Sarcopenia, a Neurogenic Syndrome?

Sarcopenia is an aging-associated condition, which is currently characterized by the loss of muscle mass and muscle strength. However, there is no consensus regarding its characterization hitherto. As the world older adult population is on the rise, the impact of sarcopenia becomes greater. Due to the lack of effective treatments, sarcopenia is still a persisting problem among the global older adults and should not be overlooked. As a result, it is vital to investigate deeper into the mechanism underlying the pathogenesis of sarcopenia in order to develop more effective therapeutic interventions and to inscribe a more uniform characterization. The etiology of sarcopenia is currently found to be multifactorial, and most of the pharmacological researches are focused on the muscular factors in aging. Although the complete mechanism underlying the development of sarcopenia is still waiting to be elucidated, we propose in this article that the primary trigger of sarcopenia may be neurogenic in origin based on the intimate relationship between the nervous and muscular system, namely, the motor neuron and its underlying muscle fibers. Both of them are affected by the cellular environment and their physiological activity.


Introduction
Sarcopenia (Greek: sarx means "�esh, " penia means "loss") is an age-related geriatric syndrome �rst described on a meeting in 1988 by Dr. Rosenberg as a phenomenon whereby the age-related decline in lean body mass affects ambulation, mobility, energy intake, overall nutrient intake and status, independence, and breathing [1]. More recently, sarcopenia is characterized by the gradual loss of muscle mass, muscle strength, and muscle function/quality in aging [2,3]. However, there are studies indicating that sarcopenia should be referred only as the age-related loss in muscle mass whilst the age-related loss in muscle strength should be isolated as a new condition called "dynapenia" based on the evidences indicating that the loss of muscle mass and strength are two distinct processes with different pathophysiology [4].
Hitherto, there is no consistent data among a variety of prevalence studies probably due to the difference in study sample, de�nition of sarcopenia, and the assessment tool used [3]. For example, for the population of over 80 years old, American study of New Mexico Elder Health Survey has found that there were >40% of women and 50% of men who were sarcopenic whilst the NHANES III database study reveals that 11% of women and 7% of men were sarcopenic. Also, the Italian study of InCHIANTI cohort reveals that 15% of women and 70% of men were sarcopenic [3]. In summary, the prevalence of this syndrome depends on age, sex, race [3,[5][6][7], morbidity [7,8], nutrition [9], and physical activity [10,11].
Some studies indicate that sarcopenia leads to functional limitations, impaired mobility, disability, falls, and fractures, which in turn lead to the loss of independence, frailty, and increased risk of mortality [11][12][13]. In contrast, some studies indicate that the parameter of muscle mass may not relate to the functional status and mortality [4]. No matter whether sarcopenia may affect both the quality and quantity of life of individuals or not, there are no effective treatment for sarcopenia and its related outcomes yet. Pharmacological interventions currently present are not effective and possess a considerable level of side effects. ese include hormonal (e.g., growth hormones, testosterones, estrogens, tibolone) and nonhormonal (e.g., losartan, telmisartan) interventions [14]. Hitherto, only exercise training except endurance training, especially by power training [11,14], and with adequate nutrition [9] seems to be the relatively effective intervention with the least side effects. Together with the inconformity of sarcopenia characterization among different studies, it is imperative to explore deeper into the mechanism or etiology of sarcopenia which in turn will provide further insight into the development of more effective therapy as well as a better understanding of the rationale that leads to a better characterization of sarcopenia.
In this article, we aimed to provide another perspective on sarcopenia and propose that sarcopenia may be neurogenic in nature despite its muscle-related features. In the following sections, we will discuss �rst the de�nition of sarcopenia, followed by commonly accepted etiology of sarcopenia, and then the impact and overview of the physiological factors that link up the nervous and muscular system.
Despite the characterization of sarcopenia varied among different studies [2-4, 15, 16], the major impact of sarcopenia is the age-related progressive decline in muscle mass. Under normal circumstances, when a healthy individual is trying to perform a particular physical activity, the relevant muscles on the corresponding part of the body will start to generate strength or force by neural action potential-induced contraction. e part of the body moves only when the overall strength produced overcomes the weight exert by the corresponding body part and the resistance forces induced by the activity. It is commonly assumed that if every muscle �ber of a single type has the same rate of force generation and produces the same force, then the muscle strength shall be positively correlated with the number of muscle �bers present in the muscle. us, the loss of muscle mass shall at least partly contribute to the loss of muscle strength which in turn contribute to the decline in muscle function due to the impaired ability to overcome resistance forces involved in the physical activity. In fact, the association between muscle mass and strength was supported by early cross-sectional studies until recent longitudinal studies demonstrated that there may be a disassociation between age-related changes in muscle mass (sarcopenia) and strength (dynapenia), and there are distinct mechanisms accounting for each component [15,16]. ese recent evidences not only bring a new terminology "dynapenia" into the �eld but also a reconsideration of the mechanism and etiology that underlies the problems as well as examining the problem from other perspectives. However, according to the original de�nition of sarcopenia [1], no decline with age is as dramatic or potentially more signi�cant than the decline in lean body mass. In fact, there may be no single feature of agerelated decline more striking than the decline in lean body mass in affecting ambulation, mobility, energy intake, overall nutrient intake and status, independence and breathing. Irwin H. Rosenberg, 1988 Notwithstanding, the focus is on the decline of lean body mass, and if scrutinized carefully, the statement is actually referred to a phenomenon that relates to both the body mass and function but not the strength. us, "sarcopenia" in 1988 is de�ned as the change of body functions and behavior due to the loss of lean body mass. However, as strength is an independent predictor of body functions including falls and mortality [4,16], it eventually replaces the body function and becomes part of the de�nition of sarcopenia in some studies [2,3]. Since the de�nition of sarcopenia plays a central role in its research affecting the signi�cance of its related research �ndings therea�er, we should have a consensus regarding this de�nition. Recently, some studies have pointed out the dissociation between the muscle mass and muscle strength [4,15,16] and have introduced the concept of "dynapenia" into the �eld� the strength parameter should be isolated from the de�nition of sarcopenia once again. However, when reading the original Albuquerque statement, it should be noted that Dr. Rosenberg has actually used the term "lean body mass" which includes the mass of muscles, blood, bones, and other nonfat tissues. All these tissues could experience aging and contribute to the decline in body function at a certain degree. �ven the pre�x "sarco" is commonly used to depict the muscles, and the Greek translation for "sarx" is only �esh whilst the one for muscle is "myx". As a result, the term "myopenia" may be more appropriate for the current pathological condition of the age-related decline in muscle mass.
Virtually all diseases and pathological conditions involve a change in body physiology in which a phenotype is determined by a myriad of molecular factors that weave different molecular cascades in an interlacing fashion. Interestingly, one physiological factor may link up to several diseases (e.g., in�ammation involved in both Alzheimer's disease and Parkinson's disease) and one sort of disease may also have several underlying physiological factors (e.g., amyotrophic lateral sclerosis has several subtypes and each of which is associated with a different gene or protein). In the case of sarcopenia, although muscle wasting and muscle atrophy are main features of its pathology, it is not unique at least Cachexia has a similar characteristics and consequence as sarcopenia [8,17,18]. e certain degree of pathological overlapping suggests that at least some underlying molecular mechanisms are common to/shared between these pathologies. For instance, in�ammation where proin�ammatory cytokines and ubiquitin-proteasome degradation pathway are upregulated [17]. Despite the similarity and overlapping characteristics with cachexia, sarcopenia is a separate clinical condition with a certain degree of discrepancies. Sarcopenia is a chronic muscle wasting condition associated with a low grade systemic in�ammation which is not necessary to be the pathological trigger whilst cachexia is an acute muscle wasting condition that only develops under an overlying in�ammation [8,17]. In summary, it may be more appropriate to account the loss of muscle mass in subtypes or in a way similar to the de�nition of amyotrophic lateral sclerosis. For example, the subtype with a muscle-in-origin etiology shall call "type I sarcopenia" whilst the subtype with a neuron-in-origin etiology shall call "type II sarcopenia". Or from the other perspective, the term "sarcopenia" shall be a pronoun for all types of chronic muscle mass decline and each of its subtypes is de�ned by one sort of etiological mechanism. For instance, the one shared with cachexia shall be called "cachexic sarcopenia" whilst the one shared with amyotrophic lateral sclerosis shall be called "Hawking's sarcopenia. "

Commonly Accepted Etiology of Sarcopenia
Currently, the body physiology or the etiology of sarcopenia is believed to be affected by but not restricted to �ve main features: (1) aging, (2) genetics, (3) morbidity, (4) nutrition, and (5) activity. Nevertheless, it is certain that muscle mass, strength, function, and quality are determined by at least three cardinal physiological systems: (1) neurological system [15], (2) muscular system [15], and (3) circulatory system. us, it is not surprising that any diseases or conditions that affect or alter these physiological systems may contribute to the development of dynapenia and sarcopenia, for example, genetic factors, neurodegenerative diseases, hormonal dysregulatory diseases, autoimmune diseases, in�ammation, malnutrition, physical injuries, and inactivity [5,8,12]. As the muscle function relies on the status of motor units (each of which consisted of a motor neuron, motor neurites (axons), neuromuscular junctions (NMJ), and muscle �bers) in addition to the circulation factors, the pathology of sarcopenia may be neurogenic, musculogenic (term created to differ from "myogenic"), synaptogenic (from NMJ), and/or vasculogenic (from blood vessels) ( Figure 1).

Muscular Factors.
Aging is a symplcetic ("sym": together; "plektos": braid) natural process of matters and contributes signi�cantly to sarcopenia. For skeletal muscle, aging leads to a decline in muscle function. At the systemic level, both the upper and lower limbs of men and women have an age-associated sequential loss in muscle power, muscle strength, and muscle mass, starting from the age of 40 years, 30 years, and 24 years, respectively [19]. e age-related loss of muscle power is more rapid than the parallel loss of muscle strength which in turn is more rapid than the loss of muscle mass [12,19]. e loss in muscle power and muscle strength is at least partly attributable to the reduction in muscle mass. At the molecular level, the loss of muscle power and muscle strength is further associated with a reduction in the amount of Ca 2+ available for the mechanical response in muscles [20] and with a reduction in Ca 2+ release in response to the mechanical action of muscles due to the age-associated reduction in dihydropyridine receptors at the t-tubule and sarcoplasmic reticulum membrane which in turn results in uncoupling of Ca 2+ release channels or ryanodine receptors in type II muscle �bers [15,19,20]. On the myocellular level, skeletal muscle �bers are basically two types. Type I �bers are slow and oxidative which mainly operate in the weight bearing/antigravity functions, whilst type II �bers are fast and glycolytic which are mainly involved in the explosive actions (e.g., sprinting). Patients with sarcopenia manifested a reduction in the number of both type I/slow-twitch and type II/fast-twitch muscle �bers and an atrophy speci�c to the type II �bers (being more prominent in IIB �bers than IIA �bers) [12,19]. is may be resulted from a hypotrophic or hypercatabolic state of muscle �bers which may be a cause or an effect of the denervation of motor units and/or the loss of motor neurons [21]. ese are the common features of aging and are being more prominent in type II than type I �bers. However, the hypercatabolic state of muscle �bers may also attribute to the reduction in the number of satellite cells [22]. In other words, the loss of muscle mass is also partly attribute to the diminished ability of muscle self-repair due to the decreased number and impaired function of satellite cells [2,22]. At the cellular level, aging is associated with a reduction in cell density of the satellite cell population in type II �bers as well as a diminished satellite cell proliferation capacity or a replicative senescence, which may relate to the shortening of telomeres [2,22,23].

Neurological Factors.
On the neurological side, the loss of muscle power and muscle strength is associated with the age-related changes in motor units and in the degree of coactivation of antagonist muscles, respectively [19]. At the cellular level, aging is associated with a reduction in motor axon conduction velocity and the number of myelinated axons. Further, it is associated with a reduction in motor unit reinnervation aer denervation, and with a reduction in the number of motor units and motor neurons speci�c to the type II muscle �bers [19,21]. As the fast-twitch motor units are the determinant of the degree of power exerted by muscles, their loss in aging contributes to the loss in muscle power [19]. In fact, under normal aging process, a preferential denervation of type II muscle �bers occurs and these denervated �bers are then reinnervated by the axonal sprouting from slow motor neurons in a process called motor unit remodeling. However, if denervation outpaces reinnervation, then a population of denervated �bers will undergo atrophy and degeneration [24] due to the loss of trophic factors [25]. is process contributes to the loss of muscle mass at least partly by apoptosis [26]. At the molecular level, rat studies have shown that progressive denervation during aging have disrupted the precise overlapping between the presynaptic nerve terminal and the postsynaptic acetylcholine receptor (AChR) clusters at the NMJ [27]. Also, denervated muscles have elevated the expression of proapoptotic/atrophic factors including bax, caspase 3, 7, 8, and 10 [26] along with a reduction in the trophic factor signals including TrkB signaling via BDNF and NT-4/5 [27]. ese in turn increase the apoptotic potential of myocytes. us, denervation seems to be the trigger for muscle loss.

Circulation Factors.
Blood circulation is vital to the whole body and thus may also contribute to the pathology. Aging is associated with the changes in microcirculation and ultrastructure of the vascular endothelium [28], a decline in vascular endothelial functions [29], and a decline in exerciseinduced blood �ow which may be partly resulted from an agerelated reduction in vasodilatory capacity and capillarization [28]. e reduced blood �ow leads to a reduction in the exchange of oxygen, energy sources, metabolites, and heat between blood and the body cells. is results in a less trophic environment for the cells in the corresponding region [28].

Common Pathophysiology Shared between the Aging Nervous System and the Aging Muscular System
According to most of the studies, contributors to the loss of muscle mass in sarcopenia are explained mainly by, but not limited to: (1) mitochondrial dysfunction, (2) elevation of oxidative stress, (3) in�amm-aging, (4) altered rate of protein turnover, (5) decreased hormones, growth factors, and proteins that maintain proper cellular functions, (6) declines in intake of essential nutrients, and (7) declines in physical activity [5,12,19,21]. Interestingly, most of these contributors are not unique to the muscular system. ey may also applicable to the nervous system.

Mitochondrial Dysfunction.
Mitochondrial dysfunction may arise from the age-related decline in mitochondriogenesis [14,30] and mitochondrial function. Both of which may be associated with an increase in the mitochondrial DNA damage by oxidative stress, changes in the mitochondrial respiratory chain enzymes, and changes in the mitochondrial proapoptotic proteins. Mitochondrial dysfunction results in an impaired mitochondrial oxidative function and energy production. ese in turn affect cell viability through necrosis and/or apoptosis of both myocytes and neurons [21,31].

Elevation of Oxidative Stress.
Elevation of oxidative stress is commonly seen in aged animal cells with an increase in the oxidative species (e.g., H 2 O 2 species, MDA/4-HAE, nitrotyrosine, catalase [32], iNOS [17]) and a decrease in the antioxidative species (e.g., MnSOD [32], G6PDH [33]). Also, accumulation of the oxidative stress-induced advanced age glycation end-product (AGE) and lipoxidation endproducts (ALE) on the extracellular and intracellular proteins during aging impairs the activities of these proteins [21]. e consequence of an elevated oxidative stress in muscles is the iNOS-mediated downregulation of a set of myogenic proteins including CKM and MyoD [17], and the concomitant inhibition of general protein translation by both the phosphorylation of eIF2 and the inhibition of mTOR [17]. Additionally, aging upregulates the iNOS which correlates with an increase in caspase 2 and JNK signaling activity, this suggests the involvement of JNK-mediated apoptotic signaling [33]. In the perspective of the nervous system, oxidative stress may lead to an alteration in the balance between mitochondrial �ssion and fusion as well as an activation of the apoptotic pathway in neurons [34].

4.�. �n�amm�A�in� �A�in��Associated �hronic �n�amma� tion).
In�ammation is intimately linked to the oxidative stress. In�amm-aging is an age-related elevation of the baseline level of proin�ammatory markers and cytokines (e.g., TNF-, IL-6, CRP) [10]. e most representative cytokines are TNF-and IL-6. TNF-induce apoptosis directly through its iteraction with the death domain receptors which in turn leads to the activation of procaspase 8 [21,26]; and indirectly through the activation of its downstream effectors, NF-B, which activity is also elevated by aging [17]. Activated NF-B upregulates MSTN/GDF8 [35], iNOS, and MuRF1 [17], these factors play a negative role in the trophic state of myocytes. Additionally, IL-6 plays a similar role by downregulating IGF-1 [2]. As a result, the anabolic potential of myocytes including the satellite cells is impaired due to (1) reduced expression of proteins involved in myogenesis and other relevant muscle growth processes (e.g., MRF, myogenin, MyoD, and CKM) [17,26]; (2) elevated expression of MSTN which exerts its effect on muscle growth by regulating the Activin receptor-mediated pathway, MAPK pathway, and Akt/TORC1/p70S6K pathway [5]. Additionally, MSTN induces reactive oxygen species (ROS) production via NADPH oxidase and TNF-. e elevated TNF-in turn induces further MSTN production and the higher levels of MSTN promotes proteasome-mediated catabolism of intracellular proteins [35]. In addition to the muscular system, both oxidative stress and in�ammation have great impacts on the nervous system as they are commonly disclosed in the neurodegenerative diseases [34,36].

Altered Rate of Protein Turnover.
Altered protein balance is one of the major features in aging cells. In myocytes, there is an age-associated change in expression of dystrophic factors (e.g., Id1, Id2 and Id3, etc.) [26] and trophic factors (e.g., MGF, etc.) [19]. Similarly, the expression pro�le of dystrophic/proapoptotic factors (e.g., bax and procaspase 3, etc.) [37] and trophic factors (e.g., CNTF, etc.) [19] in neurons are also altered by aging. e fate of a cell is determined by the balance between the rate of positive metabolism and the rate of negative metabolism which are positively correlated to the level of trophic signal (e.g., growth factormediated pathways) and atrophic/dystrophic signal (e.g., proapoptotic factor-mediated pathways), respectively. us, when the rate of negative metabolism exceeds the rate of positive metabolism, the cell will undergo atrophy and �nally death by apoptosis. In the case of aging myocytes, despite the mechanism is not clear, the loss of multinucleated myocyte nuclei is suggested to be caused by apoptosis regulated by AIF-mediated caspase-independent DNA fragmentation. Unlike single-nucleated neurons, apoptosis of one single nucleus of the myocyte may not result in cell death [21]. Instead it will undergo an atrophy due to the decrease of the nuclear domain [19]. Together with the "use it or lose it" perspective (discuss in later section), this may explain the more remarkable reduction in the size of type II muscle �bers than that of the type I muscle �bers in sarcopenia. Additionally, this also suggested that myocytes may have a greater potential to resist death than neurons. At the transcription level, miRNAs may also contribute to the agerelated alteration in protein turnover as they are capable of regulating protein expression. Many miRNA candidates altered their expression level during aging in both myocytes and neurons [38][39][40].

Decreased Hormones, Growth Factors, and Functional
Proteins. Hormones, growth factors, and proteins that maintain proper cellular functions are associated with the trophic state of myocytes. Aging is associated with a decline in sex hormones in both male and female, for example, androgen and estrogen [2]. On the neurological side, the alteration in sex hormone levels may also affect brain functions as circulating sex hormones can penetrate the blood-brain barrier [41]. Additionally, aging is associated with a decline in growth factors and their relevant regulators affecting both myocytes and neurons, for example, (1) GH, which regulates the synthesis of IGF-1 [19] and the survival of neurons [42]; (2) IGFs, which stimulate amino acid and glucose transport and are important trophic factors to both myocytes [5,12] and neurons [43][44][45]. IGF-1 regulates growth, differentiation, and regeneration of myocytes [12] by inducing hypertrophy pathways (e.g., PI3K and MAPK pathways) [5] whilst IGF-2 is associated with the proliferative action in adult muscles [12]; (3) CNTFs, which are important hypertrophic factors for both myocytes and neurons [12] and may play a role in the reinnervation of muscle �bers by motor neurons aer muscle and nerve injury [5]. Apart from the growth factors, aging is also associated with a reduction in stress-induced expression of HSP70, which normally functioned as chaperones and expressed by both myocytes and neurons [21,23]. HSP70 reduces the apoptotic potential of a cell by inhibiting the formation of apoptosome and functioning as an antagonist of AIF [21]. us, the age-associated decline in these candidates may have a serious consequence on both the muscular and nervous systems.

Malnutrition.
Aging is commonly associated with a decline in the ability to utilize exogenous amino acids. is may be due but not limited to: (1) reductions in transmembrane amino acid transport for protein synthesis; (2) alterations in the whole body amino acid turnover which results in a reduced availability of substrate for protein synthesis; (3) alterations in the endogenous hormonal response; and/or (4) alterations in the response of muscle to the hormonal stimuli aer meal intake [47]. e current recommended daily nutrition intake for the prevention of sarcopenia and frailty is 24-36 kcal and 0.8-1.2 g high quality protein per kg body weight [9]. Essential amino acids, in particular the branchedchain amino acids (BCAA) especially Leucine, are potent anabolic signals for protein accretion [47,48], which requires ∼0.7 kcal/g of muscle protein synthesized [47]. erefore, lacking such nutrients may alter the protein turnover and thus contribute to the development of sarcopenia [8].

Disuse
Atrophy. Physical inactivity, induced by either sedentary lifestyle or immobility due to illness/injury, is a trigger of muscle disuse atrophy [18]. At the molecular level, physical inactivity is associated with an inhibition of the IGF-1 hypertrophic signaling and a concomitant upregulation of proteasomal (ubiquitin) and lysosomal (autophagy) degradation signaling via FOXO proteins [18,49]. is contributes to a reduced trophic state in myocytes. In contrast, increased physical activity level by resistance training enhances the muscle mass, muscle strength, and balance which in turn reduces the risk of physical limitation and/or the onset of frailty [11,21]. e effect of exercise training is dose dependent. e higher the intensity involved in the training, the better the yield of the effect. Training at 60%-85% of the individual maximum voluntary strength can increase the muscle mass whilst more than 85% can also increase the rate of force development. e addition of a sensorimotor component to the exercise training program may also help improving the postural control in older persons [50]. In addition to the muscles, the in�uence of exercise training to the nervous system is also well described [51]. Interestingly, although having a positive impact on both muscle mass and strength, exercise trainings do not prevent the age-related impairment in muscle features. Recent studies reported that both the muscle size and functions are impaired in aged sprint-trained athletes. Similar to sarcopenia, type II muscle �bers were suffered from a more remarkable impairment than type I muscle �bers [52].

Use It or Loss It
On the neurological perspective, physical inactivity re�ects a reduced activity of the corresponding motor units. Unused or seldom used neurons will undergo disuse degeneration which in turn results in a further disuse degeneration of its synaptically connected cells [53]. us, it is possible that the age-associated progressive denervation and the ageassociated loss of muscle �bers are due to the disuse atrophy and degeneration of the NMJ and/or the motor neurons. is "use it or loss it" doctrine at least partly explains why there are more prominent type II motor unit atrophy and degeneration in sarcopenia and why sedentary individuals are more susceptible to sarcopenia. As sedentary individuals have less explosive actions, the frequency of usage and/or length of activation of the fast motor unit (type II �bers) is lesser than that of the slow motor unit (type I �bers) which is frequently engaged in the antigravity functions. us, the potential of disuse atrophy and degeneration for type II �bers is higher. In fact, age-related denervation, loss of motor units, and motor neurons are all being more prominent in the type II �bers in comparison to the type I �bers [19,54]. Further, space �ight studies reported that the loss of muscle mass, strength, and power are more prominent in the type I �bers than those of the type II �bers under microgravity [55]. ese may be explained by the "use it or loss it" doctrine again.
As gravity is reduced, the usage of slow motor unit is lesser than that of the fast motor unit. Hence the potential of disuse atrophy and degeneration for the type I �bers is higher. It is interesting to note that a�er the space �ight, the type II �bers were also lesser. is may due to the reduction in gravity which leads to the reduction in resistance force for activity, and the type II motor units were then using lesser strength, energy, or power for the same work. As a result, they were susceptible to the disuse issue but to a lesser degree.

The Origin of Sarcopenia
Contributors to the development of sarcopenia discussed so far are common to both myocytes and neurons. us, the aforementioned contributors may be the systemic/general factors which may not necessary be the primary trigger in the etiology of sarcopenia but rather they may play a role in exacerbating the development process of sarcopenia upon triggering. Apparently, sarcopenia is linked to the interplay of assorted molecular cascades which involve a complex relationship between a variety of nucleic acids and proteins. erefore, it is also possible that the pathology is originated from these multiple independent or synergistic triggers. Additionally, morbidity factors including neurodegenerative diseases and other pathological conditions may also have a direct or indirect role in the development of sarcopenia, that is, sarcopenia as a complication of other diseases. By putting these pictures together, the development of sarcopenia may originate either from the following: (1) muscle �ber atrophy and degeneration which in turn leads to the denervation and loss of motor neuron (musculogenic); (2) synapse atrophy and degeneration of the NMJ which in turn leads to the atrophy and degeneration of muscle �bers (synaptogenic); (3) motor neuron atrophy and degeneration which in turn leads to the atrophy and degeneration of muscle �bers (neurogenic); (4) all of these. On the other hand, the exercise-induced hypertrophy of muscles may be explained either by (1) hypertrophy of the muscle �ber which in turn reinforces and stabilizes the synapses (muscleinduced); (2) hypertrophy of the synapses at the NMJ by synaptic facilitation through reinforcing signals and this in turn potentiates the trophic status of the muscle �bers (nerve induced); (3) both. Interestingly, the nervous system-based ideas seem more feasible due to ( Figure 2) the following: (1) the trophic state of the muscle is determined by the net protein balance and some myogenic factors, e.g. myogenin, are strongly regulated by the electrical activity [25]; (2) some trophic factors, e.g. NT-4/5 and TrkB, are innervation dependent [56]; (3) some neurotrophic factors, CNTF, nourishes both the muscular and nervous system [57]; (4) the loss of muscle mass and strength albeit having different onset time, both of them are well maintained or decline slowly until the age of 60 when a more rapid rate of decline commences. Coincidentally, the onset of age-associated denervation is also around the age of 60 [19]; (5) physiological change in the presynaptic terminal is greater than the postsynaptic terminal in aged animals [27]; (6) the nerve activity determines the muscle phenotype and this is mediated mainly by the Ras-MAPK pathway [25]; (7) the neurotrypsin-dependent NMJ degeneration results in a full sarcopenia phenotype in young adult mice [58].

One Picture Has Two Sides
Nature is amazing and sometimes surprising, this makes science even challenging and fascinating especially when analyzing a particular phenomenon with a different or even antagonistic logic. For example, although hypertrophic state is commonly considered to be important for the survival of cells, chronic hyperactivity of growth-promoting pathways may not possess any positive impacts. Animal studies reported that hyperactivation of the mTOR pathway, which originally promotes accretion and regulates initiation of translation, does not reverse the atrophy observed in obese muscles [59]. In contrast, when treated with the AMPKagonists which inhibit the mTOR pathway, the translation capacity and the mass of obese muscle increased [59]. us, hyperactivity of mTOR may lead to a secondary resistance to the growth stimuli probably due to the negative feedback of a homeostatic effect [17]. Interestingly, some human studies reported that the muscle mass is higher in obese old persons than those with lesser obesity [60,61]. is may be due to the decreased levels of SHBG which in turn results in an increased level of circulating androgens [61].
When we considered food intake as an important factor for the prevention of sarcopenia, caloric restriction without being malnutrition may have a positive impact on cells [59]. Animal studies shown that caloric restriction attenuates the progressive functional decline of organs [21]. At the cellular level, caloric restriction is associated with a decreased damage of peripheral nerve during aging by increasing the expression of chaperones and autophagic machineries [24]. It also ameliorates the loss of muscle mass, decreases abnormalities in the electron transport chain and diminished apoptotic potential in muscles [21]. Further, it is associated with neuronal protection against degeneration in animal CNS [62]. However, more ongoing investigations in humans are required to determine its efficacy in reality.
Every picture has two sides, like the above examples, although the nervous system may have an important vital role for the muscular system, the muscular system is also playing an important vital role for the nervous system as the muscle �bers are supplying the NGF-like factors to the motor neuron for its survival [63]. us, when considering the motor unit holistically, the common musculogenic model of sarcopenia is also valid.

Conclusion
Sarcopenia is an age-associated condition which links to multiple etiological factors ranging from external factors (physical activities, nutrients, and diseases) to internal factors (interplay between di�erent cells, epigenetic pro�le of the cells, and congenital genetic con�guration of an individual). In this article, we propose that sarcopenia may be neurogenic in origin due to the intimate relationship between the nervous system and the muscle cells. By summarizing the aforementioned evidences, it seems that the pathological importance at the presynaptic side (nerve side) precedes the postsynaptic side (muscle side). is presumption is in agreement with the age-associated degeneration of motor neurons [21]. Further, the age-associated denervation is more likely to be triggered by the disuse atrophy of synapse or even motor neurons. is is consistent with the fact that individuals with a sedentary life style or physical inactivity are usually more susceptible to sarcopenia compared to the physical active ones. However, more investigation is required in order to validate this belief. For example, to perform an in vitro experiment on the primary muscle cells which cultured with the necessary nervous-system-derived factors and observe whether the change in these factors would signi�cantly a�ect the potential for sarcopenia development. But before that, a consensus for the de�nition of sarcopenia must be committed.

Con�ict of �nterests
e authors declare that they have no con�ict of interests.