Exercise as it relates to Disease/The effects of high-intensity resistance and impact training on women with Osteopenia and Osteoporosis

This Wikibook page is a critique on the research article “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” by Steven L Watson, Benjamin K Weeks, Lisa J Weis, Amy T Harding, Sean A Horan and Belinda R Beck. This was done as an assessment for the unit Health, Disease and Exercise, 2021, studied at the University of Canberra.

What is the background to this research?

Osteopenia and Osteoporosis are conditions which result in the thinning and weakening of bones. As the bones become more fragile there is a higher risk of injury such as fractures from falls. These conditions are highly prevalent in women affecting around 14% of women aged 55-64, around 23% aged 65-74, and around 29% of women aged 75 and over. As these conditions are highly prevalent it is important to find the most effective methods of treatment. The article being critiqued tests the effects of High Intensity Resistance and Impact Training (HIRIT) on physical performance and bone mineral density in women with these conditions. HIRIT is generally discouraged as a method of treatment for those with Osteopenia and Osteoporosis due to the said risks of injury or adverse events occurring and many exercise guidelines for these conditions state moderate intensity resistance training is recommended rather than high intensity resistance training. Although this is the case, the intervention in this article provides evidence on the effectiveness of participating in HIRIT for women with Osteopenia and Osteoporosis in reducing related decreases in bone mineral density and physical performance.

Where is the research from?

This research was published from the American Society for Bone and Mineral Research which is a large society with more than 4000 members including medical and health professionals. The Authors of the article (Steven L Watson, Benjamin K Weeks, Lisa J Weis, Amy T Harding, Sean A Horan, Belinda R Beck) all have multiple research articles published on the American Society for Bone and Mineral Research's website on bone health and conditions and have related accreditations. Belinda R Beck and Lisa J Weis are both directors of the Bone Clinic in Brisbane, QLD.

What kind of research was this?

This research consisted of a randomised control trial called LIFTMOR in which participants were women aged 58 and over with osteoporosis who had low bone mass recorded at the femoral neck and/or lumbar spine. There was a strict inclusion criterion for more valid and reliable results and out of 406 willing participants, 101 were chosen. Then participants were randomly selected to either the control or intervention group. By conducting a randomized control trial, the researchers were able to compare results of the control and intervention groups pre and post intervention.

What did the research involve?

The Intervention group participated in 8 months of twice weekly, 30 minute bouts of supervised HIRIT where as the control group participated in low intensity home based exercise over the same period. The main outcomes measured were bone mineral density of the femoral neck and lumbar spine, and functional performance. The femoral neck and lumbar spine are valid and reliable measurement sites as the most common fractures due to Osteoporosis are of the hip and the lumbar spine is the best site for monitoring treatment. Bone measures were taken using DXA which is the current most effective measure. Four tests were taken before and after the 8-month intervention to assess functional performance. These tests were timed up-and-go, five times sit-to-stand, functional reach test and vertical jump test. These are all valid tests of physical performance as they test the functional capabilities of the participants femoral neck and lumbar spine in combination with the surrounding muscles. An improvement in these tests would constitute greater physical performance caused by the intervention.

What were the basic results?

Table 1: Physical performance tests pre and post intervention

	Control (n = 43)		HIRIT (n = 43)
Parameter/ test	Baseline	Follow-up	Baseline	Follow-up
Leg extensor strength (kg)	59.2 ±14.7	61.4 ± 13.7	62.5 ± 16.3	80.7 ± 13.9
Back extensor strength (kg)	32.5 ± 9.3	34.2 ± 10.3	32.8 ± 10.3	42.6 ± 8.7
Timed up-and-go (sec)	5.9 ± 0.6	6.1 ± 0.6	6.2 ± 0.7	5.8 ± 0.5
Five times sit-to-stand (sec)	9.8 ± 1.4	9.6 ± 1.2	9.8 ± 1.2	8.6 ± 1.1
Functional reach test (cm)	40.9 ± 4.9	40.8 ± 4.7	40.3 ± 5.5	42.4 ± 5.3
Vertical jump (N·s/kg)	1.34 ± 0.2	1.35 ± 0.2	1.24 ± 0.2	1.31 ± 0.2

Table 2: Bone Mineral Density DXA measures pre and post intervention

	Control (n = 43)		HIRIT (n = 43)
Parameter	Baseline	Follow-up	Baseline	Follow-up
LS BMD (g/cm2)	0.81 ± 0.09	0.80 ± 0.09	0.82 ± 0.10	0.84 ± 0.11
FN BMD (g/cm2)	0.68 ± 0.05	0.67 ± 0.05	0.69 ± 0.08	0.70 ± 0.08

(* BMD = bone mineral density, LS = lumbar spine, FN= femoral neck)

Results in table 1 show the HIRIT participants had a larger increase in leg extensor and back extensor strength compared to the control group from baseline to follow-up. The timed up-and-go test and the five times sit-to-stand test also saw greater performances in the HIRIT participants than the control group with a decrease in time taken to complete the tests. The functional reach and vertical jump test performances increased greater in the HIRIT participants than the control participants.

Results in table 2 show an increase in both lumbar spine and femoral neck bone mineral density in the HIRIT group from baseline to follow-up where as the bone mineral density in both areas in the control group decreased. This decrease in the control group's bone mineral density could be due to the low intensity exercise not being able to stimulate an osteogenic response from the the low levels of skeletal strain . It could also be due to the control group not being under supervision which could result in falsely reported completion of set training.

There were no injuries or adverse events during the intervention. The authors claim since this is the case women with Osteopenia or Osteoporosis should not be discouraged to participate in HIRIT. Although this is the case, the low level of injuries in the HIRIT participants may be due to the supervision of their training and should be considered before participating HIIT in an environment which isn't supervised.

What conclusions can we take from this research?

As shown by the results, there was a greater increase in both bone mineral density and physical performance in the HIRIT participants compared to the control participants. Therefore High Intensity Resistance and Interval Training is an effective way of reducing the adverse effects of Osteopenia and Osteoporosis in women. Although moderate exercise is recommended by many guidelines, HIRIT is a greatly effective way of improving bone mineral density and physical performance and should be a preferential treatment method.

The positive results of this intervention could be due to the effective methodology, testing parameters and the supervision of the HIRIT participants.

The control group being unsupervised could have led to unreliable results in the control group although this does not effect the outcome of the HIRIT group's improvements in bone mineral density and physical performance pre to post intervention.

Practical advice

For women with Osteopenia or Osteoporosis High Intensity Resistance and Impact training can be very beneficial. As shown from the LIFTMOR intervention, HIRIT is a more effective way to help prevent the adverse affects of these conditions than lower intensity training. When beginning resistance training as a treatment for these conditions start training at a low intensity and gradually progress to a higher intensity as the body becomes more capable. As supervision of HIRIT was undertaken we would recommend supervision to reduce the risk of injury or adverse events occurring.

Further information/ resources

Osteoporosis: Current Concepts - Akkawi I, Zmerly H. Osteoporosis: Current Concepts. Joints. 2018;6(2):122-127. Published 2018 Jun 14. doi:10.1055/s-0038-1660790

Effects of Resistance Exercise on Bone Health - Hong AR, Kim SW. Effects of Resistance Exercise on Bone Health. Endocrinol Metab (Seoul). 2018;33(4):435-444. doi:10.3803/EnM.2018.33.4.435

Maximal Strength Training in Postmenopausal Women with Osteoporosis or Osteopenia - Mosti MP, Kaehler N, Stunes AK, Hoff J, Syversen U. Maximal strength training in postmenopausal women with osteoporosis or osteopenia. J Strength Cond Res. 2013 Oct;27(10):2879-86. doi: 10.1519/JSC.0b013e318280d4e2. PMID: 23287836.