Muscle strength (MS) is defined as the tensile capacity that each muscle group can generate at a specific execution speed against a resistance¹. Although there are several methods for its assessment, the most widely used technique is handgrip strength (HGS) by dynamometry². HGS reflects the maximum force derived from the combined contraction of the extrinsic and intrinsic muscles of the hand³. According to the criteria established by the European Working Group on Sarcopenia in Older People (EWGSOP) ⁴, low HGS is defined as a measurement of > 2.5 standard deviations below the sex-specific population mean, as determined by dynamometry. While the majority of evidence about the correlation between low HGS and health conditions is primarily concentrated in the older adult population^{5), (6}, recent data suggest this association is present throughout the life cycle⁷. Low HGS is a risk factor for cardiometabolic disease, neurodegenerative syndromes, and all-cause mortality in young and middle-aged adults^{7), (9}. The UK Biobank study (n=493,774) showed that individuals in the lowest quartile of HGS had an increased risk of developing cardiometabolic disease (HR 1.46; 95% CI 1.34-1.60) and all-cause mortality (HR 1.87; 95% CI 1.64-2.14) compared to those in the highest quartile¹⁰. The growing acknowledgement of HGS as a clinical indicator of general and metabolic health has led to increased awareness and knowledge of the subject^{11), (12}. It is, therefore, essential that healthcare professionals possess an adequate understanding of the role of MS in health status, as well as its implications for the treatment and prognosis of different conditions. However, the Sarcopenia Road Show demonstrated a limited awareness of MS. For instance, only 2% of healthcare professionals were able to correctly identify the cut-off points for determining low MS^{13), (14}. Moreover, the primary barriers to routine assessment of MS identified were lack of awareness, unavailability of measurement equipment, and time constraints^{13), (14}. The present study assessed the knowledge of MS as a risk factor for multiple adverse health events, its measurement, and the education received on this topic among medical and non-medical healthcare providers in Colombia.

During the study period, 501 participants completed the surveys. The sample was predominantly female with 52.49% (n=263), the majority identified themselves as general practitioners, accounting for 53.89% (n=270), followed by specialist physicians at 18.16% (n=91), physiotherapists at 4.79% (n=24), other health professionals at 16.96% (n=85), and nurses at 6.18% (n=31). The most common workplaces were hospitals/clinics 35.92% (n=180) and private practice 24.15% (n=121). (Table 1).

The category of other health professionals was composed of 60% (n=51) women, with a predominance of bacteriologists 8.23% (n=7), followed by students 7.05% (n=6), surgical instrument technician 5.88% (n=5), and speech therapists 1.17% (n=1) (Table S1).

When assessing knowledge of low MS and cardiometabolic disease risk by profession, specialist physicians were found to have a higher percentage of correct answers than general practitioners, nurses, and other professionals (p= 0.013). (Figure 1) (Table S2).

Table 1

Characteristics	(501)
Age Median (SD) - years	37.9 ± 13.7
Male- % (n)	47.05 (238)
Profession - % (n)
General practitioners	53.89 (270)
Specialist physicians	18.16 (91)
Nurses	6.18 (31)
Physiotherapists	4.79 (24)
Other health professionals3	16.96 (85)
Workplace - n (%)
Hospital/Clinic	35.92 (180)
Solo practice/ self-employed	24.15 (121)
University	18.96 (95)
Multidisciplinary practice	9.18 (46)
Pharmaceutical/commercial industry	4.79 (24)
Administrative/Government	1.79 (9)
Unemployed	0.19 (1)
Others3	4.79 (24)

^a

Other professionals include bacteriologists, surgical instrument technicians, speech therapists, students and other professionals who did not specify their training.

Figure 1 P-value: Statistical significance (a) of 0.05, Pearson's Chi-Squared test

Similarly, when assessing knowledge of low MS and mortality, specialist physicians had a higher percentage of correct answers than nurses and general practitioners (p= <0.001). (Figure 2).

Figure 2 P-value: Statisticalsignificance (a) of 0.05, Pearson's Chi-Squared test

With regard to the population groups for which MS measurement is indicated, the age

group most frequently identified was adults. This group was identified by 378 professionals, of whom 76.92% (n=70) were specialist physicians and 75.93% (n=205) were general practitioners. Older adults were identified by 282 professionals, (86.81% (n=79) were specialist physicians, 83.33% (n=20), physiotherapists 83.33% (n=20) and general

physicians 74.44% (n=201)). The most frequently identified age group was adults, with 378 professionals (specialist physicians 76.92% (n=70), general practitioners 75.93% (n=205)) reporting this indication. Adolescents were identified less frequently, with 227 professionals (specialist physicians 78.02% (n=71), physiotherapists 70.83%, general physicians 40.00% (n=108)) reporting this indication. In children, it was reported by 225 professionals (specialist physicians 76.92% (n=70), physiotherapists 58.33% (n=14)) (p < 0.001) (Figure 3).

Figure 3 P-value: Statistical significance (a) of 0.05, Pearson's Chi-Squared test

59.15% (n=84) of general practitioners and 61.02% (n=36) of specialist physicians reported knowing some method of measuring MS. On the contrary nurses 77.78% (n=7) and in physiotherapists 75.00% (n=18) responded that they knew methods of measuring MS. (Table S3)

Instrumental measurement methods (dynamometry and bioimpedance) were identified similarly among all the groups evaluated. (Figure 4A).

Figure 4 A. Knowledge ofinstrumental methods for muscle strength evaluation by profession. Reasons for not performing routine muscle strength measurement by profession. C.Academic training on strength and health by profession. D. Continuing health education on strength by profession. P-value: statistical significance (a) of 0.05, Pearson's Chi-Squared test

Non-instrumental measurement methods were primarily identified by the group of physiotherapists (72.22%, n=13), while in the other groups, less than half of the respondents identified these methods. In addition, knowledge of reference values was known by 75.00 % (n=18) of the physiotherapists and by less than 30% of the participants in the other groups, general practitioners 24.07% (n=65), specialists 30.77% (n=28), and nurses 32.26% (n=10) (Table S3).

The main barriers to MS measurement were lack of equipment and time (Figure 4B). In the education component, physical therapists most frequently reported having received academic information on MS and health 95.83% (n=23), followed by general practitioners 55.18% (n=149), and specialist physicians 51.64% (n=47). The group that least reported having received academic information were nurses 29.03% (n=9) (p<0.001) (Figure 4C). Likewise, physical therapists most frequently reported having received continuing education at 58.33% (n=14), followed by specialist physicians at 42.85% (n=39) and general practitioners at 40.74% (110), and to a lesser extent, other professionals at 38.82% (n=33) and nurses 22.58% (n=7). (Figure 4D).

The findings of this study demonstrate that a significant number of health workers surveyed in Colombia exhibited limited awareness regarding the association between low MS and various health conditions. A high percentage of participants had no formal training or had not participated in continuing education. Although all participants identified low MS as a risk factor for at least one health condition, the association with cardiometabolic disease and mortality was only identified by a high proportion of specialist physicians. A high percentage of participants reported knowing some method of measuring MS, with instrumental methods (dynamometry and bioimpedance) being the most frequent. Finally, less than half of the participants, with the exception of physiotherapists, knew the reference values for diagnosing low MS, and few performed measurements as part of their daily practice, mainly due to lack of equipment and time.

This is the first study in Colombia to assess the knowledge and practices of MS measurement among health personnel. Similar out comes have been observed in studies conducted in high-in come countries. The Sarcopenia Roadshow is a continuing education program designed to strengthen strategies for the diagnosis and management of sarcopenia in the Netherlands, Australia, and New Zealand^{13), (14}. In Australia and New Zealand, a high percentage of surveyed participants (81.4%) demonstrated knowledge of the diagnosis of MS. However, only 12% (n=30) of these individuals applied diagnostic methods in their daily practice. Regarding MS measurement methods, 33.9% (n=75) of health professionals in the Netherlands utilized HGS¹⁴. Our findings indicate that approximately 50% of the participants reported familiarity with a measurement method, with the most frequently selected method being HGS. Only a small percentage (2.0%), of Australian and New Zealand professionals demonstrated an accurate understanding of the diagnostic values for low MS as assessed with HGS. In our study, the percentages of knowledge were similarly low, except for the physiotherapist group. The primary obstacles to the implementation of diagnostic strategies, as reported by 62.7% of Dutch professionals, were identified as a lack of knowledge and equipment, as well as time constraints¹⁴. Similarly, 77.8% of Swiss nutritionists reported a lack of instruments, and 78.6% cited a lack of knowledge to perform the assessments¹¹.

A study conducted in the United States that evaluated health personnel with a high probability of caring for patients with low MS in primary care demonstrated that 35% exhibited limited knowledge of FM²¹. In Colombia, the equivalent of these personnel are general practitioners. Despite a high percentage of respondents indicating familiarity with the concepts, only 17.41% (n=47) utilize them in their practice, and only 24.07% (n=65) employ standardized definitions for diagnosis²².

With regard to the continuing education of healthcare personnel, over half of the participants indicated that they had not yet received training or continuing education on reference values or methods of measuring MS. This is reflected in the low percentage of professionals who routinely assess MS. Similarly, in Australia and New Zealand, the Sarcopenia Road Show evaluated the retention and implementation of knowledge following educational activities. The results indicated that only 53.8% of respondents reported applying the concepts they learned in practice following a single educational event, suggesting low retention and application of the concepts after a single educational event¹³. The results of this study indicate that a combination of educational strategies should be employed to facilitate the integration of knowledge and to reinforce its practical application. This presents a challenge in training health professionals, as physicians, nurses, physiotherapists, and other professionals should perform MS assessments.

Finally, it is worth highlighting the usefulness of conducting this type of study to identify weaknesses in the training of health professionals in our region and in the care provided to people in different settings. In this regard, a survey conducted in Latin America to evaluate knowledge and beliefs about prediabetes among health professionals demonstrated a need to enhance knowledge about prediabetes, its clinical implications, and its treatment¹⁵. The results were found to be highly comparable to those observed in our own study. Consequently, it is imperative to cultivate a greater understanding among health professionals about the prevalent conditions and risk factors affecting the population and instill a sense of urgency for developing and implementing educational tools to address these gaps.

The study has some limitations, including the use of a survey with an incipient process of validation of the questionnaire and a lack of evidence for its validation. Another limitation is that most of the participants surveyed were physicians attending medical congresses, which may have given rise to a selection bias. Additionally, the sample included was selected foEDr convenience, which limits the generalizability of the results; therefore, more studies are needed that include more people who are not health personnel. One of the strengths of this study is that it provides, for the first time in Colombia, insight into the knowled.

This study demonstrates that the knowledge and practices of healthcare professionals on MS are deficient, so there is a need to increase knowledge through educational interventions that can be incorporated into clinical practice. Future research is needed to evaluate the impact of increased knowledge on better management of conditions associated with muscle strength loss.