Keywords
bone mineral density, bone turnover marker, osteoporosis, high-impact, odd-impact, resistance exercise, balance training, multimodal training
This article is included in the Research Synergy Foundation gateway.
Background: To minimize fracture risk, multimodal training regimens are recommended. However, their effectiveness in community settings remains uncertain. This study evaluated the feasibility of 19-weeks of multimodal training in a local community center with emphasis on musculoskeletal health in postmenopausal women.
Methods: In a controlled trial, 28 postmenopausal women (53-68-years-old) were assigned to a multimodal training group (MMT, n=15) or a control group (CON, n=13). The training consisted of high- and odd-impact, resistance and balance-coordination training 1-2 hours weekly. The outcomes were attendance rate, regional and total bone mineral density (BMD), bone mineral content (BMC), bone turnover markers (BTM), body composition, functional muscle strength and power, and dynamic balance. All were determined at baseline and after 19 weeks of training. BTM was assessed after three weeks.
Results: Overall, 22(79%) participants (MMT, n=9; CON, n=13) completed the study, and the mean attendance rate for MMT was 65.5% of the maximum sessions (2) offered. Only right trochanter BMD increased (p<0.05) by 1.0±1.1% in MMT, which was higher(p<0.05) than CON. While whole-body BMC was not changed at 19 weeks from baseline in MMT, it decreased (p<0.05) in CON resulting in a significant difference (p<0.05) in whole-body BMC delta values between the two groups. Compared to baseline, body fat percentage(%BF), fat mass(FM), and visceral adipose tissue (VAT)-mass and -volume were decreased (p<0.01) in MMT, and were larger (p<0.05) than CON. No significant changes were observed in BTM, muscle strength and power, and dynamic balance after 19 weeks.
Conclusions: Nineteen weeks of multimodal training 1-2 hours per week in a local community had a health-enhancing effect on %BF, FM, and VAT, whereas the musculoskeletal health impact was modest. We hypothesize that the reason might be too low training volume and frequency and supposedly too low musculoskeletal training intensity for some participants.
Registration: ClinicalTrials.gov NCT05164679 (21/12/2021).
bone mineral density, bone turnover marker, osteoporosis, high-impact, odd-impact, resistance exercise, balance training, multimodal training
- Revised the relevant tables to include F-statistics, p-values, and eta-squared values for the interaction effects between group and time.
- Expanded Exercise Details
- We have deleted Figure 3 to prevent the repetition of results already presented in Table 4.
-The title has been revised.
See the authors' detailed response to the review by Melanie Kistler-Fischbacher
See the authors' detailed response to the review by Robert Wen-Wei Hsu
See the authors' detailed response to the review by Jan Gajewski
Osteoporosis is a growing public health concern. The disease is characterized by impaired bone strength due to the reduction of bone mass and impairment of the micro-architecture of the bone, which increase the risk of bone fracture.1 It is estimated that 200 million females are affected worldwide and causes more than 8.9 million fractures per year.2 Falls in osteoporotic patients are linked to high morbidity and mortality.3 Therefore, fall prevention strategies while improving the bone strength aimed at the high-risk population are needed.4
One way to prevent osteoporosis can be through engaging in evidence-based training to improve bone mineral density (BMD) and reduce age-related bone loss,5 such as high-impact and resistance training. Furthermore, balance and coordination training can minimize the risk of falls and fractures, which is relevant to the high-risk population.4 Studies have shown that high-impact exercises, which produce high vertical ground reaction forces with a high force development rate,6 are beneficial for bone structure and mineralization in children,7 adults,8 and the elderly.9 In a previous study of the acute osteogenic response to high-impact jumping in postmenopausal women,10 stimulation of bone formation without any increase in bone resorption after jumping was reported. Moreover, the latter study showed a dose-response relationship between vertical as well as combined three-axes ground reaction forces (GRF) and the acute procollagen type I amino-terminal propeptide (P1NP)-response after countermovement jumps.
In addition, resistance exercise, which induces various muscle loads applied to the bone,11 is reported to be a relevant osteogenic training modality for maintaining or increasing bone density and mass in older people.12 Besides, to prevent falls, balance and coordination exercises are crucial to be included as they improve static and dynamic balance.13 Therefore, it is hypothesized in the present study that training (which combines evidence-based exercise) as health promotion will have an osteogenic effect on bone mass and bone strength that may counteract the normal age-related bone loss in postmenopausal women and improve the dynamic balance as well as muscle strength and power, which may prevent falls and reduce the fracture risk.
Although the association between exercise training, bone loss, and falls prevention in older adults appears to be established in intervention studies,14 only a few studies have examined the effects of combined training on musculoskeletal health in postmenopausal women,9,15–21 and the results are varied. Therefore, there is still a need for safe, reliable, affordable, and evidence-based training programs that can be introduced, embraced, and sustained in high-risk populations, such as postmenopausal women.
The present study was performed in a local community setting. The aim was to investigate the feasibility and the health-promoting musculoskeletal effects of 19wk multimodal training (high- and odd-impact, resistance, balance, and coordination training) for postmenopausal women. The primary outcomes were bone mass and BTM, while body composition, dynamic balance, muscle strength and power were the secondary outcomes.
This is a feasibility study in a local community with a non-randomized controlled trial approach. The multimodal training was offered to postmenopausal healthy women in a local community. The outcomes for the training group (MMT) were compared with a sedentary control group (CON). The primary outcomes were musculoskeletal health, namely BMD, bone mass, and bone turnover markers (BTM), while the secondary outcomes were attendance rate, dropout, body composition including body weight and height, vertical jump height, and dynamic balance. Training was offered twice weekly for one hour, and the average attendance rate of MMT participants over the 19wk had to be >1 hour weekly. To collect baseline (BASE) data, all participants showed up in the laboratory on three occasions prior to the intervention (a description of the specific methods used is given in later sections). On the first visit, resting blood samples were collected to evaluate the concentration of BTM, body weight, height, body composition including BMD and bone mass were measured. On the second visit, a dynamic balance test (four square step test) and a functional muscle strength and power test (jump-and-reach test) were performed. On the third visit, the aerobic capacity was evaluated by assessment of VO2-max. After three weeks (3wk) of training, resting blood samples were additionally collected. After 19wk of training, all assessments were repeated and compared with baseline and MMT and CON were compared.
Blood sample collection, DXA-scanning, and VO2-max tests were carried out at the Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark. The testing of vertical jump height, as well as dynamic balance, were performed at the health promotion training initiative in the Copenhagen area, Denmark. The blood samples were analyzed at the Department of Clinical Biochemistry, Rigshospitalet Glostrup Hospital, Denmark.
The trial was registered retrospectively at ClinicalTrials.gov and published on December 21st, 2021 (NCT05164679). As registration at ClinicalTrials.gov has until recently not been a part of the general research policy in our team, the trial was registered after completion of the study.
Healthy, sedentary postmenopausal women aged below 70 years were eligible to participate in the present study. Inclusion criteria were non-smoker and body mass index (BMI) <30 kg/m2. Exclusion criteria were: T-score < -3 SD in the lumbar spine or hip; Z-score > 1.5 SD (high age-related BMD); use of hormone therapy, medical treatment, or supplements that affect bone metabolism; previous or current medical condition affecting bone health; engagement in regular and systematic weight-bearing training or strength training during the preceding two years (to distinguish active from sedentary). The engagement in regular, systematic training here means engage minimum at least one time a week and has a goal of the training.
Initially, twenty women were recruited to the training via advertisements online and an in a local newspaper, of which 19 showed up for pre-testing (Figure 1). After a medical examination, one participant was excluded due to low BMD (T-score < -3 SD), and two were excluded due to high BMI (≥30 kg/m2). In addition, one woman refrained from participating in the training, and thus, 15 participants were recruited to MMT. CON consisted of 13 age-matched sedentary postmenopausal women (12 from a previous study (not a long time before the present study) plus the woman who refrained from participating in the training) which recruited with the same procedure, via advertisement online and a local newspaper. Participants’ baseline characteristics, including maximum oxygen consumption (VO2-max), are shown in Table 1.
Every participant was fully informed in writing and verbally before giving her written consent to the procedures and potential discomfort associated with the study. The study was conducted in accordance with the Declaration of Helsinki and approved by the local ethics committee of the Capital Region of Denmark, H-18044190.
The present feasibility study evaluated the osteogenic impact of a training concept already offered by a health promotion initiative, “Knoglestærk” (“Bone strong”), in a local community.
According to the initiative, the training was offered as “evidence-based bone training” aimed at enhancing musculoskeletal health. It was carried out 2 × 60 minutes weekly and included three main components: 1) High- and odd-impact exercise, including multi-directional games; 2) Progressive resistance training (PRT); and 3) Balance and coordination training.
The participants engaged in recurrent gymnastic activities and small games designed to impose osteogenic and varied strain on bones, primarily targeting the legs and arms. The training included various jumping exercises, such as counter-movement jumps, jumps from the floor up onto a bench, and from a bench down to the floor. Other exercises involved quick walking up and down on gymnastics equipment and sprinting over short distances in different directions, often integrated into small games to promote interaction between participants.
To ensure a high strain rate and strain magnitude necessary for stimulating bone formation, the training incorporated exercises like unilateral jumps from side to side, random unilateral jumps, and jumps in a square. The intensity of these exercises varied from low (jogging and brisk walking) to medium (catch games, dodgeball, jumps, and leaps) and high intensity (box jumps with drop landing, plyometric jumps, and sprints with a sudden stop). Each training session included at least 40 medium-to-high-intensity impacts to maximize the osteogenic stimulus.
In addition to these impact exercises, the PRT component consisted primarily of exercises using participants' own body weight, supplemented with medicine balls, resistance bands, and sandbags weighing 5–15 kg. The resistance training started with 15–20RM and gradually progressed to 6–12RM, with 2–3 sets per exercise. Exercises included back extensions, air squats, wall balls, rows with resistance bands, lunges, jumping lunges, and sprints with partner resistance. These exercises were performed intermittently and varied to prevent the desensitization of the skeleton that is often observed with repetitive stimuli, thereby enhancing the osteogenic response.
The overall training approach was designed to provide a comprehensive osteogenic stimulus through a combination of high-impact, odd-impact, and resistance exercises, all delivered in an engaging, community-based format.
In the present study, the feasibility was measured by the attendance rate. The attendance rate range, first and last four weeks reported.
To test the BMD exclusion criteria at baseline as well as evaluate bone adaptation in proximal femur (PF), lumbar spine (LS), and whole-body (WB) after 19wk of training, BMD (g/cm2) were assessed by Dual-energy X-ray Absorptiometry scanning (iDXA, Lunar Corporation, Madison, Wisconsin, USA) according to standard procedures. The regions of interests were determined by the encore software (encore software version 14.10.022, GE Medical Systems, Madison, United States). In addition, body composition was evaluated by the whole-body scan: body weight (BW, kg), BMI (kg/m2), body fat percentage (%BF, %), total fat mass (FM, g), total lean body mass (LBM, g), visceral adipose tissue (VAT) mass (g) and volume (m3), and total bone mineral content (BMC, g). The participants were asked to remove metal objects and empty their bladder prior to scanning.
The plasma concentration of BTM at BASE, after 3wk, and after 19wk of training were measured. After an overnight fast and without any vigorous activities in the previous 48 hours, participants showed up in the laboratory in the early morning. Blood samples were collected from the antecubital vein with a butterfly needle, then transferred to EDTA tubes and centrifuged immediately. The plasma fractions were put on dry ice. Eighteen ml of blood were taken from each participant per test day. Following each test, a sample was placed at -80°C for future P1NP, OC, and CTX analysis, which were assessed by the Chemiluminescence method using a fully automated immunoassay system (iSYS, Immunodiagnostic Systems Ltd., Bolton, England). The assay performance expressed as inter-run variation coefficients were 8% for P1NP, 9% for OC, and 10% for CTX.
To estimate the participants’ general training status, a progressive test of maximal oxygen uptake (VO2-max) (ml/kg/min) was performed on an electronic bicycle ergometer (Monark 839E, Monark Exercise AB, Vansbro, Sweden) according to standard procedures. A breath-by-breath gas online analyzing system (Jaeger Oxycon Pro, VIASYS Healthcare, Höchberg, Germany) was connected to the participant, and a direct VO2-max measurement was conducted.
The “four square step test” (FSST) was performed to evaluate the dynamic balance22 in MMT. The test requires a person to move systematically forward, sideward, backward, and sideward again over four narrow sticks circa 2.5 cm in diameter and 100 cm in length placed on the floor like a cross. The participants were requested to complete the sequence as fast as possible without touching the sticks. Facing the cross, the participants started in the lower left quadrant by stepping forward over the stick into the next left quadrant, stepped sideward over the stick again into the upper right quadrant, and stepped backward over the stick into the lower right quadrant, then stepped sideward over the stick into the left quadrant where they started. Thus, they were moving in a clockwise direction. The floor in each square must be contacted by both feet, and the participants were asked to face forward for the whole sequence. However, the participants were allowed to turn to step into the next square if needed. They started and finished in the same square, and the score was given in seconds (sec). The test was done twice, and the fastest time was used as the FSST score.
The functional muscle strength and power were evaluated in MMT by a jump-and-reach test (vertical jump height) (Vertec Sports Imports, Hilliard, OH). First, the participants were taught how to perform a countermovement jump and how to displace the vanes that was placed above reaching height on a vertical stand. After thoroughly instruction and familiarization, the jump-and-reach test was performed. The maximum vertical jump height (cm) was determined by the difference between the participant standing reach height and the highest displaced vane. The greatest value out of three trials was taken as the result.
All of the statistical analyses were conducted using the Statistical Package for the Social Sciences (SPSS, version 26.0, IBM Corp., Armonk, NY, USA). The standard descriptive statistics and unpaired T-test were used to describe and test the baseline characteristics of the participants. Repeated measurements ANOVA and general linear model with post hoc tests were used to test the effect of training on BTM, BMD, dynamic balance, and the jump-and-reach test. Interaction effects between group and time were evaluated using F-statistics, and effect sizes were calculated using eta squared (η2) to provide a more nuanced understanding of the intervention’s impact. A p-value < 0.05 was considered significant. Unless otherwise stated, values are given as mean ± standard error (SE).
During the study, two participants in the MMT group dropped out due to personal reasons, and four participants did not meet the mean attendance criterion of at least one session weekly (Figure 1). Therefore, 9 participants from the MMT group and 13 from the CON group were included in the final analysis. At baseline, there were significant differences between MMT and CON for BW, BMI, FM, left and mean femur BMD values, OC, and CTX (Table 1).
MMT (n = 9) | CON (n = 13) | p-value | |
---|---|---|---|
Age (years) | 62.4 ± 3.8 | 58.7 ± 4.7 | 0.061 |
Height (cm) | 166.9 ± 6.4 | 166.9 ± 5.2 | 0.989 |
Weight (kg) | 72.8 ± 5.6 | 64.2 ± 10 | 0.022* |
BMI (kg/m2) | 26.3 ± 2.2 | 22.9 ± 2.9 | 0.009* |
Body Fat Percentage (%) | 39.4 ± 3.1 | 33.7 ± 8.5 | 0.070 |
Total Fat Mass (kg) | 28.7 ± 2.7 | 22.2 ± 8.6 | 0.043* |
Total Lean Body Mass (kg) | 41.8 ± 4.3 | 39.8 ± 3.4 | 0.233 |
VAT-mass (g) | 793 ± 351.2 | 511 ± 434.8 | 0.123 |
VAT-volume (cm3) | 840.6 ± 372.2 | 541.7 ± 460.9 | 0.123 |
Total BMC (g) | 2266.9 ± 206.5 | 2067.2 ± 300.2 | 0.100 |
BMD (g/cm2) | |||
Whole-body | 1.121 ± 0.073 | 1.046 ± 0.099 | 0.066 |
Lumbar spine | 1.088 ± 0.137 | 1.014 ± 0.111 | 0.175 |
Right Femur neck | 0.918 ± 0.092 | 0.834 ± 0.097 | 0.057 |
Left Femur neck | 0.941 ± 0.088 | 0.823 ± 0.076 | 0.003* |
Mean Femur neck | 0.929 ± 0.089 | 0.829 ± 0.085 | 0.015* |
Right Total Femur | 0.947 ± 0.098 | 0.864 ± 0.091 | 0.056 |
Left Total Femur | 0.949 ± 0.101 | 0.840 ± 0.091 | 0.016* |
Mean Total Femur | 0.948 ± 0.098 | 0.852 ± 0.090 | 0.028* |
Right Trochanter | 0.741 ± 0.087 | 0.683 ± 0.092 | 0.149 |
Left Trochanter | 0.745 ± 0.091 | 0.661 ± 0.097 | 0.055 |
Mean Trochanter | 0.743 ± 0.086 | 0.672 ± 0.093 | 0.084 |
Right Shaft | 1.151 ± 0.126 | 1.046 ± 0.125 | 0.068 |
Left Shaft | 1.149 ± 0.131 | 1.008 ± 0.121 | 0.017* |
Mean Shaft | 1.150 ± 0.126 | 1.027 ± 0.121 | 0.033* |
BTM | |||
P1NP (μg/l) | 52.8 ± 16.6 | 62.1 ± 21.3 | 0.298 |
OC (μg/l) | 19 ± 6.5 | 28.9 ± 7.1 | 0.003* |
CTX (ng/l) | 331.2 ± 100.7 | 627.8 ± 253.8 | 0.001* |
VO2-max (ml/min/kg) | 28.2 ± 3.6 | 30.5 ± 4.7 | 0.204 |
As described in the participants section, two persons in MMT dropped out due to personal reasons, and four participants did not meet the mean attendance criterion of at least 1 session weekly (>19 sessions) and were subsequently excluded in the data analyses. The mean attendance rate for the remaining MMT participants (9 women) was 24.2 sessions (65.5%) of the maximum number of sessions offered (37 sessions), with individual attendance rates ranging from 20 to 30 sessions (54.1-81.1%). Attendance decreased over time, from 78% (6.2 out of 8 sessions) in the first four-week period to 64% (5.1 out of 8 sessions) in the last four-week period.
The attendance rate range (54.1-81.1%) in the present study showed that there is inter-individual variability. The participants attended the training more in the first than the last four-week.
After 19wk of training, right trochanter BMD (g/cm2) increased significantly from baseline for MMT (1.0%, p=0.03), which was significantly different from CON (p=0.03) (Table 2), but there was no significant BMD change in any other region. Whole-body BMC decreased significantly (0.7%, p=0.016) within CON (Figure 2).
MMT (n=9) | CON (n=13) | F | p-valuea | Partial Eta Squared | |||
---|---|---|---|---|---|---|---|
Baseline | 19wk | Baseline | 19wk | ||||
Whole body | 1.121 ± 0.073 | 1.119 ± 0.070 | 1.046 ± 0.099 | 1.045 ± 0.099 | 0.026 | 0.873 | 0.001 |
Lumbar spine | 1.088 ± 0.137 | 1.100 ± 0.128 | 1.014 ± 0.111 | 1.005 ± 0.110 | 3.755 | 0.067 | 0.158 |
Right Femur neck | 0.918 ± 0.092 | 0.920 ± 0.104 | 0.834 ± 0.097 | 0.829 ± 0.088 | 0.883 | 0.359 | 0.042 |
Left Femur neck | 0.941 ± 0.088 | 0.939 ± 0.083 | 0.823 ± 0.076 | 0.817 ± 0.079# | 0.967 | 0.337 | 0.046 |
Mean Femur neck | 0.929 ± 0.089 | 0.929 ± 0.092 | 0.829 ± 0.085 | 0.823 ± 0.081 | 2.249 | 0.149 | 0.101 |
Right Total Femur | 0.947 ± 0.098 | 0.950 ± 0.104 | 0.864 ± 0.091 | 0.857 ± 0.086 | 4.199 | 0.054 | 0.174 |
Left Total Femur | 0.949 ± 0.101 | 0.947 ± 0.088 | 0.840 ± 0.091 | 0.837 ± 0.092 | 0.093 | 0.763 | 0.005 |
Mean Total Femur | 0.948 ± 0.098 | 0.948 ± 0.094 | 0.852 ± 0.090 | 0.847 ± 0.088 | 2.408 | 0.136 | 0.107 |
Right Trochanter | 0.741 ± 0.087 | 0.749 ± 0.090# | 0.683 ± 0.092 | 0.677 ± 0.093 | 5.814 | 0.026* | 0.225 |
Left Trochanter | 0.745 ± 0.091 | 0.746 ± 0.073 | 0.661 ± 0.097 | 0.660 ± 0.099 | 0.087 | 0.771 | 0.004 |
Mean Trochanter | 0.743 ± 0.086 | 0.747 ± 0.077 | 0.672 ± 0.093 | 0.669 ± 0.095 | 2.508 | 0.129 | 0.111 |
Right Shaft | 1.151 ± 0.126 | 1.154 ± 0.140 | 1.046 ± 0.125 | 1.040 ± 0.118 | 0.986 | 0.333 | 0.047 |
Left Shaft | 1.149 ± 0.131 | 1.142 ± 0.117 | 1.008 ± 0.121 | 1.006 ± 0.121 | 0.468 | 0.502 | 0.023 |
Mean Shaft | 1.150 ± 0.126 | 1.148 ± 0.126 | 1.027 ± 0.121 | 1.023 ± 0.118 | 0.174 | 0.681 | 0.009 |
*Significant between-group difference (p < 0.05). #Significant within-group difference (p < 0.05).
For body composition, there were significant reductions in %BF (4.0%, p=0.006), FM (6.0%, p=0.013), VAT-mass (11.3%, p=0.004), VAT-volume (11.3%, p=0.004) within the MMT compared to BASE. Compared to CON, there were significant differences for %BF (p=0.049), FM (p=0.021), VAT-mass (p=0.013), VAT-volume (p=0.013), and whole-body BMC (p=0.041) delta values.
The plasma concentrations of P1NP, OC, and CTX are shown in Table 4. There was no significant within- or between-group difference observed at 3wk or 19wk compared to baseline for all markers.
MMT (9) | CON (n=13) | F | p-valueb | Partial Eta Squared | |||
---|---|---|---|---|---|---|---|
Baseline | 19wk | Baseline | 19wk | ||||
Weighta (kg) | 72.8 ± 5.6 | 71.2 ± 5.3 | 64.2 ± 10.3 | 63.8 ± 10.3 | 2.105 | 0.162 | 0.095 |
BMI (kg/m2) | 26.3 ± 2.2 | 25.9 ± 2.4 | 22.9 ± 2.9 | 22.9 ± 3 | 1.357 | 0.258 | 0.064 |
%BF (%) | 39.4 ± 3.1 | 37.8 ± 2.7# | 33.7 ± 8.5 | 33.5 ± 8 | 4.410 | 0.049* | 0.181 |
Total Fat Mass (kg) | 28.7 ± 2.7 | 26.9 ± 2.7# | 22.2 ± 8.6 | 22 ± 8.3 | 6.232 | 0.021* | 0.238 |
Total Lean Mass (kg) | 41.8 ± 4.3 | 42 ± 3.8 | 39.8 ± 3.4 | 39.7 ± 3.4 | 0.183 | 0.673 | 0.009 |
VAT-mass (g) | 793 ± 351.2 | 694 ± 307# | 511 ± 434.8 | 508.8 ± 421.5 | 7.349 | 0.013* | 0.269 |
VAT-volume (cm3) | 840.6 ± 372.2 | 735.7 ± 325.4# | 541.7 ± 460.9 | 539.4 ± 446.8 | 7.348 | 0.013* | 0.269 |
Whole-body BMC (g) | 2266.9 ± 206.5 | 2269.8 ± 202.4 | 2067.2 ± 300.2 | 2052.6 ± 301.3# | 4.750 | 0.041* | 0.546 |
There were no significant changes in both FSST and jump-and-reach test at 19-week compared to baseline for MMT (Table 5). However, there was a trend towards faster FSST times at 19-week (p=0.06).
The present study aimed at evaluating the feasibility and whether 19wk of multimodal training offered as musculoskeletal health promotion in a local community had an effect on musculoskeletal health, body composition, dynamic balance, and functional muscle strength in postmenopausal women. The main finding from this study was that the multimodal training program effectively improved body composition, particularly by significantly reducing body fat percentage, total fat mass, and visceral adipose tissue (VAT) in postmenopausal women. Additionally, the training program led to a significant increase in BMD at the right trochanter, indicating localized benefits for bone health.
This study demonstrated that the right trochanter BMD significantly increased by 1.0% in the MMT group, supported by an F-statistic of 5.814 and an eta squared value of 0.225, indicating a medium effect size for the interaction between the training and time on BMD. This suggests that the targeted exercises were particularly effective in enhancing bone density in this specific region. The lack of significant changes in other BMD regions may be attributed to insufficient training frequency and intensity, as the average attendance did not meet the recommended guidelines for osteogenic training. According to Daly and Giangregorio,23 the minimum frequency of resistance training is at least two days per week and for weight-bearing impact exercise 4-7 times per week, which the present study not met as no participant fulfilled 37 times in total for 19wk of training.
The whole-body BMC was not changed in MMT, whereas it was significantly decreased (p=0.02) by 0.7% in CON, which was significantly (p=0.04) different from MMT (Table 3). Thus, it seems from the present study that the training at “Knoglestærk” maintained total bone mass, even with a required minimum training attendance of just one hour weekly. The loss of whole-body BMC (-0.7%, p=0.016) in CON group is consistent with Gallagher et al.,24 who investigated the effect of age and menopause status on bone. The finding that the change in BMC differed between MMT and CON is not in line with Mosti et al.,16 who investigated the impact of three sessions of squat exercise maximal strength training in postmenopausal women with osteoporosis or osteopenia (mean age: 61.9 ± 5.0 y) for 12 weeks. Moreover, they found an increase in lumbar spine BMC not whole-body. Thus, they found an increase of 2.9 ± 2.8% (p=0.01) LS BMC from baseline in training group, and this change was higher (p=0.03) than in control group.
The significant reductions in %BF and FM, as shown in Table 3, are supported by F-statistics of 4.410 (p=0.049, η2=0.181) and 6.232 (p=0.021, η2=0.238) respectively, indicating moderate to large effects. These findings align with previous research, such as Daly et al.,25 who investigated the effect of one year supervised and structured multi-component training program in community-dwelling independently living men (27%) and women (73%) (mean age: 67.4 y, 60-86 years). They found that the FM was significantly decreased (p<0.001) by 3.2%, which is lower than the present study (6.0%, p=0.01). The higher reduction in the present study compared to Daly et al.25 study might be due to the younger participant (62.4 ± 3.8 y) which has a higher metabolic rate than the older one (66 – 94 y)26, that could influence the change of body fat. The reduction in %BF and FM is in line with Nielsen et al.27 as well, who investigated the feasibility and physiological health effects of 15-week training performed minimum once a week for sedentary elderly. They found that the total FM was significantly decreased (-2.0 kg, p=0.01) and the %BF as well (-1.6%, p=0.01).
As the VAT assessment by iDXA is a fairly new functionality, only very few studies report results for this outcome, and it seems that none has studied training effects on VAT for healthy postmenopausal women. Moreover, no normal reference intervals for specific populations have been established yet. The present finding of a 11.3% reduction in VAT seems in line with the Yen et al. study,28 which reported a 6.3% decrease in VAT after eight weeks of aerobic and resistance exercise intervention. However, the study participants were a group of male and female patients receiving chemotherapy for head and neck cancer (mean age: 52 ± 10.7 y). As reported by Yen et al.28 the lower response than the present study (-6.3% vs. -11.3%) may be due to the disease or the shorter duration (8wk vs. 19wk), even though their intervention more frequent (3 days/week vs. one day/week).29 Moreover, it could be hypothesized that the participants in Yen et al.28 study had a lower %BF and VAT at baseline, therefore, it is more difficult to induce a training response. Nevertheless, more studies still needed on healthy postmenopausal women.
Despite the favorable result, as evidenced by the significant F-statistics and effect sizes reported, the present study has several limitations. The differences in baseline value and the selection of the participants were not randomized, these could lead to bias. The duration was short (<6 months) according to the guide to the optimal prescription, preferably 12 to 24 months.30 The dietary intakes were not recorded. Thus, the changes that occur in the body composition could not be known whether entirely due to the training or dietary intake of participants. Future studies should consider taking the dietary intake history and monitoring habitual daily physical activity, which may add an explanation regarding the changes specifically in body composition in the present study. Another thing to note is that the Knoglestærk health promotion program is a real-life setting and thus the training is not as well controlled as in a laboratory setting. Since neither heart rate (HR) nor accelerometer measurements were recorded during exercise, it cannot be ruled out that the individual training intensity varied among the participants. Hence, the use of HR monitor and accelerometer would improve the control and the standardization of the training and thus reduce the variation in the individual response and the reliability of the results. Recent studies18,20 have shown that exercise intensity is positively associated with bone changes, and that low-intensity exercise is ineffective. In addition, we did not carry out a priori power analyses. The power calculations were performed after the studies had been conducted (provided as Extended data31), and the statistical power of the present study seems to be underpowered. Therefore, a larger sample size would have a positive effect on the effect sizes due to a reduction in standard error and thus an improvement of the statistical power. The effect size of the intervention was varied, with the greatest effect on VAT-volume & mass, total BMC, weight, total fat mass and body fat percentage. On the contrary, the intervention has smaller effect on general and specified BMDs. The given amount of time (19wk) and specified intervention (multimodal training group) had greater effect on fat changes rather than bone changes. The interesting part was the total BMC that affected by the intervention was not followed by BMD’s changing.
The results of the present study indicate that while 19 weeks of multimodal musculoskeletal training as offered by the Knoglestærk health promotion training initiative is feasible for postmenopausal women by inducing health-enhancing effects on body composition, however, due to attendance compliance, the training did only elicit minor significant improvements in BMD, thus an increase was found in right trochanter BMD and whole-body BMC. No changes in dynamic balance or functional muscle strength were observed in the present study. To promote musculoskeletal improvements for all participants, better control of the individual musculoskeletal training intensity, frequency, and attendance rate is highly recommended.
RSP contributed to the research concept and study design, literature review, data collection, data analysis and interpretation, statistical analyses, and writing of the manuscript. MB and SE contributed to the research concept and study design, data collection, and reviewing/editing of the manuscript. NRJ contributed to the literature review, reviewing/editing a draft of the manuscript. FAY contributed to data analysis and reviewing/editing a draft of the manuscript. EWH contributed to the research concept and study design, literature review, data collection, data analysis, and interpretation, and reviewing/editing the manuscript.
Figshare: Underlying data for ‘A Feasibility Study of Training in a Local Community Aimed Upon Health Promotion with Special Emphasis on Musculoskeletal Health Effects.’ https://doi.org/10.6084/m9.figshare.16836940.v3.32
This project contains the following underlying data:
- A Feasibility Study of Training Dataset1.csv (dataset of participant characteristic, body composition, and bone mineral density)
- A Feasibility Study of Training Dataset2.csv (dataset of participants’ bone turnover markers)
- A Feasibility Study of Training Dataset3.csv (dataset of functional muscle strength and power and dynamic balance result)
Figshare: Working title: A Feasibility Study of Training in a Local Community Aimed Upon Health Promotion with Special Emphasis on Musculoskeletal Health Effects. Extended data - Statistical power of the paired t-tests for body composition, regional BMD, and bone turnover markers. https://doi.org/10.6084/m9.figshare.16611655.v1.31
Figshare: Working title: A Feasibility Study of Training in a Local Community Aimed Upon Health Promotion with Special Emphasis on Musculoskeletal Health Effects. Extended data - Effect size of the Training Program. https://doi.org/10.6084/m9.figshare.16611787.v1.33
Figshare: CONSORT checklist, extension for Pilot and Feasibility Trials for study “A Feasibility Study of Training in a Local Community Aimed Upon Health Promotion with Special Emphasis on Musculoskeletal Health Effects”. https://doi.org/10.6084/m9.figshare.16610341.v1.34
Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).
We thank all the participants who took part in the study for their time and efforts. The authors thank Jens J. Nielsen for assistance in blood draws, Nadia Quardon for blood sample analysis, Andreas Meine for assistance in VO2-max testing, and Christian Ritz for support in statistics. RSP gratefully acknowledges a Ph.D. fellowship from Lembaga Pengelola Dana Pendidikan (LPDP)/Indonesia Endowment Fund for Education.
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Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Sport science, biomechanics, statistics
Is the work clearly and accurately presented and does it cite the current literature?
Yes
Is the study design appropriate and is the work technically sound?
Partly
Are sufficient details of methods and analysis provided to allow replication by others?
Partly
If applicable, is the statistical analysis and its interpretation appropriate?
Partly
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Are the conclusions drawn adequately supported by the results?
Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Sport science, biomechanics, statistics
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Orthopedics, sports medicine
Is the work clearly and accurately presented and does it cite the current literature?
No
Is the study design appropriate and is the work technically sound?
No
Are sufficient details of methods and analysis provided to allow replication by others?
No
If applicable, is the statistical analysis and its interpretation appropriate?
Yes
Are all the source data underlying the results available to ensure full reproducibility?
No
Are the conclusions drawn adequately supported by the results?
Partly
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Orthopedics, sports medicine
Is the work clearly and accurately presented and does it cite the current literature?
No
Is the study design appropriate and is the work technically sound?
No
Are sufficient details of methods and analysis provided to allow replication by others?
No
If applicable, is the statistical analysis and its interpretation appropriate?
Partly
Are all the source data underlying the results available to ensure full reproducibility?
Yes
Are the conclusions drawn adequately supported by the results?
Partly
References
1. Watson SL, Weeks BK, Weis LJ, Harding AT, et al.: 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. 33 (2): 211-220 PubMed Abstract | Publisher Full TextCompeting Interests: No competing interests were disclosed.
Reviewer Expertise: Exercise science; bone; bone-specific exercise; osteoporosis; weight lifting for bone and muscle health; postmenopausal women
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