A feasibility study of training in a local community aimed upon health promotion with special emphasis on musculoskeletal health effects

Rizky Suganda Prawiradilaga; Magnus Bendtsen; Simon Esrup; Niklas Rye Jørgensen; Fajar Awalia Yulianto; Eva Wulff Helge

doi:10.12688/f1000research.73698.1

Home Browse A feasibility study of training in a local community aimed upon health...

ALL Metrics

Views

Downloads

Get PDF

Get XML

Export

▬

✚

Research Article

A feasibility study of training in a local community aimed upon health promotion with special emphasis on musculoskeletal health effects

[version 1; peer review: 2 not approved]

Rizky Suganda Prawiradilaga ¹, Magnus Bendtsen², Simon Esrup², Niklas Rye Jørgensen^3,4, Fajar Awalia Yulianto⁵, Eva Wulff Helge²

Rizky Suganda Prawiradilaga ¹, Magnus Bendtsen², [...] Simon Esrup², Niklas Rye Jørgensen^3,4, Fajar Awalia Yulianto⁵, Eva Wulff Helge²

PUBLISHED 17 Jan 2022

Author details Author details

¹ Department of Biochemistry, Nutrition and Biomolecular. Faculty of Medicine, Universitas Islam Bandung, Bandung, Jawa Barat, 40116, Indonesia
² Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen N, 2200, Denmark
³ Department of Clinical Biochemistry, Rigshospitalet Glostrup, Glostrup, 2600, Denmark
⁴ Odense Patient data Explorative Network (OPEN), Odense University Hospital/Institute of Clinical Research, University of Southern Denmark, Odense, 50000, Denmark
⁵ Department of Public Health, Faculty of Medicine, Universitas Islam Bandung, Bandung, Jawa Barat, 40116, Indonesia

Rizky Suganda Prawiradilaga
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Magnus Bendtsen
Roles: Conceptualization, Methodology, Resources, Writing – Review & Editing

Simon Esrup
Roles: Conceptualization, Methodology, Resources, Writing – Review & Editing

Niklas Rye Jørgensen
Roles: Writing – Review & Editing

Fajar Awalia Yulianto
Roles: Data Curation, Formal Analysis, Validation, Writing – Review & Editing

Eva Wulff Helge
Roles: Conceptualization, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Research Synergy Foundation gateway.

Abstract

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).

Keywords

bone mineral density, bone turnover marker, osteoporosis, high-impact, odd-impact, resistance exercise, balance training, multimodal training

Corresponding author: Rizky Suganda Prawiradilaga

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2022 Prawiradilaga RS et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Prawiradilaga RS, Bendtsen M, Esrup S et al. A feasibility study of training in a local community aimed upon health promotion with special emphasis on musculoskeletal health effects [version 1; peer review: 2 not approved]. F1000Research 2022, 11:51 (https://doi.org/10.12688/f1000research.73698.1) First published: 17 Jan 2022, 11:51 (https://doi.org/10.12688/f1000research.73698.1) Latest published: 04 Sep 2024, 11:51 (https://doi.org/10.12688/f1000research.73698.3)

Introduction

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 evidence-based multimodal training 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 appear to be established in intervention studies,¹⁴ only a few studies have examined the effects of combined training on musculoskeletal health in postmenopausal women,¹⁵^–¹⁷ 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.

Methods

Study design

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). 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 bone turnover markers (BTM), and 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.

To ensure transparency of the study protocol, the trial was registered retrospectively at ClinicalTrials.gov and published on December 21^st, 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.

Participants

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.

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. During the study, two participants in MMT dropped out due to personal reasons and at the end of the study four participants were excluded in the analyses as their average attendance to the program was less than one hour per week. CON consisted of 13 age-matched sedentary postmenopausal women (12 from a previous study plus the woman who refrained from participating in the training), and therefore 9 MMT and 13 CON was finally included in the data analyses. Participants' baseline characteristics, including maximum oxygen consumption (VO2-max), are shown in Table 1.

Figure 1. CONSORT flow diagram.

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.

Training program

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 upon enhancing musculoskeletal health. It was carried out 2 × 60 minutes weekly. The training concept included: 1) High- and odd-impact exercise including multi-directional games; 2) Progressive resistance training; 3) Balance and coordination training. The participants were engaged in intermittent gymnastics and small game sessions aimed at imposing osteogenic and diverse strain on the skeleton, mainly in the legs and arms. Thus, the training included various jumping exercises (e.g., counter-movement jumps, jumps from the floor up onto a bench, and from a bench down to the floor), quick walking up and down on gymnastics equipment, sprinting over short distances in different directions (in small games form). In addition, resistance exercises with elastic power bands, heavy exercise balls (medicine balls), and sandbags of 5-7 kg were applied. The training was performed intermittent and varied to ensure that the bones would not be desensitized, as it is observed in repetitive endurance training.

BMD and body composition

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.

Blood sampling & biochemical analyses

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.

Training status

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.

Dynamic balance

The “four square step test” (FSST) was performed to evaluate the dynamic balance¹⁸ 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.

Functional muscle strength and power

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.

Statistical analysis

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. A p-value < 0.05 was considered significant. Unless otherwise stated, values are given as mean ± standard error (SE).

Results

Participant characteristics

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).

Table 1. Baseline characteristics of the participants.

	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

* Significant difference between groups (p < 0.05). Unpaired T-test.

Attendance and dropout

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 participants (9 women) was 24.2 sessions (65.5%) of the maximum number of sessions offered (37 sessions). The individual attendance rates were 20-30 sessions (54.1-81.1%). with a decrease in attendance rate over time from 6.2 out of 8 sessions (78%) in the first four-week period and 5.1 out of 8 sessions (64%) 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.

BMD and body composition

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. However, LS (1.2%) and right total femur (0.3%) tended to increase (both, p < 0.1) for MMT (Figure 2). Whole-body BMC decreased significantly (0.7%, p = 0.016) within CON.

Table 2. Absolute BMD values (Mean ± SD).

	MMT (n = 9)		CON (n = 13)		p-value^a
	Baseline	19wk	Baseline	19wk	p-value^a
Whole body	1.121 ± 0.073	1.119 ± 0.070	1.046 ± 0.099	1.045 ± 0.099	0.873
Lumbar spine	1.088 ± 0.137	1.100 ± 0.128	1.014 ± 0.111	1.005 ± 0.110	0.067
Right Femur neck	0.918 ± 0.092	0.920 ± 0.104	0.834 ± 0.097	0.829 ± 0.088	0.359
Left Femur neck	0.941 ± 0.088	0.939 ± 0.083	0.823 ± 0.076	0.817 ± 0.079^#	0.337
Mean Femur neck	0.929 ± 0.089	0.929 ± 0.092	0.829 ± 0.085	0.823 ± 0.081	0.149
Right Total Femur	0.947 ± 0.098	0.950 ± 0.104	0.864 ± 0.091	0.857 ± 0.086	0.054
Left Total Femur	0.949 ± 0.101	0.947 ± 0.088	0.840 ± 0.091	0.837 ± 0.092	0.763
Mean Total Femur	0.948 ± 0.098	0.948 ± 0.094	0.852 ± 0.090	0.847 ± 0.088	0.136
Right Trochanter	0.741 ± 0.087	0.749 ± 0.090^#	0.683 ± 0.092	0.677 ± 0.093	0.026*
Left Trochanter	0.745 ± 0.091	0.746 ± 0.073	0.661 ± 0.097	0.660 ± 0.099	0.771
Mean Trochanter	0.743 ± 0.086	0.747 ± 0.077	0.672 ± 0.093	0.669 ± 0.095	0.129
Right Shaft	1.151 ± 0.126	1.154 ± 0.140	1.046 ± 0.125	1.040 ± 0.118	0.333
Left Shaft	1.149 ± 0.131	1.142 ± 0.117	1.008 ± 0.121	1.006 ± 0.121	0.502
Mean Shaft	1.150 ± 0.126	1.148 ± 0.126	1.027 ± 0.121	1.023 ± 0.118	0.681

a General Linear Model + post hoc test.

* Significant difference between group (p < 0.05).

# Significant difference within group (p < 0.05).

Figure 2. Percent change (± SE) in whole-body and regional bone mineral density (BMD) following the 19-week multimodal training.

*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 (Table 3). 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.

Table 3. Body composition values (Mean ± SD).

	MMT (9)		CON (n = 13)		p-value^b
	Baseline	19wk	Baseline	19wk	p-value^b
Weight^a (kg)	72.8 ± 5.6	71.2 ± 5.3	64.2 ± 10.3	63.8 ± 10.3	0.162
BMI (kg/m²)	26.3 ± 2.2	25.9 ± 2.4	22.9 ± 2.9	22.9 ± 3	0.258
%BF (%)	39.4 ± 3.1	37.8 ± 2.7#	33.7 ± 8.5	33.5 ± 8	0.049*
Total Fat Mass (kg)	28.7 ± 2.7	26.9 ± 2.7#	22.2 ± 8.6	22 ± 8.3	0.021*
Total Lean Mass (kg)	41.8 ± 4.3	42 ± 3.8	39.8 ± 3.4	39.7 ± 3.4	0.673
VAT-mass (g)	793 ± 351.2	694 ± 307#	511 ± 434.8	508.8 ± 421.5	0.013*
VAT-volume (cm³)	840.6 ± 372.2	735.7 ± 325.4#	541.7 ± 460.9	539.4 ± 446.8	0.013*
Whole-body BMC (g)	2266.9 ± 206.5	2269.8 ± 202.4	2067.2 ± 300.2	2052.6 ± 301.3#	0.041*

a Geometric mean.

b General Linear Model + post hoc test.

* Significant difference between groups (p < 0.05).

# Significant difference within-group (p < 0.05).

BTM

The plasma concentrations of P1NP, OC, and CTX are shown in Figure 3 and Table 4. There was no significant within- or between-group difference observed at 3wk or 19wk compared to baseline for all markers.

Figure 3. Bone turnover markers.

(A) Procollagen type-1 amino-terminal propeptide (P1NP), (B) osteocalcin (OC), and (C) C-terminal telopeptide of type-1 collagen (CTX). Time measurements: Immediately before exercise (baseline), after 3 weeks (3wk), after 19 weeks (19wk). The lines represent means ± SE.

Table 4. Bone turnover marker (BTM) concentrations at BASELINE, after 3 weeks of training (3wk), and after 19 weeks of training (19wk).

Outcome	Group	BASELINE	3wk	19wk	p-value within-group	p-value between-group
Markers of bone formation
P1NP (μg/L)	MMT (n = 9)	52.8 ± 5.5	58.8 ± 4.5	58.4 ± 4.8	0.193	0.304
	CON (n = 13)	62.1 ± 5.9	69.7 ± 7.3	62.4 ± 5.9	0.218	0.304
OC (μg/L)	MMT (n = 9)	19.0 ± 2.2	19.6 ± 1.7	20.0 ± 1.4	0.810	0.231
	CON (n = 13)	28.9 ± 2.0	25.1 ± 1.8	24.8 ± 2.6	0.173	0.231
Marker of bone resorption
CTX (ng/L)	MMT (n = 9)	331.2 ± 33.6	356.6 ± 32.2	374.8 ± 18.5	0.330	0.394
	CON (n = 13)	627.8 ± 70.4	678.2 ± 82.1	729.5 ± 115.8	0.243	0.394

FSST & Jump-and-reach test

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 tendency to be faster in FSST at 19-week (p = 0.06).

Table 5. Dynamic balance and functional muscle strength result for multimodal training group (n=9). Paired t-test.

	Mean ± SD	Difference ± SD	CI-95%	p-value
Four Squared Step Test (sec)
Baseline	7.5 ± 1.0	0.6 ± 0.8	−0.04 – 1.2	0.062
19wk	6.9 ± 0.8			0.062
Jump and reach test (cm)
Baseline	20.2 ± 6.1	−1.3 ± 3.7	−4.2 – 1.5	0.308
19wk	21.6 ± 6.3			0.308

Discussion

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 training program had a positive effect on body composition. Thus, %BF, FM, VAT-mass, and VAT-volume were significantly reduced in MMT compared to CON, showing that the body composition change was due to the training program. In addition, the right trochanter BMD was improved for MMT, and the whole-body BMC was maintained for MMT in contrast to a significant reduction in CON.

This study found that only right trochanter BMD was significantly increased (1.0%, p < 0.05) in MMT. There was no significant changes in other regions of BMD. This finding could be due to the participant attendance did not meet the recommendations of training intensity, volume, and frequency. According to Daly and Giangregorio,¹⁹ 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.,²⁰ 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 reduction in %BF and FM (Table 3) in this study is in agreement with Daly et al.,²¹ 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.²¹ 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),²² that could influence the change of body fat. The reduction in %BF and FM is in line with Nielsen et al.²³ 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 are established yet. The present finding of a 11.3% reduction in VAT seems in line with the Yen et al. study,²⁴ 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.²⁴ 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).²⁵ Moreover, it could be hypothesized that the participants in Yen et al.²⁴ 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, the present study has several limitations. 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. Because 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. 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 data²⁶), 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 greatest effect on VAT-volume & masse, 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.

Conclusions

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 the 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 the functional muscle strength were observed in the present study. To promote musculoskeletal improvements for all participants, a better control of the individual musculoskeletal training intensity, frequency, and attendance rate is highly recommended.

Data availability

Underlying data

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.16836940.²⁹

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)

Extended data

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.v1²⁶

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.v1²⁷

Reporting guidelines

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.v1²⁸

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

Acknowledgements

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.

References

1. Kanis JA, Melton LJ, Christiansen C, et al.: The diagnosis of osteoporosis. J Bone Miner Res. 1994 Aug 1; 9(8): 1137–1141. Publisher Full Text
2. Facts and Statistics|International Osteoporosis Foundation: [cited 2017 Oct 4]. Reference Source
3. Sinaki M, Brey RH, Hughes CA, et al.: Balance disorder and increased risk of falls in osteoporosis and kyphosis: significance of kyphotic posture and muscle strength. Osteoporos Int. 2005 Aug 1; 16(8): 1004–1010. PubMed Abstract | Publisher Full Text
4. Beck BR, Daly RM, Singh MAF, et al.: Exercise and Sports Science Australia (ESSA) position statement on exercise prescription for the prevention and management of osteoporosis. Journal of Science and Medicine in Sport. 2017 May 1; 20(5): 438–445. Publisher Full Text
5. Dalsky GP: Exercise: its effect on bone mineral content. Clin Obstet Gynecol. 1987 Dec; 30(4): 820–832. PubMed Abstract | Publisher Full Text
6. Nikander R, Sievänen H, Heinonen A, et al.: Load-specific differences in the structure of femoral neck and tibia between world-class moguls skiers and slalom skiers. Scand J Med Sci Sports. 2008 Apr; 18(2): 145–153. PubMed Abstract | Publisher Full Text
7. Nogueira RC, Weeks BK, Beck BR: Exercise to improve pediatric bone and fat: a systematic review and meta-analysis. Med Sci Sports Exerc. 2014 Mar; 46(3): 610–621. PubMed Abstract | Publisher Full Text
8. Vainionpää A, Korpelainen R, Leppäluoto J, et al.: Effects of high-impact exercise on bone mineral density: a randomized controlled trial in premenopausal women. Osteoporos Int. 2005 Feb; 16(2): 191–197. Publisher Full Text
9. Karinkanta S, Heinonen A, Sievänen H, et al.: A multi-component exercise regimen to prevent functional decline and bone fragility in home-dwelling elderly women: randomized, controlled trial. Osteoporos Int. 2007 Apr; 18(4): 453–462. Publisher Full Text
10. Prawiradilaga R, Madsen A, Jørgensen N, et al.: Acute response of biochemical bone turnover markers and the associated ground reaction forces to high-impact exercise in postmenopausal women. Biol Sport. 2020; 37(1): 41–48. PubMed Abstract | Publisher Full Text
11. Turner C, Robling A: Exercises for improving bone strength. Br J Sports Med. 2005 Apr; 39(4): 188–189. PubMed Abstract | Publisher Full Text
12. Zehnacker CH, Bemis-Dougherty A: Effect of Weighted Exercises on Bone Mineral Density in Post Menopausal Women: A Systematic Review. Journal of Geriatric Physical Therapy; La Cross. 2007; 30(2): 79–88. PubMed Abstract | Publisher Full Text
13. Dizdar M, Irdesel JF, Dizdar OS, et al.: Effects of Balance-Coordination, Strengthening, and Aerobic Exercises to Prevent Falls in Postmenopausal Patients With Osteoporosis: A 6-Month Randomized Parallel Prospective Study. J Aging Phys Act. 2017 Dec 19; 26(1): 41–51. PubMed Abstract | Publisher Full Text
14. Howe TE, Shea B, Dawson LJ, et al.: Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2011.
15. Borer KT, Fogleman K, Gross M, et al.: Walking intensity for postmenopausal bone mineral preservation and accrual. Bone. 2007 Oct; 41(4): 713–721. PubMed Abstract | Publisher Full Text
16. Mosti MP, Kaehler N, Stunes AK, et al.: Maximal strength training in postmenopausal women with osteoporosis or osteopenia. J Strength Cond Res. 2013 Oct; 27(10): 2879–2886. Publisher Full Text
17. Pereira A, Costa AM, Palmeira-de-Oliveira A, et al.: The effects of combined training on bone metabolic markers in postmenopausal women. Sci Sports. 2016 Jun; 31(3): 152–157. Publisher Full Text
18. Moore M, Barker K: The validity and reliability of the four square step test in different adult populations: a systematic review. Syst Rev. 2017 Sep 11 [cited 2020 May 15]; 6: 6. Publisher Full Text Reference Source
19. Daly RM, Giangregorio L: Exercise for Osteoporotic Fracture Prevention and Management. Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. John Wiley & Sons, Ltd; 2018 [cited 2019 Dec 16]. p. 517–525. Publisher Full Text
20. Gallagher JC, Goldgar D, Moy A: Total bone calcium in normal women: Effect of age and menopause status - Gallagher - 1987. Journal of Bone and Mineral Research - Wiley Online Library. [cited 2020 Jun 2]; 2: 491–496. PubMed Abstract | Publisher Full Text
21. Daly RM, Gianoudis J, Kersh ME, et al.: Effects of a 12-Month Supervised, Community-Based, Multimodal Exercise Program Followed by a 6-Month Research-to-Practice Transition on Bone Mineral Density, Trabecular Microarchitecture, and Physical Function in Older Adults: A Randomized Controlled Trial. J Bone Miner Res. 2019 [cited 2019 Dec 16]; 35: 419–429. Publisher Full Text
22. Rizzo MR, Mari D, Barbieri M, et al.: Resting metabolic rate and respiratory quotient in human longevity.2005; 90(1): 409–413.
23. Nielsen T-T, Møller TK, Andersen LL, et al.: Feasibility and Health Effects of a 15-Week Combined Exercise Programme for Sedentary Elderly: A Randomised Controlled Trial. BioMed Res Int. 2019 Jan 23; 2019: 1–12. Publisher Full Text
24. Yen C-J, Hung C-H, Kao C-L, et al.: Multimodal exercise ameliorates exercise responses and body composition in head and neck cancer patients receiving chemotherapy. Support Care Cancer. 2019 Dec 1; 27(12): 4687–4695. PubMed Abstract | Publisher Full Text
25. Clark J: The impact of duration on effectiveness of exercise, the implication for periodization of training and goal setting for individuals who are overfat, a meta-analysis. Biol Sport. 2016 Dec; 33(4): 309–333. PubMed Abstract | Publisher Full Text
26. Prawiradilaga RS, Magnus B, Esrup S, et al.: 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. figshare.2021 [cited 2021 Sep 13]. Publisher Full Text
27. Prawiradilaga RS, Bendtsen M, Esrup S, et al.: 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. figshare.2021 [cited 2021 Sep 13]. Publisher Full Text
28. Prawiradilaga RS, Bendtsen M, Esrup S, et al.: 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”. figshare.2021 [cited 2021 Sep 13]. Publisher Full Text
29. Prawiradilaga RS, Bendtsen M, Esrup S, et al.: Underlying data for ‘A Feasibility Study of Training in a Local Community Aimed Upon Health Promotion with Special Emphasis on Musculoskeletal Health Effects.’. figshare2021 [cited 2021 Sep 13]. Publisher Full Text

Comments on this article Comments (0)

Version 3

VERSION 3 PUBLISHED 17 Jan 2022

Author details Author details

Magnus Bendtsen
Roles: Conceptualization, Methodology, Resources, Writing – Review & Editing

Simon Esrup
Roles: Conceptualization, Methodology, Resources, Writing – Review & Editing

Niklas Rye Jørgensen
Roles: Writing – Review & Editing

Fajar Awalia Yulianto
Roles: Data Curation, Formal Analysis, Validation, Writing – Review & Editing

Eva Wulff Helge
Roles: Conceptualization, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (3)

version 3

Revised

Published: 04 Sep 2024, 11:51

https://doi.org/10.12688/f1000research.73698.3

version 2

Revised

Published: 09 Mar 2023, 11:51

https://doi.org/10.12688/f1000research.73698.2

version 1

Published: 17 Jan 2022, 11:51

https://doi.org/10.12688/f1000research.73698.1

© 2022 Prawiradilaga RS et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Download

Export To

metrics

	Views	Downloads
F1000Research	-	-
PubMed Central Data from PMC are received and updated monthly.	-	-

Citations

SEE MORE DETAILS

CITE

how to cite this article

Prawiradilaga RS, Bendtsen M, Esrup S et al. A feasibility study of training in a local community aimed upon health promotion with special emphasis on musculoskeletal health effects [version 1; peer review: 2 not approved]. F1000Research 2022, 11:51 (https://doi.org/10.12688/f1000research.73698.1)

NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.

track

receive updates on this article

Track an article to receive email alerts on any updates to this article.

Open Peer Review

Version 1

VERSION 1

PUBLISHED 17 Jan 2022

Views

Reviewer Report 08 Nov 2022

Robert Wen-Wei Hsu, Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Pu-Tz City, Taiwan

Not Approved

https://doi.org/10.5256/f1000research.77367.r152766

Thank you for sending this paper for reviewing. There were some comments on the following:

The sample size is too small to validate the effect of training.
How was the sample

Thank you for sending this paper for reviewing. There were some comments on the following:

The sample size is too small to validate the effect of training.
How was the sample size determined?
Statistical power should be calculated.
The exercise program is not strong enough to have physiological impact to the health.
The duration of exercises is not long enough.
The study is required to do prospective study. The assignment to exercise and control group should be randomized.

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

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

CITE

Report a concern

Author Response 09 Mar 2023

Rizky Suganda Prawiradilaga

09 Mar 2023

Author Response
1. We are aware of that. We tried to equate the number of samples with our previous studies but, in our feasibility study with community settings, it turned out
... Continue reading
We are aware of that. We tried to equate the number of samples with our previous studies but, in our feasibility study with community settings, it turned out that 6 people from the MMT group dropped out.

The sample size was determined by the Author judgement based on the previous study on Bone Turnover Markers (Prawiradilag et al. (2020)).

The Statistical power calculations were performed with Power and Sample Size Calculations version 3.0 for the paired t-test and performed with SPSS for the repeated ANOVA measurement. The results are in the link in the ‘Extended data’ section.

We apologize; we do not actually understand, what do you mean by not strong enough? The Health initiative program uses multimodal training including 1) High- and odd-impact exercise including multi-directional games; 2) Progressive resistance training (PRT); 3) Balance and coordination training which has an osteogenic impact based on evidence, but we are aware that frequency, duration did not meet the recommendation. In addition, we didn’t measure the heart rate for intensity.

We understand that the Health Promotion initiative program was not long enough (19 weeks) and did not meet the recommendation (6-12 months) for osteogenic exercise. We would like to see whether there were bone turnover markers (BTM) changes in this short period since, in our previous study, there were acute responses in BTM.

Thank you for your suggestions.

Is the work clearly and accurately presented and does it cite the current literature?

We have cited the current literature

Is the study design appropriate and is the work technically sound?

We have added, “This is a feasibility study in a local community with a non-randomized controlled trial approach.”

Are sufficient details of methods and analysis provided to allow replication by others?

We think it is sufficient since the study method and the training program were described clearly.

Are all the source data underlying the results available to ensure full reproducibility?

We share the raw data in the ‘Extended data’ section.
We are aware of that. We tried to equate the number of samples with our previous studies but, in our feasibility study with community settings, it turned out that 6 people from the MMT group dropped out.

The sample size was determined by the Author judgement based on the previous study on Bone Turnover Markers (Prawiradilag et al. (2020)).

The Statistical power calculations were performed with Power and Sample Size Calculations version 3.0 for the paired t-test and performed with SPSS for the repeated ANOVA measurement. The results are in the link in the ‘Extended data’ section.

We apologize; we do not actually understand, what do you mean by not strong enough? The Health initiative program uses multimodal training including 1) High- and odd-impact exercise including multi-directional games; 2) Progressive resistance training (PRT); 3) Balance and coordination training which has an osteogenic impact based on evidence, but we are aware that frequency, duration did not meet the recommendation. In addition, we didn’t measure the heart rate for intensity.

We understand that the Health Promotion initiative program was not long enough (19 weeks) and did not meet the recommendation (6-12 months) for osteogenic exercise. We would like to see whether there were bone turnover markers (BTM) changes in this short period since, in our previous study, there were acute responses in BTM.

Thank you for your suggestions.

Is the work clearly and accurately presented and does it cite the current literature?

We have cited the current literature

Is the study design appropriate and is the work technically sound?

We have added, “This is a feasibility study in a local community with a non-randomized controlled trial approach.”

Are sufficient details of methods and analysis provided to allow replication by others?

We think it is sufficient since the study method and the training program were described clearly.

Are all the source data underlying the results available to ensure full reproducibility?

We share the raw data in the ‘Extended data’ section.
Competing Interests: The authors have no professional relationships with companies or manufacturers that might benefit from this study. The results do not constitute an endorsement of any product. Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 09 Mar 2023

Rizky Suganda Prawiradilaga

09 Mar 2023

Author Response
1. We are aware of that. We tried to equate the number of samples with our previous studies but, in our feasibility study with community settings, it turned out
... Continue reading
We are aware of that. We tried to equate the number of samples with our previous studies but, in our feasibility study with community settings, it turned out that 6 people from the MMT group dropped out.

The sample size was determined by the Author judgement based on the previous study on Bone Turnover Markers (Prawiradilag et al. (2020)).

The Statistical power calculations were performed with Power and Sample Size Calculations version 3.0 for the paired t-test and performed with SPSS for the repeated ANOVA measurement. The results are in the link in the ‘Extended data’ section.

We apologize; we do not actually understand, what do you mean by not strong enough? The Health initiative program uses multimodal training including 1) High- and odd-impact exercise including multi-directional games; 2) Progressive resistance training (PRT); 3) Balance and coordination training which has an osteogenic impact based on evidence, but we are aware that frequency, duration did not meet the recommendation. In addition, we didn’t measure the heart rate for intensity.

We understand that the Health Promotion initiative program was not long enough (19 weeks) and did not meet the recommendation (6-12 months) for osteogenic exercise. We would like to see whether there were bone turnover markers (BTM) changes in this short period since, in our previous study, there were acute responses in BTM.

Thank you for your suggestions.

Is the work clearly and accurately presented and does it cite the current literature?

We have cited the current literature

Is the study design appropriate and is the work technically sound?

We have added, “This is a feasibility study in a local community with a non-randomized controlled trial approach.”

Are sufficient details of methods and analysis provided to allow replication by others?

We think it is sufficient since the study method and the training program were described clearly.

Are all the source data underlying the results available to ensure full reproducibility?

We share the raw data in the ‘Extended data’ section.
We are aware of that. We tried to equate the number of samples with our previous studies but, in our feasibility study with community settings, it turned out that 6 people from the MMT group dropped out.

The sample size was determined by the Author judgement based on the previous study on Bone Turnover Markers (Prawiradilag et al. (2020)).

The Statistical power calculations were performed with Power and Sample Size Calculations version 3.0 for the paired t-test and performed with SPSS for the repeated ANOVA measurement. The results are in the link in the ‘Extended data’ section.

We apologize; we do not actually understand, what do you mean by not strong enough? The Health initiative program uses multimodal training including 1) High- and odd-impact exercise including multi-directional games; 2) Progressive resistance training (PRT); 3) Balance and coordination training which has an osteogenic impact based on evidence, but we are aware that frequency, duration did not meet the recommendation. In addition, we didn’t measure the heart rate for intensity.

We understand that the Health Promotion initiative program was not long enough (19 weeks) and did not meet the recommendation (6-12 months) for osteogenic exercise. We would like to see whether there were bone turnover markers (BTM) changes in this short period since, in our previous study, there were acute responses in BTM.

Thank you for your suggestions.

Is the work clearly and accurately presented and does it cite the current literature?

We have cited the current literature

Is the study design appropriate and is the work technically sound?

We have added, “This is a feasibility study in a local community with a non-randomized controlled trial approach.”

Are sufficient details of methods and analysis provided to allow replication by others?

We think it is sufficient since the study method and the training program were described clearly.

Are all the source data underlying the results available to ensure full reproducibility?

We share the raw data in the ‘Extended data’ section.
Competing Interests: The authors have no professional relationships with companies or manufacturers that might benefit from this study. The results do not constitute an endorsement of any product. Close
Report a concern

Views

Reviewer Report 16 May 2022

Melanie Kistler-Fischbacher, Menzies Health Institute Queensland, Griffith University, Gold Coast, Qld, Australia

Not Approved

https://doi.org/10.5256/f1000research.77367.r134828

This non-randomised controlled study reports the effect of a 19-week multicomponent exercise intervention (resistance, balance and impact training) on bone markers, bone mineral density and body composition outcomes among 28 postmenopausal women. I have concerns about the study design and methodological rigor of the trial. Specifically, the duration of the trial 19 weeks is insufficient to detect changes in bone, bias associated with the differences between groups at baseline and the lack of adjustment for multiple comparisons.

Introduction

Paragraph (P) 1: “is it estimated that 200 million females…”. This number actually includes males and females.
P2: “One way to prevent… age-related bone loss”. This is a very old reference. Since 1987 a large number of exercise trials for bone have been conducted. I suggest including a more recent reference.
P3 & 4: In para 3 you hypothesize that “evidence-based multimodal training will have an osteogenic effect and in para 4 you state that there is a need for “evidence-based trainings”. This is contradicting and I don’t think you can call this MMT “evidence based”
P4: “Only few studies have examined…”. There has been a large number of studies that have tested combined impact, resistance and balance training interventions in recent years which showed safety and efficacy.^¹,²,³,⁴ These should be cited here plus the existing gap in the literature identified.
P5: “The aim was to investigate the feasibility…” Feasibility is mentioned in the title, the aims and discussion (e.g. discussion 1^st sentence and conclusion 1^st sentence), however, it is unclear how feasibility was measured. Feasibility is also not listed as an endpoint (e.g. clinicaltrials.gov). Please clarify.

Methods

General: please clarify which outcomes were primary and which ones were secondary.
P1: Please explain how participants were recruited, particularly the sedentary control group.
P1: The duration of 19 weeks is inappropriate to measure changes in bone mineral density. A minimum of 6-8 months is needed to detect changes in bone.
P3: “to ensure transparency” The trial was registered close to manuscript submission data, which does not ensure transparency. I suggest deleting this part of the sentence.
P4: How was sedentary defined?

Was there a minimum age set?
How was postmenopausal defined? (e.g. how many years post menopause?)
How was regular, systematic training defined?

P5: The information on the number of participants and drop outs should be moved to the results section.
P5: “…12 from a previous study...”. Please describe the control group somewhere.
P8: How many sets and repetitions were performed of each exercise, and how did you ensure the resistance training was progressive?
P9: Can you include information on the short-term measurement variability of BMD and body composition measures in your lab?
P12/13: Why were FSST and jump-and-reach tests not performed in the control group?
P14: Given the large number of outcomes, adjustment for multiple comparison is strongly recommended.

Results

P1: There are significant baseline differences between groups which is of great concern. How did you address this, were analyses adjusted for baseline values?
P4: “… LS and total femur… tended to increase”. Reporting of trends is controversial; I suggest removing this sentence.
Table 2: Please explain why you are reporting mean femur BMD in addition to right and left femur values.
Table 2/3: Your findings show a decrease in whole body BMC and an increase in BMD. How would you explain these differences.

Discussion

Rather than comparing present findings to individual studies, I would recommend reviewing the large body of systematic reviews and meta-analyses on the topic. Many of those have examined the influence of training parameters (e.g. intensity, volume and frequency. ^³,⁵) Interpretation of your findings in context of those findings would be helpful. For example, recent studies have shown that exercise intensity is positively associated with bone changes, and that low-intensity exercise is ineffective.

There are a number of limitations of the present study that have not been addressed in the discussion. E.g. bias related to baseline differences, not randomised, only short term (< 6 months), generalisability.

You state that no power calculation was undertaken. 1) How was the sample size determined? 2) How was a posteriori power calculated and what were the results?

I would like to see a section about clinical significance of the findings.

Conclusion

“… inducing health-enhancing effects”. In light of the significant baseline differences, other study limitations and the fact that only body composition variables (which were significantly different between groups at BL) improved, I think this is overstating the findings of the study.

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 Text
2. Kistler-Fischbacher M, Yong JS, Weeks BK, Beck BR: A Comparison of Bone-Targeted Exercise With and Without Antiresorptive Bone Medication to Reduce Indices of Fracture Risk in Postmenopausal Women With Low Bone Mass: The MEDEX-OP Randomized Controlled Trial.J Bone Miner Res. 36 (9): 1680-1693 PubMed Abstract | Publisher Full Text
3. Kistler-Fischbacher M, Weeks BK, Beck BR: The effect of exercise intensity on bone in postmenopausal women (part 2): A meta-analysis.Bone. 143: 115697 PubMed Abstract | Publisher Full Text
4. Karinkanta S, Heinonen A, Sievänen H, Uusi-Rasi K, et al.: A multi-component exercise regimen to prevent functional decline and bone fragility in home-dwelling elderly women: randomized, controlled trial.Osteoporos Int. 2007; 18 (4): 453-62 PubMed Abstract | Publisher Full Text
5. Shojaa M, von Stengel S, Kohl M, Schoene D, et al.: Effects of dynamic resistance exercise on bone mineral density in postmenopausal women: a systematic review and meta-analysis with special emphasis on exercise parameters.Osteoporos Int. 2020; 31 (8): 1427-1444 PubMed Abstract | Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Exercise science; bone; bone-specific exercise; osteoporosis; weight lifting for bone and muscle health; postmenopausal women

CITE

Report a concern

Author Response 10 Mar 2023

Rizky Suganda Prawiradilaga

10 Mar 2023

Author Response
Introduction
P1: We are sorry if we were mistaken. We got it from the Facts and Statistics International Osteoporosis Foundation (IOF) [cited 2017 Oct 4]. Some other references that said ... Continue reading
Introduction
P1: We are sorry if we were mistaken. We got it from the Facts and Statistics International Osteoporosis Foundation (IOF) [cited 2017 Oct 4]. Some other references that said the same that 200 million women: COLOSTEO (the project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No. 778277)¹, and de Villiers and Goldstein (2022)².

P2: Thank you. We have changed the reference to: Zhang S, Huang X, Zhao X, Li B, Cai Y, Liang X, et al. Effect of exercise on bone mineral density among patients with osteoporosis and osteopenia: A systematic review and network meta-analysis. J Clin Nurs. 2022 Aug; 31(15–16):2100–11.

P3 & 4: We agree with you, we have changed a little bit “it is hypothesized in the present study that evidence-based multimodal training as health promotion will have an osteogenic effect” into “it is hypothesized in the present study that training (which combined evidence-based exercise) as health promotion will have an osteogenic effect”. We have revised it.

P4: We have added the references:

Watson SL, Weeks BK, Weis LJ, 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. 2018 Feb; 33(2):211–220.PubMed Abstract | Publisher Full Text

Kistler-Fischbacher M, Yong JS, Weeks BK, et al.:A Comparison of Bone-Targeted Exercise With and Without Antiresorptive Bone Medication to Reduce Indices of Fracture Risk in Postmenopausal Women With Low Bone Mass: The MEDEX-OP Randomized Controlled Trial. J Bone Miner Res. 2021; 36(9):1680–1693. Publisher Full Text

Kistler-Fischbacher M, Weeks BK, Beck BR:The effect of exercise intensity on bone in postmenopausal women (part 2): A meta-analysis. Bone. 2021 Feb 1; 143: 115697. Publisher Full Text

Karinkanta S, Heinonen A, Sievänen H, et al.: A multi-component exercise regimen to prevent functional decline and bone fragility in home-dwelling elderly women: randomized, controlled trial. Osteoporos Int. 2007 Apr; 18(4): 453–462. PubMed Abstract | Publisher Full Text

Shojaa M, von Stengel S , Kohl M, et al.:Effects of dynamic resistance exercise on bone mineral density in postmenopausal women: a systematic review and meta-analysis with special emphasis on exercise parameters. Osteoporos Int. 2020 Aug; 31(8):1427–1444. PubMed Abstract | Publisher Full Text | Free Full Text

P5: Thank you for the suggestion, We have added attendance rate as a feasibility endpoint in the Methods section. The feasibility outcome is already in the Results section.

Methods
General: We have clarified which outcomes were primary and which ones were secondary.

P1: It was explained in Participants section in then Methods section. The sedentary control group was from a previous study (which hasn’t been published) not a long time before the present study. The recruitment process itself was the same, via advertisement online and a local newspaper.

P1: Yes, we understand. The bone turnover occurs around 5 to 6 months, and we can detect the changes around that time of intervention. However, our study regarding the bone turnover marker (Prawiradilaga et al. (2020)³) showed that acute exercise has an acute response on bone marker (P1NP). Regarding that, we hope that we can see the change in bone turnover markers as well as the bone mineral density in only 19 months. Why only 19 months? It was the feasible range of time we can manage before everyone went to summer vacation.

P3: Alright, thank you. We have deleted that part.

P4: Sedentary is defined as someone who didn’t engage in regular and systemic weight-bearing training or strength training in the last 2 years. We have added a note to distinguish active from sedentary.

No minimum age, only maximum 70.

2 years post menopause

Minimum at least 1 time a week, has a goal of the training.

P5: We have considered your suggestion and have moved the number of participants and drop outs to the Results section.

P5: Thank you.

P8: The progressive resistance training (PRT) consisted primarily of exercises using own bodyweight, with occasional use of medicine balls, resistance bands and sandbags (5–15 kg), starting with 15–20RM and slowly progressing to 6–12RM, with 2–3 sets. We have added this in the manuscript.

P9: We don’t think we have the information on short-term of BMD and body composition. We only measure the bone turnover markers for the short-term.

P12/13: They did not want to do the test.

P14: Thank you for the suggestion.

Results
P1: Our analyses were based on the delta values.

P4: Thank you for your suggestion. We have removed “However, LS (1.2%) and right total femur (0.3%) tended to increase (both, p < 0.1) for MMT”.

Table 2: We think it is good information to give the reader the mean femur BMD.

Table 2/3: There is significant difference between MMT and Control (CON) group. While the whole-body BMC showed decrease in CON group, the whole BMC in MMT group doesn’t change. It showed that the training might inhibit the whole-body BMC to decrease in postmenopausal women. The whole-body BMD was not increased, however, the right trochanter BMD in MMT was increased compared to CON.

Discussion
Thank you for the suggestion, We have added regarding the recent studies which have shown that exercise intensity is positively associated with bone changes, and that low-intensity exercise is ineffective.

Thank you for your suggestions, we have addressed other limitations.

The sample size was determined by the Author judgement based on the previous study on Bone Turnover Markers (Prawiradilaga et al. (2020)³.

The posteriori power calculations were performed with Power and Sample Size Calculations version 3.0 for the paired t-test and performed with SPSS for the repeated ANOVA measurement. The results are in the link in the ‘Extended data’ section.

Is the work clearly and accurately presented and does it cite the current literature?

We have cited the current literature

Is the study design appropriate and is the work technically sound?

We have added, “This is a feasibility study in a local community with a non-randomized controlled trial approach.”

Are sufficient details of methods and analysis provided to allow replication by others?

We think it is sufficient since the study method and the training program were described clearly.

References

Osteoporosis Facts [Internet]. COLOSTEO. [cited 2022 Aug 12]. Available online (date last accessed: 10/03/2023)

de Villiers TJ, Goldstein SR: Bone health 2022: an update. Climacteric. 2022 Jan 2; 25(1):1–3. Publisher Full Article

Prawiradilaga R, Madsen A, Jørgensen N, et al.: Acute response of biochemical bone turnover markers and the associated ground reaction forces to high-impact exercise in postmenopausal women. Biol Sport. 2020; 37(1): 41–48. PubMed Abstract
Introduction
P1: We are sorry if we were mistaken. We got it from the Facts and Statistics International Osteoporosis Foundation (IOF) [cited 2017 Oct 4]. Some other references that said the same that 200 million women: COLOSTEO (the project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No. 778277)¹, and de Villiers and Goldstein (2022)².

P2: Thank you. We have changed the reference to: Zhang S, Huang X, Zhao X, Li B, Cai Y, Liang X, et al. Effect of exercise on bone mineral density among patients with osteoporosis and osteopenia: A systematic review and network meta-analysis. J Clin Nurs. 2022 Aug; 31(15–16):2100–11.

P3 & 4: We agree with you, we have changed a little bit “it is hypothesized in the present study that evidence-based multimodal training as health promotion will have an osteogenic effect” into “it is hypothesized in the present study that training (which combined evidence-based exercise) as health promotion will have an osteogenic effect”. We have revised it.

P4: We have added the references:

Watson SL, Weeks BK, Weis LJ, 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. 2018 Feb; 33(2):211–220.PubMed Abstract | Publisher Full Text

Kistler-Fischbacher M, Yong JS, Weeks BK, et al.:A Comparison of Bone-Targeted Exercise With and Without Antiresorptive Bone Medication to Reduce Indices of Fracture Risk in Postmenopausal Women With Low Bone Mass: The MEDEX-OP Randomized Controlled Trial. J Bone Miner Res. 2021; 36(9):1680–1693. Publisher Full Text

Kistler-Fischbacher M, Weeks BK, Beck BR:The effect of exercise intensity on bone in postmenopausal women (part 2): A meta-analysis. Bone. 2021 Feb 1; 143: 115697. Publisher Full Text

Karinkanta S, Heinonen A, Sievänen H, et al.: A multi-component exercise regimen to prevent functional decline and bone fragility in home-dwelling elderly women: randomized, controlled trial. Osteoporos Int. 2007 Apr; 18(4): 453–462. PubMed Abstract | Publisher Full Text

Shojaa M, von Stengel S , Kohl M, et al.:Effects of dynamic resistance exercise on bone mineral density in postmenopausal women: a systematic review and meta-analysis with special emphasis on exercise parameters. Osteoporos Int. 2020 Aug; 31(8):1427–1444. PubMed Abstract | Publisher Full Text | Free Full Text

P5: Thank you for the suggestion, We have added attendance rate as a feasibility endpoint in the Methods section. The feasibility outcome is already in the Results section.

Methods
General: We have clarified which outcomes were primary and which ones were secondary.

P1: It was explained in Participants section in then Methods section. The sedentary control group was from a previous study (which hasn’t been published) not a long time before the present study. The recruitment process itself was the same, via advertisement online and a local newspaper.

P1: Yes, we understand. The bone turnover occurs around 5 to 6 months, and we can detect the changes around that time of intervention. However, our study regarding the bone turnover marker (Prawiradilaga et al. (2020)³) showed that acute exercise has an acute response on bone marker (P1NP). Regarding that, we hope that we can see the change in bone turnover markers as well as the bone mineral density in only 19 months. Why only 19 months? It was the feasible range of time we can manage before everyone went to summer vacation.

P3: Alright, thank you. We have deleted that part.

P4: Sedentary is defined as someone who didn’t engage in regular and systemic weight-bearing training or strength training in the last 2 years. We have added a note to distinguish active from sedentary.

No minimum age, only maximum 70.

2 years post menopause

Minimum at least 1 time a week, has a goal of the training.

P5: We have considered your suggestion and have moved the number of participants and drop outs to the Results section.

P5: Thank you.

P8: The progressive resistance training (PRT) consisted primarily of exercises using own bodyweight, with occasional use of medicine balls, resistance bands and sandbags (5–15 kg), starting with 15–20RM and slowly progressing to 6–12RM, with 2–3 sets. We have added this in the manuscript.

P9: We don’t think we have the information on short-term of BMD and body composition. We only measure the bone turnover markers for the short-term.

P12/13: They did not want to do the test.

P14: Thank you for the suggestion.

Results
P1: Our analyses were based on the delta values.

P4: Thank you for your suggestion. We have removed “However, LS (1.2%) and right total femur (0.3%) tended to increase (both, p < 0.1) for MMT”.

Table 2: We think it is good information to give the reader the mean femur BMD.

Table 2/3: There is significant difference between MMT and Control (CON) group. While the whole-body BMC showed decrease in CON group, the whole BMC in MMT group doesn’t change. It showed that the training might inhibit the whole-body BMC to decrease in postmenopausal women. The whole-body BMD was not increased, however, the right trochanter BMD in MMT was increased compared to CON.

Discussion
Thank you for the suggestion, We have added regarding the recent studies which have shown that exercise intensity is positively associated with bone changes, and that low-intensity exercise is ineffective.

Thank you for your suggestions, we have addressed other limitations.

The sample size was determined by the Author judgement based on the previous study on Bone Turnover Markers (Prawiradilaga et al. (2020)³.

The posteriori power calculations were performed with Power and Sample Size Calculations version 3.0 for the paired t-test and performed with SPSS for the repeated ANOVA measurement. The results are in the link in the ‘Extended data’ section.

Is the work clearly and accurately presented and does it cite the current literature?

We have cited the current literature

Is the study design appropriate and is the work technically sound?

We have added, “This is a feasibility study in a local community with a non-randomized controlled trial approach.”

Are sufficient details of methods and analysis provided to allow replication by others?

We think it is sufficient since the study method and the training program were described clearly.

References

Osteoporosis Facts [Internet]. COLOSTEO. [cited 2022 Aug 12]. Available online (date last accessed: 10/03/2023)

de Villiers TJ, Goldstein SR: Bone health 2022: an update. Climacteric. 2022 Jan 2; 25(1):1–3. Publisher Full Article

Prawiradilaga R, Madsen A, Jørgensen N, et al.: Acute response of biochemical bone turnover markers and the associated ground reaction forces to high-impact exercise in postmenopausal women. Biol Sport. 2020; 37(1): 41–48. PubMed Abstract
Competing Interests: The authors have no professional relationships with companies or manufacturers that might benefit from this study. The results do not constitute an endorsement of any product. Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 10 Mar 2023

Rizky Suganda Prawiradilaga

10 Mar 2023

Author Response
Introduction
P1: We are sorry if we were mistaken. We got it from the Facts and Statistics International Osteoporosis Foundation (IOF) [cited 2017 Oct 4]. Some other references that said ... Continue reading
Introduction
P1: We are sorry if we were mistaken. We got it from the Facts and Statistics International Osteoporosis Foundation (IOF) [cited 2017 Oct 4]. Some other references that said the same that 200 million women: COLOSTEO (the project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No. 778277)¹, and de Villiers and Goldstein (2022)².

P2: Thank you. We have changed the reference to: Zhang S, Huang X, Zhao X, Li B, Cai Y, Liang X, et al. Effect of exercise on bone mineral density among patients with osteoporosis and osteopenia: A systematic review and network meta-analysis. J Clin Nurs. 2022 Aug; 31(15–16):2100–11.

P3 & 4: We agree with you, we have changed a little bit “it is hypothesized in the present study that evidence-based multimodal training as health promotion will have an osteogenic effect” into “it is hypothesized in the present study that training (which combined evidence-based exercise) as health promotion will have an osteogenic effect”. We have revised it.

P4: We have added the references:

Watson SL, Weeks BK, Weis LJ, 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. 2018 Feb; 33(2):211–220.PubMed Abstract | Publisher Full Text

Kistler-Fischbacher M, Yong JS, Weeks BK, et al.:A Comparison of Bone-Targeted Exercise With and Without Antiresorptive Bone Medication to Reduce Indices of Fracture Risk in Postmenopausal Women With Low Bone Mass: The MEDEX-OP Randomized Controlled Trial. J Bone Miner Res. 2021; 36(9):1680–1693. Publisher Full Text

Kistler-Fischbacher M, Weeks BK, Beck BR:The effect of exercise intensity on bone in postmenopausal women (part 2): A meta-analysis. Bone. 2021 Feb 1; 143: 115697. Publisher Full Text

Karinkanta S, Heinonen A, Sievänen H, et al.: A multi-component exercise regimen to prevent functional decline and bone fragility in home-dwelling elderly women: randomized, controlled trial. Osteoporos Int. 2007 Apr; 18(4): 453–462. PubMed Abstract | Publisher Full Text

Shojaa M, von Stengel S , Kohl M, et al.:Effects of dynamic resistance exercise on bone mineral density in postmenopausal women: a systematic review and meta-analysis with special emphasis on exercise parameters. Osteoporos Int. 2020 Aug; 31(8):1427–1444. PubMed Abstract | Publisher Full Text | Free Full Text

P5: Thank you for the suggestion, We have added attendance rate as a feasibility endpoint in the Methods section. The feasibility outcome is already in the Results section.

Methods
General: We have clarified which outcomes were primary and which ones were secondary.

P1: It was explained in Participants section in then Methods section. The sedentary control group was from a previous study (which hasn’t been published) not a long time before the present study. The recruitment process itself was the same, via advertisement online and a local newspaper.

P1: Yes, we understand. The bone turnover occurs around 5 to 6 months, and we can detect the changes around that time of intervention. However, our study regarding the bone turnover marker (Prawiradilaga et al. (2020)³) showed that acute exercise has an acute response on bone marker (P1NP). Regarding that, we hope that we can see the change in bone turnover markers as well as the bone mineral density in only 19 months. Why only 19 months? It was the feasible range of time we can manage before everyone went to summer vacation.

P3: Alright, thank you. We have deleted that part.

P4: Sedentary is defined as someone who didn’t engage in regular and systemic weight-bearing training or strength training in the last 2 years. We have added a note to distinguish active from sedentary.

No minimum age, only maximum 70.

2 years post menopause

Minimum at least 1 time a week, has a goal of the training.

P5: We have considered your suggestion and have moved the number of participants and drop outs to the Results section.

P5: Thank you.

P8: The progressive resistance training (PRT) consisted primarily of exercises using own bodyweight, with occasional use of medicine balls, resistance bands and sandbags (5–15 kg), starting with 15–20RM and slowly progressing to 6–12RM, with 2–3 sets. We have added this in the manuscript.

P9: We don’t think we have the information on short-term of BMD and body composition. We only measure the bone turnover markers for the short-term.

P12/13: They did not want to do the test.

P14: Thank you for the suggestion.

Results
P1: Our analyses were based on the delta values.

P4: Thank you for your suggestion. We have removed “However, LS (1.2%) and right total femur (0.3%) tended to increase (both, p < 0.1) for MMT”.

Table 2: We think it is good information to give the reader the mean femur BMD.

Table 2/3: There is significant difference between MMT and Control (CON) group. While the whole-body BMC showed decrease in CON group, the whole BMC in MMT group doesn’t change. It showed that the training might inhibit the whole-body BMC to decrease in postmenopausal women. The whole-body BMD was not increased, however, the right trochanter BMD in MMT was increased compared to CON.

Discussion
Thank you for the suggestion, We have added regarding the recent studies which have shown that exercise intensity is positively associated with bone changes, and that low-intensity exercise is ineffective.

Thank you for your suggestions, we have addressed other limitations.

The sample size was determined by the Author judgement based on the previous study on Bone Turnover Markers (Prawiradilaga et al. (2020)³.

The posteriori power calculations were performed with Power and Sample Size Calculations version 3.0 for the paired t-test and performed with SPSS for the repeated ANOVA measurement. The results are in the link in the ‘Extended data’ section.

Is the work clearly and accurately presented and does it cite the current literature?

We have cited the current literature

Is the study design appropriate and is the work technically sound?

We have added, “This is a feasibility study in a local community with a non-randomized controlled trial approach.”

Are sufficient details of methods and analysis provided to allow replication by others?

We think it is sufficient since the study method and the training program were described clearly.

References

Osteoporosis Facts [Internet]. COLOSTEO. [cited 2022 Aug 12]. Available online (date last accessed: 10/03/2023)

de Villiers TJ, Goldstein SR: Bone health 2022: an update. Climacteric. 2022 Jan 2; 25(1):1–3. Publisher Full Article

Prawiradilaga R, Madsen A, Jørgensen N, et al.: Acute response of biochemical bone turnover markers and the associated ground reaction forces to high-impact exercise in postmenopausal women. Biol Sport. 2020; 37(1): 41–48. PubMed Abstract
Introduction
P1: We are sorry if we were mistaken. We got it from the Facts and Statistics International Osteoporosis Foundation (IOF) [cited 2017 Oct 4]. Some other references that said the same that 200 million women: COLOSTEO (the project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No. 778277)¹, and de Villiers and Goldstein (2022)².

P2: Thank you. We have changed the reference to: Zhang S, Huang X, Zhao X, Li B, Cai Y, Liang X, et al. Effect of exercise on bone mineral density among patients with osteoporosis and osteopenia: A systematic review and network meta-analysis. J Clin Nurs. 2022 Aug; 31(15–16):2100–11.

P3 & 4: We agree with you, we have changed a little bit “it is hypothesized in the present study that evidence-based multimodal training as health promotion will have an osteogenic effect” into “it is hypothesized in the present study that training (which combined evidence-based exercise) as health promotion will have an osteogenic effect”. We have revised it.

P4: We have added the references:

Watson SL, Weeks BK, Weis LJ, 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. 2018 Feb; 33(2):211–220.PubMed Abstract | Publisher Full Text

Kistler-Fischbacher M, Yong JS, Weeks BK, et al.:A Comparison of Bone-Targeted Exercise With and Without Antiresorptive Bone Medication to Reduce Indices of Fracture Risk in Postmenopausal Women With Low Bone Mass: The MEDEX-OP Randomized Controlled Trial. J Bone Miner Res. 2021; 36(9):1680–1693. Publisher Full Text

Kistler-Fischbacher M, Weeks BK, Beck BR:The effect of exercise intensity on bone in postmenopausal women (part 2): A meta-analysis. Bone. 2021 Feb 1; 143: 115697. Publisher Full Text

Karinkanta S, Heinonen A, Sievänen H, et al.: A multi-component exercise regimen to prevent functional decline and bone fragility in home-dwelling elderly women: randomized, controlled trial. Osteoporos Int. 2007 Apr; 18(4): 453–462. PubMed Abstract | Publisher Full Text

Shojaa M, von Stengel S , Kohl M, et al.:Effects of dynamic resistance exercise on bone mineral density in postmenopausal women: a systematic review and meta-analysis with special emphasis on exercise parameters. Osteoporos Int. 2020 Aug; 31(8):1427–1444. PubMed Abstract | Publisher Full Text | Free Full Text

P5: Thank you for the suggestion, We have added attendance rate as a feasibility endpoint in the Methods section. The feasibility outcome is already in the Results section.

Methods
General: We have clarified which outcomes were primary and which ones were secondary.

P1: It was explained in Participants section in then Methods section. The sedentary control group was from a previous study (which hasn’t been published) not a long time before the present study. The recruitment process itself was the same, via advertisement online and a local newspaper.

P1: Yes, we understand. The bone turnover occurs around 5 to 6 months, and we can detect the changes around that time of intervention. However, our study regarding the bone turnover marker (Prawiradilaga et al. (2020)³) showed that acute exercise has an acute response on bone marker (P1NP). Regarding that, we hope that we can see the change in bone turnover markers as well as the bone mineral density in only 19 months. Why only 19 months? It was the feasible range of time we can manage before everyone went to summer vacation.

P3: Alright, thank you. We have deleted that part.

P4: Sedentary is defined as someone who didn’t engage in regular and systemic weight-bearing training or strength training in the last 2 years. We have added a note to distinguish active from sedentary.

No minimum age, only maximum 70.

2 years post menopause

Minimum at least 1 time a week, has a goal of the training.

P5: We have considered your suggestion and have moved the number of participants and drop outs to the Results section.

P5: Thank you.

P8: The progressive resistance training (PRT) consisted primarily of exercises using own bodyweight, with occasional use of medicine balls, resistance bands and sandbags (5–15 kg), starting with 15–20RM and slowly progressing to 6–12RM, with 2–3 sets. We have added this in the manuscript.

P9: We don’t think we have the information on short-term of BMD and body composition. We only measure the bone turnover markers for the short-term.

P12/13: They did not want to do the test.

P14: Thank you for the suggestion.

Results
P1: Our analyses were based on the delta values.

P4: Thank you for your suggestion. We have removed “However, LS (1.2%) and right total femur (0.3%) tended to increase (both, p < 0.1) for MMT”.

Table 2: We think it is good information to give the reader the mean femur BMD.

Table 2/3: There is significant difference between MMT and Control (CON) group. While the whole-body BMC showed decrease in CON group, the whole BMC in MMT group doesn’t change. It showed that the training might inhibit the whole-body BMC to decrease in postmenopausal women. The whole-body BMD was not increased, however, the right trochanter BMD in MMT was increased compared to CON.

Discussion
Thank you for the suggestion, We have added regarding the recent studies which have shown that exercise intensity is positively associated with bone changes, and that low-intensity exercise is ineffective.

Thank you for your suggestions, we have addressed other limitations.

The sample size was determined by the Author judgement based on the previous study on Bone Turnover Markers (Prawiradilaga et al. (2020)³.

The posteriori power calculations were performed with Power and Sample Size Calculations version 3.0 for the paired t-test and performed with SPSS for the repeated ANOVA measurement. The results are in the link in the ‘Extended data’ section.

Is the work clearly and accurately presented and does it cite the current literature?

We have cited the current literature

Is the study design appropriate and is the work technically sound?

We have added, “This is a feasibility study in a local community with a non-randomized controlled trial approach.”

Are sufficient details of methods and analysis provided to allow replication by others?

We think it is sufficient since the study method and the training program were described clearly.

References

Osteoporosis Facts [Internet]. COLOSTEO. [cited 2022 Aug 12]. Available online (date last accessed: 10/03/2023)

de Villiers TJ, Goldstein SR: Bone health 2022: an update. Climacteric. 2022 Jan 2; 25(1):1–3. Publisher Full Article

Prawiradilaga R, Madsen A, Jørgensen N, et al.: Acute response of biochemical bone turnover markers and the associated ground reaction forces to high-impact exercise in postmenopausal women. Biol Sport. 2020; 37(1): 41–48. PubMed Abstract
Competing Interests: The authors have no professional relationships with companies or manufacturers that might benefit from this study. The results do not constitute an endorsement of any product. Close
Report a concern

Comments on this article Comments (0)

Version 3

VERSION 3 PUBLISHED 17 Jan 2022

Open Peer Review

Reviewer Status

Reviewer Reports

	Invited Reviewers
	1	2	3
Version 3 (revision) 04 Sep 24			read
Version 2 (revision) 09 Mar 23		read	read
Version 1 17 Jan 22	read	read

Melanie Kistler-Fischbacher, Griffith University, Gold Coast, Australia
Robert Wen-Wei Hsu, Chang Gung Memorial Hospital, Pu-Tz City, Taiwan
Jan Gajewski, Jozef Pilsudski University of Physical Education, Warsaw, Poland

Comments on this article

All Comments(0)

Add a comment

Browse by related subjects

Back to all reports

Reviewer Report

5 Views

10 Sep 2024 | for Version 3

Jan Gajewski, Faculty of Physical Education, Jozef Pilsudski University of Physical Education, Warsaw, Poland

5 Views Cite this report Responses(0)

Approved

I read the paper and I am satisfied with the changes introduced. I thank the authors for their responses and have no further comments.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Sport science, biomechanics, statistics

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Respond to this report

Responses (0)

Back to all reports

Reviewer Report

16 Views

31 May 2024 | for Version 2

Jan Gajewski, Faculty of Physical Education, Jozef Pilsudski University of Physical Education, Warsaw, Poland

16 Views Cite this report Responses(1)

Approved With Reservations

The purpose of the study was to evaluate the feasibility of a 19-week multimodal training in a local community center targeting musculoskeletal health in postmenopausal women. The study was designed as a controlled trial. In the end, only 9 subjects in the experimental group and 13 in the control group completed participation in exercise and measurement.
I like the idea itself very much. Evaluation of the effectiveness of the exercise program in the real conditions of the local community shows the practical usefulness of similar initiatives. The feasibility of the established program turned out to be moderately satisfactory. The effects of the program have not been fully proven. This had to do primarily with the relatively small size of the groups. I checked with G*Power that the minimum sizes to detect a moderate effect (eta squared>0.06) at 80% statistical power are at least 17 people in each group. When planning the experiment, a correspondingly larger number of subjects should have been taken into account (e.g. 22 and 22). I understand that for various reasons it was not possible. It was unfortunate that the groups differed significantly in the base line parameters (especially in age, bone turnover markers. Of course it cannot be changed.
I have reservations about the statistical methods used or rather about presentation and interpretation of their outcomes. For an experiment, the most important result is the interaction of a fixed factor (Group) and a repeated factor (please report F, p and eta squared). If this interaction occurs, one can talk about a different response in the groups. This should not necessarily focus on the results of post-hoc tests. However, the authors focused on within-group and between-group differences which is not as important as interaction.
As I had some time I recalculated the results again and attached them in an excel file please refer to this link:https://f1000research.s3.amazonaws.com/linked/651424.A_Feasibility_Study_of_Training_Dataset_ver_1_1_.xlsx
When the variables involved left and right, I expanded the analysis to include a second factor repeated SIDE. I didn't check the normality of the distributions, but it should probably be done. It would be worthwhile to devote some space to the effect sizes (eta squared). In some cases, the interactions were close to significance with relatively large effect sizes. Unfortunately, due to low statistical power (group sizes), such results have low reliability but at least there is something to discuss.
I would also ask the authors to expand on the description of the exercises used. Based on the description, it would not be possible to reproduce the intervention exactly.

Specific comments
In Table 2, the p-value evaluates the group effect, which is not valid in this case. I would rather put F, p and eta2 for the interaction in the last column. Asterisks could be used to indicate any differences between groups in individual measurements (different than control).
The same goes for Table 3. Why does the designation ‘a-geometric mean’ at body weight appear (what's the reason)?
Body composition parameters are shown twice in Table 1 and Table 3.
Aren't the results shown in Figure 3 duplicated in Table 4? Let's stick to the rule that each result is presented once in one of three ways: in text, in a table or on a graph.

Summing up
Of course, the article has irremovable flaws related to the allocation into groups and their size, but if the practical aspect of the results obtained is taken into account, the value of the study increases.

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

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Respond to this report

Responses (1)

Author Response

04 Sep 2024

Rizky Suganda Prawiradilaga

Dear Reviewer,
Thank you for your thorough and insightful review of our manuscript. We appreciate the time and effort you have taken to evaluate our work and provide valuable feedback.
We would like to address some of the key points you raised:

1. Statistical Methods:
• We chose to use GLM to evaluate the interaction between the treatment (Multimodal Training, MMT) and time of observation, focusing particularly on musculoskeletal health outcomes. We recognize the limitations posed by our small sample size, yet the GLM analysis revealed a significant interaction between MMT and time observed in increasing bone density in the right trochanter. This finding underpinned our conclusion that the treatment was effective in this area.
• We did not employ repeated measures ANOVA because the assumptions necessary for this analysis were not met by our data. GLM allowed us to account for both fixed and repeated factors, making it a more appropriate choice given the design and characteristics of our study. However, we appreciate your recommendation to emphasize the interaction effects and will adjust our manuscript accordingly.

2. Presentation of Results:
• In line with your suggestion, we have revised the relevant tables to include F-statistics, p-values, and eta-squared values for the interaction effects between group and time. These revisions will help clarify the significance of these interactions and better align with standard reporting practices.
• We acknowledge the concern about the low statistical power due to the small sample size, which indeed limits the reliability of some findings. We will include a more detailed discussion of effect sizes (eta squared) and their implications, as well as the potential limitations related to power in our revised manuscript.

3. Description of the Exercises:
• Following your feedback and based on detailed information from our related research, we have expanded the description of the exercises used in the study. The training program included high- and odd-impact exercises, progressive resistance training, and balance and coordination activities. We have now provided a comprehensive explanation of these activities, including their intensity, repetitions, and the rationale behind their inclusion, ensuring that the intervention can be reproduced in future studies.

4. Data Presentation:
• We have revised the tables and figures to ensure clarity and avoid unnecessary duplication. Specifically, we have deleted Figure 3 to prevent the repetition of results already presented in Table 4. Regarding the body composition parameters, we recognize that Tables 1 and 3 serve different purposes. Table 1 provides a summary of the baseline characteristics of the study participants, including body composition metrics, to offer context for the starting points of each group. Table 3, on the other hand, presents the changes in body composition parameters throughout the intervention, highlighting the outcomes of the study. Therefore, while there may be some overlap in the parameters listed, each table is designed to address distinct aspects of the study, and the information provided in both tables is essential for a comprehensive understanding of the results.

5. The designation ‘a-geometric mean’ at body weight (what's the reason?)
• In the context of our study, body weight data may have been log-transformed to normalize the distribution before analysis, and the geometric mean was used to summarize these values appropriately. The ‘a-geometric mean’ designation was included to clarify that the mean values reported are not simple arithmetic means but are geometric means, which are more appropriate for data with a skewed distribution.

6. Summary and Conclusion:
• While we recognize that the small sample size and differences in baseline characteristics between groups represent inherent limitations in our study, we believe that the practical implications of our findings contribute valuable insights to community-based health promotion programs. We are committed to enhancing the clarity and rigor of our manuscript in light of your recommendations.
Thank you once again for your constructive feedback. We believe these revisions will significantly improve the quality of our manuscript, and we appreciate your continued consideration.

Best regards,
Rizky Suganda Prawiradilaga

View more View less

Competing Interests

No competing interests were disclosed.

Back to all reports

Reviewer Report

12 Views

22 Mar 2023 | for Version 2

Robert Wen-Wei Hsu, Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Pu-Tz City, Taiwan

12 Views Cite this report Responses(1)

Approved

No further comments to make.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Orthopedics, sports medicine

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Respond to this report

Responses (1)

Back to all reports

Reviewer Report

19 Views

08 Nov 2022 | for Version 1

Robert Wen-Wei Hsu, Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Pu-Tz City, Taiwan

19 Views Cite this report Responses(1)

Not Approved

Thank you for sending this paper for reviewing. There were some comments on the following:

The sample size is too small to validate the effect of training.
How was the sample size determined?
Statistical power should be calculated.
The exercise program is not strong enough to have physiological impact to the health.
The duration of exercises is not long enough.
The study is required to do prospective study. The assignment to exercise and control group should be randomized.

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

Respond to this report

Responses (1)

Author Response

09 Mar 2023

Rizky Suganda Prawiradilaga

We are aware of that. We tried to equate the number of samples with our previous studies but, in our feasibility study with community settings, it turned out that 6 people from the MMT group dropped out.
The sample size was determined by the Author judgement based on the previous study on Bone Turnover Markers (Prawiradilag et al. (2020)).
The Statistical power calculations were performed with Power and Sample Size Calculations version 3.0 for the paired t-test and performed with SPSS for the repeated ANOVA measurement. The results are in the link in the ‘Extended data’ section.
We apologize; we do not actually understand, what do you mean by not strong enough? The Health initiative program uses multimodal training including 1) High- and odd-impact exercise including multi-directional games; 2) Progressive resistance training (PRT); 3) Balance and coordination training which has an osteogenic impact based on evidence, but we are aware that frequency, duration did not meet the recommendation. In addition, we didn’t measure the heart rate for intensity.
We understand that the Health Promotion initiative program was not long enough (19 weeks) and did not meet the recommendation (6-12 months) for osteogenic exercise. We would like to see whether there were bone turnover markers (BTM) changes in this short period since, in our previous study, there were acute responses in BTM.

Thank you for your suggestions.

Is the work clearly and accurately presented and does it cite the current literature?

We have cited the current literature

Is the study design appropriate and is the work technically sound?

We have added, “This is a feasibility study in a local community with a non-randomized controlled trial approach.”

Are sufficient details of methods and analysis provided to allow replication by others?

We think it is sufficient since the study method and the training program were described clearly.

Are all the source data underlying the results available to ensure full reproducibility?

We share the raw data in the ‘Extended data’ section.

View more View less

Competing Interests

The authors have no professional relationships with companies or manufacturers that might benefit from this study. The results do not constitute an endorsement of any product.

Back to all reports

Reviewer Report

36 Views

16 May 2022 | for Version 1

Melanie Kistler-Fischbacher, Menzies Health Institute Queensland, Griffith University, Gold Coast, Qld, Australia

36 Views Cite this report Responses(1)

Not Approved

Was there a minimum age set?
How was postmenopausal defined? (e.g. how many years post menopause?)
How was regular, systematic training defined?

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

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Exercise science; bone; bone-specific exercise; osteoporosis; weight lifting for bone and muscle health; postmenopausal women

Respond to this report

Responses (1)

Author Response

10 Mar 2023

Rizky Suganda Prawiradilaga

Introduction
P1: We are sorry if we were mistaken. We got it from the Facts and Statistics International Osteoporosis Foundation (IOF) [cited 2017 Oct 4]. Some other references that said the same that 200 million women: COLOSTEO (the project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No. 778277)¹, and de Villiers and Goldstein (2022)².

P2: Thank you. We have changed the reference to: Zhang S, Huang X, Zhao X, Li B, Cai Y, Liang X, et al. Effect of exercise on bone mineral density among patients with osteoporosis and osteopenia: A systematic review and network meta-analysis. J Clin Nurs. 2022 Aug; 31(15–16):2100–11.

P3 & 4: We agree with you, we have changed a little bit “it is hypothesized in the present study that evidence-based multimodal training as health promotion will have an osteogenic effect” into “it is hypothesized in the present study that training (which combined evidence-based exercise) as health promotion will have an osteogenic effect”. We have revised it.

P4: We have added the references:

Watson SL, Weeks BK, Weis LJ, 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. 2018 Feb; 33(2):211–220.PubMed Abstract | Publisher Full Text
Kistler-Fischbacher M, Yong JS, Weeks BK, et al.:A Comparison of Bone-Targeted Exercise With and Without Antiresorptive Bone Medication to Reduce Indices of Fracture Risk in Postmenopausal Women With Low Bone Mass: The MEDEX-OP Randomized Controlled Trial. J Bone Miner Res. 2021; 36(9):1680–1693. Publisher Full Text
Kistler-Fischbacher M, Weeks BK, Beck BR:The effect of exercise intensity on bone in postmenopausal women (part 2): A meta-analysis. Bone. 2021 Feb 1; 143: 115697. Publisher Full Text
Karinkanta S, Heinonen A, Sievänen H, et al.: A multi-component exercise regimen to prevent functional decline and bone fragility in home-dwelling elderly women: randomized, controlled trial. Osteoporos Int. 2007 Apr; 18(4): 453–462. PubMed Abstract | Publisher Full Text
Shojaa M, von Stengel S , Kohl M, et al.:Effects of dynamic resistance exercise on bone mineral density in postmenopausal women: a systematic review and meta-analysis with special emphasis on exercise parameters. Osteoporos Int. 2020 Aug; 31(8):1427–1444. PubMed Abstract | Publisher Full Text | Free Full Text

P5: Thank you for the suggestion, We have added attendance rate as a feasibility endpoint in the Methods section. The feasibility outcome is already in the Results section.

Methods
General: We have clarified which outcomes were primary and which ones were secondary.

P1: It was explained in Participants section in then Methods section. The sedentary control group was from a previous study (which hasn’t been published) not a long time before the present study. The recruitment process itself was the same, via advertisement online and a local newspaper.

P1: Yes, we understand. The bone turnover occurs around 5 to 6 months, and we can detect the changes around that time of intervention. However, our study regarding the bone turnover marker (Prawiradilaga et al. (2020)³) showed that acute exercise has an acute response on bone marker (P1NP). Regarding that, we hope that we can see the change in bone turnover markers as well as the bone mineral density in only 19 months. Why only 19 months? It was the feasible range of time we can manage before everyone went to summer vacation.

P3: Alright, thank you. We have deleted that part.

P4: Sedentary is defined as someone who didn’t engage in regular and systemic weight-bearing training or strength training in the last 2 years. We have added a note to distinguish active from sedentary.

No minimum age, only maximum 70.
2 years post menopause
Minimum at least 1 time a week, has a goal of the training.

P5: We have considered your suggestion and have moved the number of participants and drop outs to the Results section.

P5: Thank you.

P8: The progressive resistance training (PRT) consisted primarily of exercises using own bodyweight, with occasional use of medicine balls, resistance bands and sandbags (5–15 kg), starting with 15–20RM and slowly progressing to 6–12RM, with 2–3 sets. We have added this in the manuscript.

P9: We don’t think we have the information on short-term of BMD and body composition. We only measure the bone turnover markers for the short-term.

P12/13: They did not want to do the test.

P14: Thank you for the suggestion.

Results
P1: Our analyses were based on the delta values.

P4: Thank you for your suggestion. We have removed “However, LS (1.2%) and right total femur (0.3%) tended to increase (both, p < 0.1) for MMT”.

Table 2: We think it is good information to give the reader the mean femur BMD.

Table 2/3: There is significant difference between MMT and Control (CON) group. While the whole-body BMC showed decrease in CON group, the whole BMC in MMT group doesn’t change. It showed that the training might inhibit the whole-body BMC to decrease in postmenopausal women. The whole-body BMD was not increased, however, the right trochanter BMD in MMT was increased compared to CON.

Discussion
Thank you for the suggestion, We have added regarding the recent studies which have shown that exercise intensity is positively associated with bone changes, and that low-intensity exercise is ineffective.

Thank you for your suggestions, we have addressed other limitations.

The sample size was determined by the Author judgement based on the previous study on Bone Turnover Markers (Prawiradilaga et al. (2020)³.
The posteriori power calculations were performed with Power and Sample Size Calculations version 3.0 for the paired t-test and performed with SPSS for the repeated ANOVA measurement. The results are in the link in the ‘Extended data’ section.

Is the work clearly and accurately presented and does it cite the current literature?

We have cited the current literature

Is the study design appropriate and is the work technically sound?

We have added, “This is a feasibility study in a local community with a non-randomized controlled trial approach.”

Are sufficient details of methods and analysis provided to allow replication by others?

We think it is sufficient since the study method and the training program were described clearly.

References

Osteoporosis Facts [Internet]. COLOSTEO. [cited 2022 Aug 12]. Available online (date last accessed: 10/03/2023)
de Villiers TJ, Goldstein SR: Bone health 2022: an update. Climacteric. 2022 Jan 2; 25(1):1–3. Publisher Full Article
Prawiradilaga R, Madsen A, Jørgensen N, et al.: Acute response of biochemical bone turnover markers and the associated ground reaction forces to high-impact exercise in postmenopausal women. Biol Sport. 2020; 37(1): 41–48. PubMed Abstract

View more View less

Competing Interests

The authors have no professional relationships with companies or manufacturers that might benefit from this study. The results do not constitute an endorsement of any product.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

[1] 1. Kanis JA, Melton LJ, Christiansen C, et al.: The diagnosis of osteoporosis. J Bone Miner Res. 1994 Aug 1; 9(8): 1137–1141. Publisher Full Text

[2] 2. Facts and Statistics|International Osteoporosis Foundation: [cited 2017 Oct 4]. Reference Source

[3] 3. Sinaki M, Brey RH, Hughes CA, et al.: Balance disorder and increased risk of falls in osteoporosis and kyphosis: significance of kyphotic posture and muscle strength. Osteoporos Int. 2005 Aug 1; 16(8): 1004–1010. PubMed Abstract | Publisher Full Text

[4] 4. Beck BR, Daly RM, Singh MAF, et al.: Exercise and Sports Science Australia (ESSA) position statement on exercise prescription for the prevention and management of osteoporosis. Journal of Science and Medicine in Sport. 2017 May 1; 20(5): 438–445. Publisher Full Text

[5] 5. Dalsky GP: Exercise: its effect on bone mineral content. Clin Obstet Gynecol. 1987 Dec; 30(4): 820–832. PubMed Abstract | Publisher Full Text

[6] 6. Nikander R, Sievänen H, Heinonen A, et al.: Load-specific differences in the structure of femoral neck and tibia between world-class moguls skiers and slalom skiers. Scand J Med Sci Sports. 2008 Apr; 18(2): 145–153. PubMed Abstract | Publisher Full Text

[7] 7. Nogueira RC, Weeks BK, Beck BR: Exercise to improve pediatric bone and fat: a systematic review and meta-analysis. Med Sci Sports Exerc. 2014 Mar; 46(3): 610–621. PubMed Abstract | Publisher Full Text

[8] 8. Vainionpää A, Korpelainen R, Leppäluoto J, et al.: Effects of high-impact exercise on bone mineral density: a randomized controlled trial in premenopausal women. Osteoporos Int. 2005 Feb; 16(2): 191–197. Publisher Full Text

[9] 9. Karinkanta S, Heinonen A, Sievänen H, et al.: A multi-component exercise regimen to prevent functional decline and bone fragility in home-dwelling elderly women: randomized, controlled trial. Osteoporos Int. 2007 Apr; 18(4): 453–462. Publisher Full Text

[10] 10. Prawiradilaga R, Madsen A, Jørgensen N, et al.: Acute response of biochemical bone turnover markers and the associated ground reaction forces to high-impact exercise in postmenopausal women. Biol Sport. 2020; 37(1): 41–48. PubMed Abstract | Publisher Full Text

[11] 11. Turner C, Robling A: Exercises for improving bone strength. Br J Sports Med. 2005 Apr; 39(4): 188–189. PubMed Abstract | Publisher Full Text

[12] 12. Zehnacker CH, Bemis-Dougherty A: Effect of Weighted Exercises on Bone Mineral Density in Post Menopausal Women: A Systematic Review. Journal of Geriatric Physical Therapy; La Cross. 2007; 30(2): 79–88. PubMed Abstract | Publisher Full Text

[13] 13. Dizdar M, Irdesel JF, Dizdar OS, et al.: Effects of Balance-Coordination, Strengthening, and Aerobic Exercises to Prevent Falls in Postmenopausal Patients With Osteoporosis: A 6-Month Randomized Parallel Prospective Study. J Aging Phys Act. 2017 Dec 19; 26(1): 41–51. PubMed Abstract | Publisher Full Text

[14] 14. Howe TE, Shea B, Dawson LJ, et al.: Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2011.

[15] 15. Borer KT, Fogleman K, Gross M, et al.: Walking intensity for postmenopausal bone mineral preservation and accrual. Bone. 2007 Oct; 41(4): 713–721. PubMed Abstract | Publisher Full Text

[16] 16. Mosti MP, Kaehler N, Stunes AK, et al.: Maximal strength training in postmenopausal women with osteoporosis or osteopenia. J Strength Cond Res. 2013 Oct; 27(10): 2879–2886. Publisher Full Text

[17] 17. Pereira A, Costa AM, Palmeira-de-Oliveira A, et al.: The effects of combined training on bone metabolic markers in postmenopausal women. Sci Sports. 2016 Jun; 31(3): 152–157. Publisher Full Text

[18] 18. Moore M, Barker K: The validity and reliability of the four square step test in different adult populations: a systematic review. Syst Rev. 2017 Sep 11 [cited 2020 May 15]; 6: 6. Publisher Full Text Reference Source

[19] 19. Daly RM, Giangregorio L: Exercise for Osteoporotic Fracture Prevention and Management. Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. John Wiley & Sons, Ltd; 2018 [cited 2019 Dec 16]. p. 517–525. Publisher Full Text

[20] 20. Gallagher JC, Goldgar D, Moy A: Total bone calcium in normal women: Effect of age and menopause status - Gallagher - 1987. Journal of Bone and Mineral Research - Wiley Online Library. [cited 2020 Jun 2]; 2: 491–496. PubMed Abstract | Publisher Full Text

[21] 21. Daly RM, Gianoudis J, Kersh ME, et al.: Effects of a 12-Month Supervised, Community-Based, Multimodal Exercise Program Followed by a 6-Month Research-to-Practice Transition on Bone Mineral Density, Trabecular Microarchitecture, and Physical Function in Older Adults: A Randomized Controlled Trial. J Bone Miner Res. 2019 [cited 2019 Dec 16]; 35: 419–429. Publisher Full Text

[22] 22. Rizzo MR, Mari D, Barbieri M, et al.: Resting metabolic rate and respiratory quotient in human longevity.2005; 90(1): 409–413.

[23] 23. Nielsen T-T, Møller TK, Andersen LL, et al.: Feasibility and Health Effects of a 15-Week Combined Exercise Programme for Sedentary Elderly: A Randomised Controlled Trial. BioMed Res Int. 2019 Jan 23; 2019: 1–12. Publisher Full Text

[24] 24. Yen C-J, Hung C-H, Kao C-L, et al.: Multimodal exercise ameliorates exercise responses and body composition in head and neck cancer patients receiving chemotherapy. Support Care Cancer. 2019 Dec 1; 27(12): 4687–4695. PubMed Abstract | Publisher Full Text

[25] 25. Clark J: The impact of duration on effectiveness of exercise, the implication for periodization of training and goal setting for individuals who are overfat, a meta-analysis. Biol Sport. 2016 Dec; 33(4): 309–333. PubMed Abstract | Publisher Full Text

[26] 26. Prawiradilaga RS, Magnus B, Esrup S, et al.: 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. figshare.2021 [cited 2021 Sep 13]. Publisher Full Text

[27] 27. Prawiradilaga RS, Bendtsen M, Esrup S, et al.: 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. figshare.2021 [cited 2021 Sep 13]. Publisher Full Text

[28] 28. Prawiradilaga RS, Bendtsen M, Esrup S, et al.: 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”. figshare.2021 [cited 2021 Sep 13]. Publisher Full Text

[29] 29. Prawiradilaga RS, Bendtsen M, Esrup S, et al.: Underlying data for ‘A Feasibility Study of Training in a Local Community Aimed Upon Health Promotion with Special Emphasis on Musculoskeletal Health Effects.’. figshare2021 [cited 2021 Sep 13]. Publisher Full Text

A feasibility study of training in a local community aimed upon health promotion with special emphasis on musculoskeletal health effects

Abstract

Keywords

Introduction

Methods

Study design

Participants

Figure 1. CONSORT flow diagram.

Training program

BMD and body composition

Blood sampling & biochemical analyses

Training status

Dynamic balance

Functional muscle strength and power

Statistical analysis

Results

Participant characteristics

Table 1. Baseline characteristics of the participants.

Attendance and dropout

BMD and body composition

Table 2. Absolute BMD values (Mean ± SD).

Figure 2. Percent change (± SE) in whole-body and regional bone mineral density (BMD) following the 19-week multimodal training.

Table 3. Body composition values (Mean ± SD).

BTM

Figure 3. Bone turnover markers.

Table 4. Bone turnover marker (BTM) concentrations at BASELINE, after 3 weeks of training (3wk), and after 19 weeks of training (19wk).

FSST & Jump-and-reach test

Table 5. Dynamic balance and functional muscle strength result for multimodal training group (n=9). Paired t-test.

Discussion

Conclusions

Data availability

Underlying data

Extended data

Reporting guidelines

Acknowledgements

References

Comments on this article Comments (0)

Open Peer Review

Comments on this article Comments (0)

Open Peer Review

Reviewer Status

Reviewer Reports

Comments on this article

Browse by related subjects

Competing Interests Policy

Stay Updated