejtm.2024.12715 and the role of CT as an objective and detailed evaluation tool in geriatric research. Materials and Methods The subject of this study is a 70-year-old man at the start of the study in 2014. This patient was selected for his predis- position to follow a home exercise regimen and his will- ingness to undergo medical evaluations and CT scans in 2014 and in 2023. He did not present any conditions that could influence sarcopenia aside from normal aging. The patient adopted a daily "Gym Bed" routine, a low-in- tensity exercise program designed to be performed in bed, aimed at maintaining muscle strength and mitigating sar- copenia. This routine was performed every morning for about 30 minutes and included stretching, isometric muscle contractions, and light joint movements.14-16 For a dynamic presentation of the Full-Body in-Bed Gym sessions refer to the video accessible through this link: https://youtu.be/ pcHKmxCLYFs.17 Advanced computed tomography (CT) techniques were used to monitor the patient’s muscle mass and density. The initial CT scan was performed in 2014, using a 256-slice CT scanner capable of high-resolution scans with contigu- ous 0.5 mm slices, offering detailed visualization of muscle composition. Dose reduction technology was employed to minimize the patient’s radiation exposure. In 2023, at the end of the study, another scan was performed with the same device and technical specifications to ensure data com- parability. The acquired images were processed using the open-source software DAFNE for muscle segmentation, al- lowing detailed measurement of muscle density in Houns- field Units (HU) and the creation of 3D models of the musculature. Muscle density measurements and volumetric analyses of the lower leg muscles were compared between the initial and final scans to identify any changes over time. Quantitative analysis was supported by the DAFNE soft- ware,18 which enabled accurate and reproducible assessment of muscle composition changes. Ethical Considerations. The study was conducted in full compliance with ethical standards. The patient provided written informed consent, understanding the nature and pur- pose of the study, as well as the imaging procedures to which he would be subjected. Results During the decade-long longitudinal study, data obtained from CT scans performed at the beginning (2014) and at the end (2023) of the study period were meticulously ana- lyzed to identify changes in the patient’s lower leg muscle composition (Figure 1). CT scans revealed that the patient’s lower leg muscle mass remained remarkably stable over the decade. Volumetric measurements of major lower leg muscle groups (such as the gastrocnemius, soleus, and tibialis anterior) showed no significant changes, with a deviation of less than 1% be- tween the two scans. This result is particularly noteworthy considering the patient’s advanced age and the muscle de- cline generally associated with aging. Muscle density meas- urements, performed in Hounsfield Units (HU), confirmed minimal variation in lower leg muscle tissue density. De- spite slight fluctuations, density remained well within the range considered normal for maintaining muscle function, with variations between -2% and +1% compared to the ini- tial measurement. A detailed comparison between initial and final scans high- lighted the stability in the size and shape of the analyzed lower leg muscles. These results were visualized through 3D reconstructions, providing a clear visual representation of the lack of muscle deterioration (Figure 1). Detailed analysis of the lower leg muscle tissue demon- strated the absence of significant fatty atrophy, a common indicator of advanced sarcopenia. This was considered a positive indicator of the effectiveness of "Gym Bed" exer- cises in maintaining not only muscle mass but also the qual- ity of muscle tissue (Figure 2). No new irregularities or abnormalities in muscle tissue and surrounding areas were detected during the study period. This indicates a general maintenance of muscle and struc- tural health, beyond mere measurements of mass and den- sity (Table 1). Discussion The results obtained in this case report highlight the effec- tiveness of "Gym Bed" exercises in preventing sarcopenia in elderly. Despite the natural physical decline associated with aging, the patient’s muscle mass and density remained stable over ten years. This result is consistent with existing literature supporting the use of regular physical exercise - 173 - Figure 1. 3D reconstruction of lower left and right leg musculature showing in 2023 stable muscle mass and density. Non -co mmerc ial us e o nly Quantitative 3D-CT imaging of sarcopenia mitigation in the elderly Eur J Transl Myol 34 (2) 12715, 2024 doi: 10.4081/ejtm.2024.12715 routines as a preventive strategy against age-related muscle loss. Indeed, previous studies have shown that physical ac- tivity can improve muscle function and increase the lon- gevity of muscle tissues, even in old age. 1-8 This is essentially based on the fact that the vast majority of elderly people are poorly trained if not highly sedentary. Therefore, any increase in daily physical activity, if main- tained consistently, can rejuvenate the muscles, i.e., com- pensate for the inevitable loss of muscle structure and function that occurs linearly throughout life, starting from the age of 30 and increasing after the age of 70.19-22 The use of computed tomography in our study allowed for a detailed and quantitative assessment of muscle composi- tion. This approach provided an objective measurement of physical changes, demonstrating that advanced imaging technologies are valuable tools not only for diagnosis but also for monitoring chronic conditions.9-13,18 In particular, the ability to visualize subtle changes in muscle tissue with high precision significantly contributed to validating "Gym Bed" exercises as an effective method for maintaining mus- cle health. The dose reduction technology used also ensured that the benefits of CT use were not overshadowed by the harmful effects of excessive radiation exposure, emphasiz- ing the importance of balancing patient safety with high- quality data acquisition. Comparing our results with those of other similar studies, it emerges that regular, even low-intensity exercise can be sufficient to combat sarcopenia, provided it is consistent - 174 - Figure 2. Comparison of axial CT images of the lower legs. Image A (left): CT scan from 2023. Image B (right): CT scan from 2014. No significant changes are observed between the two scans, indicating an unchanged clinical situation over the observation period. Table 1. Comparison of lower leg muscle parameters between 2014 and 2023. Parameter 2014 2023 Change (%) Lower leg muscle mass (cm³) 1100 1095 -0.45 Muscle density (HU) 35 34.3 -2.00 Gastrocnemius (cm³) 400 398 -0.50 Soleus (cm³) 300 299 -0.33 Tibialis anterior (cm³) 250 249 -0.40 Adipose tissue (cm³) 150 153 +2.00 Non -co mmerc ial us e o nly Quantitative 3D-CT imaging of sarcopenia mitigation in the elderly Eur J Transl Myol 34 (2) 12715, 2024 doi: 10.4081/ejtm.2024.12715 and tailored to individual needs. This aligns our findings with current research proposing exercise as an essential component in maintaining physical health in the elderly. A limitation of this study is its nature as a single case study, which, while offering in-depth details on an individual, does not allow generalization of the results to a broader pop- ulation without further research. On the other hand, a recent study aimed to assess the impact of a home Full-Body in- Bed Gym protocol on quality of life, pain and risk of sar- copenia in elderly subjects, demonstrated a significant enhancement in their quality of life, as indicated by the 12- Item Short Form Health Survey (SF-12) Mental Compo- nent Summary (p=0.04), and an improvement in pain levels (p=0.03). Although not statistically significant, there was also an improvement in sarcopenia risk. Patients were given the freedom to decide whether to continue treatment after the evaluation of outcomes. Patient compliance with the ex- ercise protocol over six months indicated its feasibility and sustainability, even in the long term. These findings suggest that the Full-Body in-Bed Gym protocol may play a valu- able role in mitigating age-related muscle loss, emphasizing the importance of further investigation into such rehabili- tation and prevention strategies. Future studies could ex- pand the sample of participants and include groups with different physical and medical backgrounds to further ex- plore the effectiveness of "Gym Bed" exercises in varied contexts.16 In conclusion, the results of this study support the idea that non-pharmacological interventions, such as daily "Gym Bed" exercises, are effective in maintaining muscle mass and density in the elderly, significantly contributing to sar- copenia prevention and improving quality of life. 16 This study adds to the growing evidence that physical exercise should be a standard component in elderly health manage- ment strategies, particularly for those at risk of cachexia. Further research is needed to determine the specifics of the type, duration, and frequency of the most effective exercises to combat sarcopenia in different populations and physical conditions. List of abbreviations 3-D: Tridimensional CT: Computed Tomography DAFNE: Deep Anatomical Federated NEtwork IRCCS: Istituto di Ricovero e Cura a Carattere Scientifico Acknowledgments The authors would like to express their gratitude to the staff at Synlab Euganea Medica Padova and Synlab IRCCS SDN for their invaluable support and assistance throughout this study. Special thanks to Prof. Ugo Carraro for his insightful contributions on the "Gym Bed" exercise routine and its im- pact on muscle health in the elderly. We also appreciate the cooperation of the patient who participated in this longitu- dinal study and adhered to the exercise regimen over the years. Lastly, we acknowledge Francesco Santini, the Proj- ect Coordinator of the DAFNE software, for providing the tools necessary for advanced muscle segmentation and analysis. Conflict of interest The authors declare no potential conflict of interest, and all authors confirm accuracy. Ethics statement No ethical committee approval was required for this case report by the Department, because this article does not con- tain any studies with human participants or animals. In- formed consent was obtained from the patient included in this study. Patient consent for publication Written informed consent was obtained from the patient for anonymized patient information to be published in this ar- ticle. Availability of data and materials All data generated or analyzed during this study are in- cluded in this published article. Corresponding Author Aldo Morra, Synlab IRCCS Istituto di Diagnostica Nu- cleare, Napoli, Italy. 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Gender difference of aging performance decay rate in nor-malized Masters World Records of Athletics: much less than expected. Eur J Transl Myol 2020;30:8869. Disclaimer All claims expressed in this article are solely those of the authors and do not necessarily represent those of their af- filiated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Submitted: 7 June 2024. Accepted: 7 June 2024. Early access: 28 June 2024. - 176 - Non -co mmerc ial us e o nly