Are Improvements in Bone and Physical Performance from an 8-Month High-Intensity Exercise Program Maintained in Postmenopausal Women With Low Bone Mass? 3-Year Follow-P of the LIFTMOR Trial

Links

DOI: 10.25904/1912/3027

Abstract

Introduction: In Australia, 1 in 4 women over 50 and 1 in 2 over 80 suffer from osteoporosis. There are 8.9 million osteoporosis-related fractures worldwide each year. Current recognised treatment is primarily confined to medications which are not without side effects. The discovery of an effective, nonpharmacological management strategy for osteoporosis will help reduce the financial burden on the healthcare system, and potentially reduce mortality, pain and suffering related to osteoporosis. The skeletal response to mechanical loading is dependent on the nature of the applied load. Optimal osteogenic loads induce high-magnitude strains at high rates. A high-intensity resistance and impact training program (HiRIT) was therefore designed and tested as a potential intervention for postmenopausal women with osteoporosis or osteopenia - the LIFTMOR trial. Despite concerns about inherent risks to a fragile skeleton, HiRIT in the LIFTMOR trial was observed to improve bone without causing fractures in this at-risk population. It was not known if HiRIT delivered in a non-research supervised clinical setting maintained the same level of safety and efficacy. The primary aim of the current observational study was to determine the effects of cessation, continuation or uptake of HiRIT on bone and functional outcomes for postmenopausal women with low to very low bone mass who participated in the LIFTMOR trial. Secondarily, the study assessed the safety of a HiRIT program for postmenopausal women with low to very low bone mass who participated in the LIFTMOR trial.

Methods: Of the 101 postmenopausal women who enrolled in the 8-month LIFTMOR trial (for which data was collected at baseline [T0] and completion [T1]), 86 completed and were invited for retesting. Participants underwent the identical testing protocol as the LIFTMOR trial at three-year follow-up (T2). Bone mineral density (BMD) at the lumbar spine (LS) and femoral neck (FN)(DXA), and physical performance measures (back extensor strength [BES], lower limb strength [LES], functional reach test [FRT], timed up-and-go test [TUGT], five times sit-to-stand [FTSTS] and maximal vertical jump [VJ]) were remeasured. Participants were designated to four groups based on HiRIT participation both during and after cessation of the LIFTMOR trial. Participants initially randomised to CON in the LIFTMOR trial who did or did not adopt HiRIT thereafter were designated CON-HIRT and CON-CON, respectively. Those initially randomised to HiRIT who did or did not adopt HiRIT thereafter were designated HiRIT-HiRIT and HiRIT-CON, respectively. The statistical analysis was conducted using the SPPS software (Version 25; SPSS Inc., Chicago, IL). Descriptive statistics were generated for participant characteristics, biometrics, and all dependent variables. A simple ANCOVA was performed to examine between-group differences in change from the original follow-up.

Results: Fifty women (65±5 years, 161.8±4.0 cm, 61.9±6.1 kg) agreed to participate in follow-up retesting (3.2±0.6 years). LS BMD improved more in HiRIT-HiRIT (8.63±5.29%, n=7) than HiRIT-CON (2.18±5.65%, p=0.042, n=16). LS BMD improved more in CON-HiRIT (8.54±4.08%, n=11) than HiRIT-CON (2.18±5.65%, p=0.046). FN BMD improved more in HiRIT-HiRIT (3.67±4.45%) than HiRIT-CON (2.85±5.79%, p=0.014). LES improved more in CON-HiRIT (7.1±25.7%) than HiRITCON (-8.8±-24.4%, p=0.012), HiRIT-HiRIT (2.8±22.8%, p=0.024), and CON-CON (3.1±26.5%, p=0.022, n=16). TUG improved more in CON-HiRIT (15.6±7.9%) than HiRIT-HiRIT (1.4±12.3%, p=0.001), HiRIT-CON (7.8±8.2%, p=0.021). FTSTS improved more in CON-HiRIT (7.1±12.9%) than HiRIT-CON (-6.4±20.5%, p=0.018) and CON-CON (3.9±10.9%, p=0.029). VJ improved more in CONHiRIT (17.23±11.49%) than CON-CON (-22.95±9.58%, p=0.020).

Conclusion: The LIFTMOR trial was the first to show that a brief, supervised HiRIT exercise program was efficacious and safe for improving bone at clinically-relevant sites, stature and functional performance in postmenopausal women with low bone mass. The current 3-year follow-up study demonstrated that participants who began HiRIT training after being initially randomised to CON improved bone and other outcomes in a similar way to those allocated to HiRIT in the LIFTMOR trial. LIFTMOR participants allocated to HiRIT during the trial who continued HiRIT after trial cessation continued to improve BMD and functional performance. LIFTMOR participants allocated to HiRIT but who ceased HiRIT after trial cessation continued to exhibit overall BMD and functional performance gains from baseline, but the effects had diminished. LIFTMOR participants allocated to CON who did not take up HiRIT training after the trial increased BMD and functional performance, but improvements were not as notable as those in the HiRIT groups. Although representing only 58% of the original LIFTMOR participants, to the extent that our conclusions are tempered by sample size, our follow-up analyses suggest that musculoskeletal and functional benefits from HiRIT may endure for some years. Nevertheless, ongoing participation appears to be necessary for meaningful, sustained effect.

Cited Works (35)

Year	Entry
1995	Kohrt WM, Snead DB, Slatopolsky E, Birge SJ Jr. Additive effects of weight-bearing exercise and estrogen on bone mineral density in older women. J Bone Miner Res. September 1995;10(9):1303-1311.
2008	Weeks BK, Beck BR. The BPAQ: a bone-specific physical activity assessment instrument. Osteoporos Int. November 2008;19(11):1567-1577.
1994	Nelson ME, Fiatarone MA, Morganti CM, Trice I, Greenberg RA, Evans WJ. Effects of high-intensity strength training on multiple risk factors for osteoporotic fractures: a randomized controlled trial. JAMA. December 28, 1994;271(24):1909-1914.
2001	NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy. Osteoporosis prevention, diagnosis, and therapy. JAMA. February 14, 2001;285(6):785-795.
2003	Kanis JA, Oden A, Johnell O, Laet CD, Jonsson B, Oglesby AK. The components of excess mortality after hip fracture. Bone. May 2003;32(5):468-473.
1994	Rubin CT, McLeod KJ. Promotion of bony ingrowth by frequency-specific, low-amplitude mechanical strain. Clin Orthop Relat Res. January 1994;298:165-174.
2015	Zhao R, Zhao M, Xu Z. The effects of differing resistance training modes on the preservation of bone mineral density in postmenopausal women: a meta-analysis. Osteoporos Int. May 2015;26(5):1605-1618.
2003	Turner CH, Robling AG. Designing exercise regimens to increase bone strength. Exerc Sport Sci Rev. January 2003;31(1):45-50.
2008	Clarke B. Normal bone anatomy and physiology. Clin J Am Soc Nephrol. November 2008;3(suppl 3):S131-S139.
1996	Kerr D, Morton A, Dick I, Prince R. Exercise effects on bone mass in postmenopausal women are site-specific and load-dependent. J Bone Miner Res. February 1996;11(2):218-225.
2003	Ammann P, Rizzoli R. Bone strength and its determinants. Osteoporos Int. March 2003;14(suppl 3):S13-S18.
2013	Kanis JA, McCloskey EV, Johansson H, Cooper C, Rizzoli R, Reginster J-Y; Scientific Advisory Board of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO); Committee of Scientific Advisors of the International Osteoporosis Foundation (IOF). European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int. January 2013;24(1):23-57.
2009	Holzer G, von Skrbensky G, Holzer LA, Pichl W. Hip fractures and the contribution of cortical versustrabecular bone to femoral neck strength. J Bone Miner Res. March 2009;24(3):468-474.
1993	Cummings SR, Black DM, Nevitt MC, Browner W, Cauley J, Ensrud K, Genant HK, Palmero L, Scott J, Vogt TM; Study of Osteoporotic Fractures Research Group. Bone density at various sites for prediction of hip fractures. Lancet. January 9, 1993;341(8837):72-75.
2001	Robling AG, Duijvelaar KM, Geevers JV, Ohashi N, Turner CH. Modulation of appositional and longitudinal bone growth in the rat ulna by applied static and dynamic force. Bone. August 2001;29(2):105-113.
2011	Rachner TD, Khosla S, Hofbauer LC. Osteoporosis: now and the future. Lancet. April 9, 2011;377(9773):1276-1287.
1997	Burr DB. Muscle strength, bone mass, and age‐related bone loss. J Bone Miner Res. 1997;12(10):1547-1551.
1995	Duncan RL, Turner CH. Mechanotransduction and the functional response of bone to mechanical strain. Calcif Tiss Int. December 1995;57(5):344-358.
1984	Lanyon LE, Rubin CT. Static vs dynamic loads as an influence on bone remodelling. J Biomech. 1984;17(12):897-905.
2006	Reginster J-Y, Burlet N. Osteoporosis: a still increasing prevalence. Bone. February 2006;38(2)(suppl 1):4-9.
2006	Bousson V, Bras AL, Roqueplan F, Kang Y, Mitton D, Kolta S, Bergot C, Skalli W, Vicaut E, Kalender W, Engelke K, Laredo J-D. Volumetric quantitative computed tomography of the proximal femur: relationships linking geometric and densitometric variables to bone strength. role for compact bone. Osteoporos Int. June 2006;17(6):855-864.
2018	Watson SL, Weeks BK, Weis LJ, Harding AT, Horan SA, Beck BR. High-intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: the LIFTMOR randomized controlled trial. J Bone Miner Res. February 2018;33(2):211-220.
2000	Wallace BA, Cumming RG. Systematic review of randomized trials of the effect of exercise on bone mass in pre- and postmenopausal women. Calcif Tiss Int. July 2000;67(1):10-18.
1985	Rubin CT, Lanyon LE. Regulation of bone mass by mechanical strain magnitude. Calcif Tiss Int. 1985;37(4):411-417.
1984	Rubin CT, Lanyon LE. Regulation of bone formation by applied dynamic loads. J Bone Joint Surg. March 1984;66A(3):397-402.
1993	Cooper C, Atkinson EJ, Jacobsen SJ, O’Fallon WM, Melton LJ III. Population-based study of survival after osteoporotic fractures. Am J Epidemiol. May 1, 1993;137(9):1001-1005.
2011	Howe TE, Shea B, Dawson LJ, Downie F, Murray A, Ross C, Harbour RT, Caldwell LM, Creed G. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database Sys Rev. July 6, 2011;7:CD000333.
1994	Turner CH, Forwood MR, Otter MW. Mechanotransduction in bone: do bone cells act as sensors of fluid flow? FASEB J. August 1994;8(11):875-878.
2000	Heaney RP, Abrams S, Dawson-Hughes B, Looker A, Marcus R, Matkovic V, Weaver C. Peak bone mass. Osteoporos Int. December 2000;11(12):985-1009.
1991	Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. February 1991;39(2):142-148.
1998	Turner CH, Pavalko FM. Mechanotransduction and functional response of the skeleton to physical stress: the mechanisms and mechanics of bone adaptation. J Orthop Sci. November 1998;3(6):346-355.
1995	Pruitt LA, Taaffe DR, Marcus R. Effects of a one-year high-intensity versus low-intensity resistance training program on bone mineral density in older women. J Bone Miner Res. November 1995;10(11):1788-1795.
1982	O'Connor JA, Lanyon LE, MacFie H. The influence of strain rate on adaptive bone remodelling. J Biomech. 1982;15(10):767-781.
1998	Bassey EJ, Rothwell MC, Littlewood JJ, Pye DW. Pre- and postmenopausal women have different bone mineral density responses to the same high-impact exercise. J Bone Miner Res. December 1998;13(12):1805-1813.
2006	Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int. December 2006;17(12):1726-1733.