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Effects of high-impact exercise on bone mineral density: A randomized controlled trial in premenopausal women

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The purpose of this randomized controlled study was to assess the effects of high-impact exercise on the bone mineral density (BMD) of premenopausal women at the population level. The study population consisted of a random population-based sample of 120 women from a cohort of 5,161 women, aged 35 to 40 years. They were randomly assigned to either an exercise or control group. The exercise regimen consisted of supervised, progressive high-impact exercises three times per week and an additional home program for 12 months. BMD was measured on the lumbar spine (L1-L4), proximal femur, and distal forearm, by dual-energy X-ray absorptiometry at baseline and after 12 months. Calcaneal bone was measured using quantitative ultrasound. Thirty-nine women (65%) in the exercise group and 41 women (68%) in the control group completed the study. The exercise group demonstrated significant change compared with the control group in femoral neck BMD (1.1% vs -0.4%; p=0.003), intertrochanteric BMD (0.8% vs -0.2%; p=0.029), and total femoral BMD (0.1% vs -0.3%; p=0.006). No exercise-induced effects were found in the total lumbar BMD or in the lumbar vertebrae L2-L4. Instead, L1 BMD (2.2% vs -0.4%; p=0.002) increased significantly more in the exercise group than in the control group. Calcaneal broadband ultrasound attenuation showed also a significant change in the exercise group compared with the control group (7.3% vs -0.6%; p=0.015). The changes were also significant within the exercise group, but not within the control group. There were no significant differences between or within the groups in the distal forearm. This study indicates that high-impact exercise is effective in improving bone mineral density in the lumbar spine and upper femur in premenopausal women, and the results of the study may be generalized at the population level. This type of training may be an efficient, safe, and inexpensive way to prevent osteoporosis later in life.
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ORIGINAL ARTICLE
Effects of high-impact exercise on bone mineral density:
a randomized controlled trial in premenopausal women
Aki Vainionpa
¨
a
¨
Æ Raija Korpelainen Æ Juhani Leppa
¨
luoto
Timo Ja
¨
msa
¨
Received: 2 February 2004 / Accepted: 28 April 2004 / Published online: 17 June 2004
Ó International Osteoporosis Foundation and National Osteoporosis Foundation 2004
Abstract Introduction: The purpose of this randomized
controlled study was to assess the effects of high-impact
exercise on the bone mineral density (BMD) of pre-
menopausal women at the population level. Materials
and methods: The study population consisted of a ran-
dom population-based sample of 120 women from a
cohort of 5,161 women, aged 35 to 40 years. They were
randomly assigned to either an exercise or control
group. The exercise regimen consisted of supervised,
progressive high-impact exercises three times per week
and an additional home program for 12 months. BMD
was measured on the lumbar spine (L1–L4), proximal
femur, and distal forearm, by dual-energy X-ray
absorptiometry at base line and after 12 months. Calca-
neal bone was measured using quantitative ultrasound.
Results: Thirty-nine women (65%) in the exercise group
and 41 women (68%) in the control group completed the
study. The exercise group demonstrated significant
change compared with the control group in femoral neck
BMD (1.1% vs )0.4%; p=0.003), intertrochanteric
BMD (0.8% vs )0.2%; p=0.029), and total femoral
BMD (0.1% vs )0.3%; p=0.006). No exercise-induced
effects were found in the total lumbar BMD or in the
lumbar vertebrae L2–L4. Instead, L1 BMD (2.2% vs
)0.4%; p=0.002) increased significantly more in the
exercise group than in the control group. Calcaneal
broadband ultrasound attenuation showed also a
significant change in the exercise group compared with
the control group (7.3% vs )0.6%; p=0.015). The
changes were also significant within the exercise group,
but not within the control group. There were no signif-
icant differences between or within the groups in the
distal forearm. Conclusions: This study indicates that
high-impact exercise is effective in improving bone
mineral density in the lumbar spine and upper femur in
premenopausal women, and the results of the study may
be generalized at the population level. This type of
training may be an efficient, safe, and inexpensive way to
prevent osteoporosis later in life.
Keywords Clinical trial Æ Mechanical loading Æ
Osteoporosis Æ Population based Æ Premenopausal
women Æ Prevention
Introduction
Osteoporosis and osteoporotic fractures have become
one of the major health problems in Western countries
[1]. One in three white women over the age of 50 will
experience at least one fragility fracture during their
remaining life [2]. The 1st-year total direct cost of oste-
oporotic fractures is estimated to be 25 billion euros in
Europe [3]. There is therefore an urgent need to develop
preventive strategies.
Epidemiological, clinical, and experimental exercise
studies have suggested that exercise enhances bone
development and augments bone mineral density
(BMD) during adolescence and may prevent osteopo-
rosis and fractures during old age [4, 5, 6, 7, 8]. Regular
exercise, especially resistance and high-impact activities,
contributes to development of high peak bone mass and
may reduce risk of falls and osteoporotic fractures in
later life [9, 10]. A recent meta-analysis indicated that
high-impact exercise was most effective regarding the
femoral neck BMD [9], and it has also been suggested
that gains induced by high-impact exercise are main-
tained after intervention [11].
Osteoporos Int (2005) 16: 191–197
DOI 10.1007/s00198-004-1659-5
A. Vainionpa
¨
a
¨
(&) Æ T. Ja
¨
msa
¨
Department of Medical Technology,
University of Oulu,
PO Box 5000, 90014, Oulu, Finland
E-mail: avainion@paju.oulu.fi
Tel.: +358-40-5451942
Fax: +358-8-5376000
A. Vainionpa
¨
a
¨
Æ J. Leppa
¨
luoto
Department of Physiology,
University of Oulu, Oulu, Finland
A. Vainionpa
¨
a
¨
Æ R. Korpelainen
Department of Sports Medicine,
Deaconess Institute of Oulu,
Oulu, Finland
There are few randomized controlled prospective
studies concerning exercise and bone mineral density in
premenopausal women [ 12, 13, 14, 15, 16], and most of
the studies have included voluntary premenopausal wo-
men who are likely to be willing to participate in health-
related physical activities [17]. Additionally, study sam-
ples in exercise interventions may have been selected and
limited [9]. To our knowledge, no population-based
randomized controlled exercise trials in premenopausal
women have been conducted. Therefore, our aim was to
evaluate the effects of high-impact physical exercise on
lumbar, hip, and distal forearm BMD and calcaneal
ultrasound attenuation in a population-based random-
ized cohort of premenopausal women.
Materials and methods
Subjects
The study population consisted of a random sample of
Finnish women from a cohort of 5,161 women aged 35
to 40 years residing in the city of Oulu, Finland, in
March 2002 (Fig. 1). The name, address, and social
security number of the subjects were obtained from the
National Population Register of Finland. To detect a
3% (or more) difference between the exercise and con-
trol groups in BMD, with 5% significance level and
power of 80%, 120 participants were needed with an
equal dropout rate of ten subjects per group. The par-
ticipants were contacted in random order, and to get 120
participants, 287 women were contacted. Of these, 125
women were unwilling to participate, and 42 women
were excluded. The exclusion criteria were cardiovascu-
lar, musculoskeletal, respiratory, or other chronic dis-
eases that might limit training and testing; diseases or
medication affecting the bone; pregnancy and breast-
feeding; and regular current or previous participation in
impact-type exercises and long-distance running more
than three times a week. The subjects were randomly
assigned to an exercise group (n=60) or a nonexercise
control group (n=60) using a com puter-generated
number code. The study protocol was approved by the
Ethical Committee of the Northern Ostrobothnia Hos-
pital District, and all the participants gave informed and
written consent. The procedure of the study was in
accordance with the Declaration of Helsinki.
Questionnaires and anthropometry
A self-administered health questionnaire was mailed to all
contacted women, request ing information regarding
weight history and height, occupational history [18],
current and past physical activity [19] and medical factors,
fractures beyond the age of 15, menarcheal age, menstrual
status, parity, months of breast-feeding, current and
previous use of hormones, current and previous dietary
factors including intake of calcium and vitamin D [20],
current and past smoking and consumption of alcohol,
and possible vitamin or mineral supplementation.
Anthropometrical characteristics were measured at
baseline and after 12 months. Body weight and height
were measured, and body mass index was calculated.
Body fat and lean mass percentages were measured with
bioimpedance equipment (Bodystat 1500; Bodystat,
Douglas, Isle of Man, UK).
Bone measurements
Areal bone mineral density (BMD, g/cm
2
) was measured
on the lumbar spine (L1–L4) and the left proximal femur
with dual-energy X-ray absorptiometry (DXA) (Hologic
Delphi QDR; Hologic, Bedford, MA, USA). The femoral
neck, trochanter, intertrochanter, and Ward’s triangle of
the hip, and vertebras L1–L4 were analyzed separately.
The same operator did all of the scanning and analyses.
The scanner was calibrated daily by bone phantoms
(Hologic, Bedford, MA, USA) for quality assurance, and
no evidence of machine drift appeared during this study.
BMD was also measured from the distal ulna, distal ra-
dius, and ultradistal radius, with peripheral DXA (Oste-
ometer DTX 200; Osteometer Meditech, Roedovre,
Denmark). Calcaneal broadband ultrasound attenuation
(BUA, dB/MHz) and speed of sound (SOS, m/s) were
measured using quantitative ultrasound (QUS) (Hologic
Sahara; Hologic, Bedford, MA, USA). The measure-
ments were performed in the beginning and at the end of
the intervention.
Exercise training protocol
The training sessions were carried out three times a week
for 12 months. All training sessions were supervised by a
Fig. 1 Study protocol
192
physiotherapist and were done with the accompaniment
of music. The training regimen was based upon a pilot
study and upon the previous literatu re. Each workout
lasted 60 min, includ ing a 10-min warm-up, a 40-min
high-impact training session, and a 10-min cooling-
down and stretching period. The warm-up period in-
cluded walking and running on the spot, with and
without arm movements and knee bends. The high-im-
pact period included step patterns, stamping, jumping,
running, and walking. After 3 months of training, a one-
step bench (height 10 cm) (Reebok UK, Lancaster, UK)
was used to enhance the impact effect and after
6 months, two or three benches were used. The cool-
down mainly consisted of stretching. The programs were
modified bimonthly and during the intervention, the
program became more demanding and included higher
jumps and drops. Additionally, the participants were
asked to train 10 min daily at home following a specially
designed program, which consisted of similar patterns of
exercise to those in the supervised sessions. The home
program was also modified seasonally. The women in
the control group were asked to continue their normal
daily life and to mai ntain their current physical activity
during the 12 months. All participants carried a physical
activity recorder (Newtest, Oulu, Finland) on their waist
during the study. These physical activity data will be
analyzed and reported later.
Statistical analysis
The data were analyzed using the SPSS statistical
package (SPPS 11.5 for Windows; SPPS, Chicago, IL,
USA). The results are reported as mean and standard
deviation (SD) or 95% confidence interval (95% CI). All
participants, including the subjects who discontinued
exercise, were invited for the follow-up measurements.
All subjects with both baseline and follow-up data were
included in the analysis according to their group
assignment. Distributions of outcome vari ables were
tested for normality. Independent samples t-test and
v-square tests were used to assess the differences between
the study subjects and women who did not participate in
the study. Independent samples t-test (or Mann-Whitney
U-test if the distribu tion was not normal) was used to
compare the groups with respect to changes from base-
line in bone mineral density and also the differences
between the study subjects and dropouts. Paired samples
t-test (or Wilcoxon signed-rank test) was used to analyze
the percentage change from baseline within the groups.
Repeated measures analysis of covariance, using change
of weight and BMI as covariates, was also performed,
but analyses did not differ from unadjusted tests and are
not reported. Analyses condu cted on raw units of
change and percentages produced similar results. In all
tests, p<0.05 was considered statistically significant.
Results
Characteristics and compliance
All 120 (100%) subjects and 70 (42%) excluded or
unwilling women returned the baseline questionnaire.
We analyzed the characteristics of the nonparticipants
and found they did not differ from the study group
(Table 1). The baseline characteristics of the participants
are given in Table 2. Thirty-nine women (65%) in the
training group and 41 women (68%) in the control
group completed the study, representing a dropout fre-
quency of 33.3%. There were no significant differences
in any baseline variables between the dropouts and
subjects who completed the study. The reasons for
withdrawal were medical problems unrelated to the
intervention program (n=3), pregnancy (n=8), moving
from the study area (n=2), change of vocation or
schedule (n=6), or other reasons (n=21). The reasons
for withdrawal were divided equally for both groups.
For women completi ng the study, the average compli-
ance defined as exercise sessions attended was 0.9 times
Table 1 Characteristics of
selected variables from baseline
questionnaire. NS statistically
not significant
a
p Values for differences
between groups
Characteristics Control
group
(n=60)
Exercise
group
(n=60)
Nonparticipants
(n=70)
p Value
a
Mean (SD) of continuous variables
Age, years 38.5 (1.6) 38.1 (1.7) 37.8 (1.8) NS
Height (as given by the subject), cm 160.8 (20.1) 164.5 (5.4) 163.6 (18.7) NS
Weight (as given by the subject,
at the age of 30), kg
63.0 (14.6) 61.4 (8.8) 62.1(8.3) NS
Calcium intake, mg/day 1,099 (511) 1,099 (657) 1,126 (451.1) NS
Menarcheal age, years 12.6 (1.5) 12.8 (1.4) 12.9 (1.1) NS
Exercise, times/week 3.8 (4.1) 3.2 (2.6) 3.5 (2.0) NS
Exercise time (one period), min 52.6 (21.7) 49.4 (21.7) 49.6 (20.5) NS
Distribution of category variables, %
Smokers 18.6 18.6 20.0 NS
Alcohol >1 drink/week 26.7 22.0 24.3 NS
Moderate exercise <1 time/week (15 min) 25.4 18.6 18.8 NS
Heavy exercise <1 time/week (15 min) 45.8 49.2 37.1 NS
Any fracture beyond the age of 15 years 15.0 15.3 18.6 NS
Any use of hormone medication (>1 year) 63.8 72.9 84.3 NS
193
per week in supervised sessions and 2.2 in home sessions.
The training program was well tolerated by all partici-
pants, and none devel oped stress-related or other inju-
ries. During the study, the participants consulted an
attending physician three times for the following rea-
sons; mild ankle distorsion (one), tibial contusion (one),
and unspecified stomach pain (one). The training was
interrupted for at most 1 week because of these injuries.
According to the endpoint questionnaires, 6 participants
from the control group estimated that they were physi-
cally less active, 7 were more active, and 28 equally
active compared with baseline.
Anthropometrics and bone measurements
During the 12 months of high-impact exercise inter-
vention, the training group lost some weight ()1.1%),
while the control group had a minor weight gain (1.1%)
(p=0.082). Bone mineral acquisition was significantly
greater in the exercise group than in the control group at
most of the lower extremity bone sites (Table 3). The
exercise group demonstrated a significant gain compared
with the control group in femoral neck BMD (1.1%
vs )0.4%; p=0.003), intertrochanteric BMD (0.8% vs
)0.2%; p=0.029), and total femoral BMD (0.1% vs
)0.3%; p=0.006) (Fig. 2A). In addition, trochanteric
BMD increased more in the exercise group than in the
control group (1.1% vs 0.1%), the difference being al-
most statistically significant (p=0.052). The changes
within the exercise group were significant in every vari-
able in the upper femur. In the lumbar area, L1 BMD
increased more in the exercise group than in the control
group (2.2% vs )0.4%; p=0.002) and change was also
significant within the exercise group (Fig. 2B). There
were no significant changes in the L2–L4 region between
or within the groups. Calcaneal BUA increased in the
exercise group (7.3%) and decreased in the control
group ()0.6%) (p=0.015). The changes between or
within the groups were not significant in the non-weight-
bearing sites in the distal forearm. Results from
covariance analyses did not differ from unadjusted
values.
Discussion
The aim of this study was to investigate the effects of
high-impact exercise on bone mineral density in pre-
menopausal women. The study revealed that 12 months
of regular high-impact exercise led to significantly in-
creased bone mass at the loaded bone sites in lower
extremities, but not at the non-weight-bearing bone
sites. Our findings confir m the previous information on
the positive effects of high-impact exercise on weigh t-
bearing bones.
Table 2 Baseline characteristics. Values are mean (SD)
Characteristics Control
group
(n=60)
Exercise
group
(n=60)
Age, years 38.5 (1.6) 38.1 (1.7)
Height, cm 164.6 (6.0) 162.8 (5.8)
Weight, kg 69.4 (12.3) 68.0 (12.6)
BMI 25.7 (4.6) 25.6 (4.4)
Percentage body fat 31.2 (6.7) 30.3 (6.4)
Fat mass, kg 21.7 (8.4) 20.8 (8.1)
Percentage lean body mass 68.8 (6.7) 69.7 (6.4)
Lean body mass, kg 45.8 (4.7) 46.0 (5.6)
Waist, cm 82.3 (11.6) 81.1 (10.3)
Hip, cm 100.8 (8.0) 100.5 (8.6)
Calcium intake, mg/day 1,099 (511) 1,099 (657)
Table 3 Bone measurements at baseline and at 12 months for completed subjects. Values are mean (SD). NS statistically not significant,
BMD bone mineral density, SOS speed of sound, BUA broadband ultrasound attenuation
Control group (n=41) Exercise group (n=39) p Value
a
Baseline At 12 months Baseline At 12 months
Femoral neck BMD, g/cm
2
0.804 (0.100) 0.801 (0.099) 0.789 (0.097) 0.797 (0.093)** 0.003
Trochanter BMD, g/cm
2
0.701 (0.080) 0.702 (0.078) 0.698 (0.092) 0.705 (0.093)** 0.052
Intertrochanter BMD, g/cm
2
1.141 (0.114) 1.138 (0.114) 1.128 (0.129) 1.136 (0.132)* 0.029
Femoral total BMD, g/cm
2
0.950 (0.097) 0.947 (0.096) 0.940 (0.107) 0.939 (0.115)*
#
0.006
#
Ward’s triangle BMD, g/cm
2
0.702 (0.107) 0.708 (0.102) 0.687 (0.104) 0.705 (0.107)*** NS
L1 BMD, g/cm
2
0.931 (0.112) 0.926 (0.112) 0.916 (0.116) 0.936 (0.115)*** 0.002
L2 BMD, g/cm
2
1.028 (0.112) 1.031 (0.104) 1.028 (0.116) 1.026 (0.116) NS
L3 BMD, g/cm
2
1.062 (0.116) 1.060 (0.108) 1.050 (0.104) 1.046 (0.106) NS
L4 BMD, g/cm
2
1.067 (0.120) 1.063 (0.119) 1.040 0.110) 1.036 (0.115) NS
Lumbar total BMD, g/cm
2
1.027 (0.109) 1.025 (0.104) 1.014 (0.100) 1.015 (0.102) NS
Radius BMD, g/cm
2
0.488 (0.053) 0.484 (0.055) 0.503 (0.062) 0.500 (0.059) NS
Ulna BMD, g/cm
2
0.389 (0.051) 0.397 (0.057) 0.411 (0.059) 0.408 (0.057) NS
#
Distal radius BMD, g/cm
2
0.448 (0.050) 0.448 (0.051) 0.466 (0.059) 0.464 (0.056) NS
Ultradistal radius BMD, g/cm
2
0.351 (0.048) 0.351 (0.050) 0.368 (0.060) 0.367 (0.057) NS
Calcaneal SOS, m/s 1,566.13 (25.04) 1,570.19 (25.56) 1,570.13 (29.11) 1,574.38 (32.85) NS
Calcaneal BUA, dB/MHz 86.74 (14.75) 85.98 (16.43) 83.68 (13.74) 89.76 (19.50) 0.015
*p<0.05; **p<0.01; ***p<0.001, annual change within the group;
#
nonparametric test
a
p Values for differences between the control group and the exercise group over the 12-month study period
194
The training regimen proved to be safe, judging from
the minimum need for medical services (3 visits over the
entire study period) and also showed efficacy in
improving the BMD in the upper femur with the mean
attendance of 0.9 times per week in supervised sessions
and 2.2 times per week in additional home sessions.
Although the compliance with supervised sessions was
moderately low, exercise-induced benefits appeared.
This might point to the fact that even 1 to 2 hours of
high-impact exercise plus two home -based exercise ses-
sions would be enough to get benefits.
In our study, the exercise group demonstrated a sig-
nificant 1.1% gain in femoral neck BMD and 7.3% in
calcaneal BUA during the 12 months of high-impact
exercise regimen, while there were no significant changes
in control group values and no changes at the non-
weight-bearing sites. In addition, BMD in the first
lumbar vertebra increased 2.2%, but there were no
exercise-induced effects in other vertebrae. Our findings
are in agreement with previous randomized controlled
high-impact exercise interventions in premenopausal
women. In the study by Friedlander et al. [15], there
were significant positive differences in BMD between the
exercise and stretching groups for spinal trabecular
(2.5%), femoral neck (2.4%), femoral trochanteric
(2.3%), and calcaneal (6.4%) measurements after a 2-
year high-impact exercise period. Heinonen et al. [16]
observed a positive exercise effect on several risk factors
for osteoporotic fractures, including a positive exercise
effect on femoral neck BMD and lumbar spine BMD
after 18 months of high-impact exercise training. Also
Bassey et al. [21] reporte d significant differences between
the exercise and control group in trochanter area BMD
in premenopausal women after 5 months of training
consisting of 50 vertical jumps on 6 days per week.
Exercise regimen was effective on premenopausal wo-
men, but no significant differences were found in the
bone mineral densities of postmenopausal women.
Resistance and endurance training have also been re-
ported to affect positively bone mineral status in pre-
menopausal women [12, 14, 22]. Sinaki and colleagues
[23] reported in their 3-year randomized controlled trial
of dose-specific loading and strengthening exercises that
lumbar spine BMD improved at 1 year with increased
levels of exercise in the subjects who had lower BMD
initially. However, at the completion of the study at
3 years, there was no significant change in BMD at the
spine, hip, or midradius. Gleeson et al. [24] and Rock-
well et al. [ 25] found that exercise training, including
mostly weight-lifting, had no effect on bone mineral at
the proximal femur. The apparently conflicting results
may be due to differences in the type, intensity, fre-
quency, or duration of exercise. In addition, the selec-
tion of the study samples and characteristics of the
volunteers participating (e.g., age, nutrition, and hor-
monal status) may have affected the results. Indeed, re-
cent meta-analyses have revealed clear positive effects of
exercise training on lumbar spine and femoral neck in
premenopausal women. The exercise training programs
prevented or reversed almost 1% bone loss in pre-
menopausal women [6, 9]. Furthermore, results of
Wallace and Cummi ng [9] indicate also that both high-
impact and non-impact exercises have a positive effect
on the lumbar spine, but only high-impact exercise has a
positive effect on the femoral neck. Moreover, aerobic
and step exercises are popular among premenopausal
women, a point which suggests high feasibility in the
general population. In addition, risks of injuries are
minor in healthy premenopausal women, so high-impact
exercise seems to be suitable for the prevention of
osteoporosis.
In the lumbar spine, no exercise-induced effects were
found in the total lumbar BMD or in the lumbar ver-
tebrae L2 to L4. Instead, impact exercise seemed to
strengthen the lumbar vertebra L1. There is little existing
data on the difference in the sensitivity of the lumbar
vertebrae for impact loading, since most studies report
only the combined BMD values for L1–L4 or L2–L4.
The BMD measurement of the vertebrae one by one is
less reliable than the combined values from a set of
vertebrae, which has to be considered. However, the
biomechanical loading varies between the vertebrae,
which might partly explain the difference. The cross-
sectional area of L1 is sm aller than that of L2–L4, which
Fig. 2A, B Mean percentage changes in (A) femoral BMD and (B)
lumbar BMD over the 12-month study period. The error bars
represent 95% confidence intervals; p values are for differences
between the groups over the study period. *p<0.05; **p<0.01;
***p<0.001, for the change within the group;
#
nonparametric test.
LT lumbar total, FN femoral neck, TR trochanter, IT intertro-
chanter, FT femoral total, and WT Ward’s triangle
195
generates higher loading stresses. At baseline, BMD was
also lower in L1 than in the lower spine; impact-loading
may therefore have had a more positive effect on this site
with lower BMD [26]. Impact exercise may also have
effects not only through weight-bearing, but the muscle
forces may also play some role. It is known that the
transversus abdominis muscle has an important role in
spinal stiffness generation [27]. It supports the spine by
intra-abdominal pressure [28], which may partly explain
the differences between the vertebrae. The effects of
impact-loading especially for the L1 may have great
clinical impo rtance since the number of atraumatic
fractures is the greatest in L1 due to its role as the
transition area (Th11–L1) between it and the low-
mobility thoracic region, and hence the highly mobile
lumbar area is susceptible to injury [29, 30, 31, 32].
These findings needs confirmation, however, and further
studies are needed to clarify the effects of impact-loading
on other vertebrae in the transition area.
In this study, the decrease in body weight in the exercise
group and increase in the control group, although non-
significant, may account for the responses of bone mineral
status during the study period, so the results may under-
estimate the effects of exercise on bone. Body weight and
weight changes are strongly linked to BMD changes in
women regardless of body site. Weight and weight in-
crease are associated with maintenance of BMD and re-
duced bone loss, whereas thinness and weight loss lead to
low BMD and enhanced bone loss [33, 34, 35].
Our study had some limitations. The dropout rate of
33% over the 12-month period for this study was
moderately high and higher than the expected 10 per
group (17%) used in our power calculat ion. The high
dropout rate is not unusual for exercise intervention
trials. Studies by Snow-Harter et al. [12], Gleeson et al.
[24], and Friedlander et al. [15] reported attrition rates of
40% in just 8 months, 38% in 1 year, and 50% in
2 years, respectively. Our population-based approach
may have had an effect on the dropout rate. In most of
the previous studies, voluntary premenopausal women
already interested in exercise training have been re-
cruited. The subjects may have been more active and
interested in participating in the exercise program than
the general population. In addition, the previous phys-
ical activity of the subjects in these studies may have
been higher than in the general population. In this study,
we recruited subjects from the whole age cohort residing
in a specified area. Furthermore, we excluded the women
already involved in high-impact exercise, thus we cer-
tainly also excluded the highly motivated subjects.
However, the high number of women who were
unwilling to participate in the study may have caused
some selection bias. The dropout rate similar to other
studies may indicate that the subjects in our study were
not less motivated than the women in other studies,
which were based on different recruitment. Premeno-
pausal women seem to be more difficult to keep involved
in a routine exercise program due to their numerous
family responsibilities and career obligations compared
with postmenopausal women. The reasons listed by our
subjects for discontinued participation were predomi-
nantly unrelated to the study intervention and therefore
unlikely to have affected the study outcomes.
In conclusion, this study indicates that high-impact
exercise is safe and effective in improving bone mineral
density in the lumbar spine and upper femur in healthy
premenopausal women. If done on a regular basis, this
type of training may be an efficient, safe, and inexpensive
way of preventing osteoporosis later in life.
Acknowledgements The authors would like to express special
thanks to Minna Tervo, physiotherapist in our study, for her
dedication and hard work in supervising the training and testing of
our subjects. We thank Ms Sari-Anna Vaara and Ms Arja Retsu
for performing the bone scans, Pentti Nieminen, Ph.D., for statis-
tical advice, and the whole staff of the Department of Sports
Medicine in the Deaconess Institute of Oulu for their assistance.
Financial support was provided by the National Technology
Agency of Finland; Newtest, Oulu, Finland; the Juho Vainio
Foundation; and the Finnish Foundation for Sports Research.
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La desmineralización ósea provoca una fragilidad estructural en los huesos, que conlleva a fracturas o lesiones que trastornan la vida cotidiana y generan grandiosos gastos a nivel salud. Esta situación se magnifica con una vida sedentaria, malos hábitos alimentarios y en mujeres menopaúsicas. El objetivo de este trabajo fue verificar los efectos de diversos programas de ejercicio físico (PEF) sobre la densidad mineral ósea en mujeres mayores de 20 años con o sin osteoporosis no medicadas, mediante una revisión sistemática sobre estudios experimentales con ensayos clínicos aleatorios. La búsqueda se realizó en 4 bases de datos (SPORTDiscus, Medline, ScienceDirect y Springer Link) entre el año 2000 y 2016, los criterios de inclusión: publicación en inglés o español, grupo de intervención con PEF y un grupo control, registro pre y post intervención la densidad mineral ósea (DMO) con Dual Energy X-ray Absorptiometry (DXA) a nivel del cuello del fémur o vértebras lumbares (L1, L2,L3 y L4). Se obtuvieron 872 estudios, 32 fueron incluidos en él meta análisis. Se calculó a nivel lumbar y femoral el efecto medio estandarizado (SMD), intervalos de confianza (IC) y la heterogeneidad entre estudios mediante el (I2) con un P valor de 0,95. Resultados: Lumbares (SMD=1.315) y IC (0.855 a 1.775) con un I2=94.2%, fémur (SMD= 1.412) y IC (0.786 a 2.039) con un I2=96.9%, debido a la elevada heterogeneidad se realizó una meta regresión con variables moduladoras para comprender la variabilidad entre estudios. Limitaciones: El meta análisis muestra un posible sesgo de publicación, y los estudios fueron seleccionados por un solo investigador. Conclusiones: los PEF tienen efectos estadísticamente positivos en la DMO femoral y lumbar. La variabilidad de los resultados entre estudios es elevada, explicada en parte por la edad (a mayor edad mayor efecto del PEF) y el tipo de PEF implementado, los trabajos de fuerza explican un 24,36% de la heterogeneidad mostrando efectos negativos a nivel femoral, mientras los ejercicios con el propio peso corporal explican un 13,34% de efectos adversos a nivel de las lumbares, comparándolos con el resto de los programas de ejercicios analizados en este meta-análisis
Article
Objectives To clarify the factors associated with prevention, diagnosis, and treatment of osteoporosis, and to present the most recent information available in these areas. Participants From March 27-29, 2000, a nonfederal, nonadvocate, 13-member panel was convened, representing the fields of internal medicine, family and community medicine, endocrinology, epidemiology, orthopedic surgery, gerontology, rheumatology, obstetrics and gynecology, preventive medicine, and cell biology. Thirty-two experts from these fields presented data to the panel and an audience of 699. Primary sponsors were the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Institutes of Health Office of Medical Applications of Research. Evidence MEDLINE was searched for January 1995 through December 1999, and a bibliography of 2449 references provided to the panel. Experts prepared abstracts for presentations with relevant literature citations. Scientific evidence was given precedence over anecdotal experience. Consensus Process The panel, answering predefined questions, developed conclusions based on evidence presented in open forum and the literature. The panel composed a draft statement, which was read and circulated to the experts and the audience for public discussion. The panel resolved conflicts and released a revised statement at the end of the conference. The draft statement was posted on the Web on March 30, 2000, and updated with the panel's final revisions within a few weeks. Conclusions Though prevalent in white postmenopausal women, osteoporosis occurs in all populations and at all ages and has significant physical, psychosocial, and financial consequences. Risks for osteoporosis (reflected by low bone mineral density [BMD]) and for fracture overlap but are not identical. More attention should be paid to skeletal health in persons with conditions associated with secondary osteoporosis. Clinical risk factors have an important but poorly validated role in determining who should have BMD measurement, in assessing fracture risk, and in determining who should be treated. Adequate calcium and vitamin D intake is crucial to develop optimal peak bone mass and to preserve bone mass throughout life. Supplementation with these 2 nutrients may be necessary in persons not achieving recommended dietary intake. Gonadal steroids are important determinants of peak and lifetime bone mass in men, women, and children. Regular exercise, especially resistance and high-impact activities, contributes to development of high peak bone mass and may reduce risk of falls in older persons. Assessment of bone mass, identification of fracture risk, and determination of who should be treated are the optimal goals when evaluating patients for osteoporosis. Fracture prevention is the primary treatment goal for patients with osteoporosis. Several treatments have been shown to reduce the risk of osteoporotic fractures, including those that enhance bone mass and reduce the risk or consequences of falls. Adults with vertebral, rib, hip, or distal forearm fractures should be evaluated for osteoporosis and given appropriate therapy.
Article
Study Design: The contribution of transversus abdominis to spinal stabilization was evaluated indirectly in people with and without low back pain using an experimental model identifying the coordination of trunk muscles in response to a disturbance to the spine produced by arm movement. Objectives: To evaluate the temporal sequence of trunk muscle activity associated with arm movement, and to determine if dysfunction of this parameter was present in patients with low back pain. Summary of Background Data: Few studies have evaluated the motor control of trunk muscles or the potential for dysfunction of this system in patients with low back pain. Evaluation of the response of trunk muscles to limb movement provides a suitable model to evaluate this system. Recent evidence indicates that this evaluation should include transversus abdominis. Methods: While standing, 15 patients with low back pain and 15 matched control subjects performed rapid shoulder flexion, abduction, and extension in response to a visual stimulus. Electromyographic activity of the abdominal muscles, lumbar multifidus, and the contralateral deltoid was evaluated using fine‐wire and surface electrodes. Results: Movement in each direction resulted in contraction of trunk muscles before or shortly after the deltoid in control subjects. The transversus abdominis was invariably the first muscle active and was not influenced by movement direction, supporting the hypothesized role of this muscle in spinal stiffness generation. Contraction of transversus abdominis was significantly delayed in patients with low back pain with all movements. Isolated differences were noted in the other muscles. Conclusions: The delayed onset of contraction of transversus abdominis indicates a deficit of motor control and is hypothesized to result in inefficient muscular stabilization of the spine.
Article
By using the meta-analytic approach, the purpose of this study was to examine the effects of exercise on regional bone mineral density in postmenopausal women. A total of 11 randomized trials yielding 40 outcome measures and a total of 719 subjects (370 exercise, 349 nonexercise) met the criteria for inclusion: (1) randomized trials; (2) exercise as a primary intervention in postmenopausal women; (3) changes in regional bone mineral density reported; (4) comparative nonexercise group included; (5) studies published in English-language journals between January 1975 and December 1995. Across all designs and categories, treatment effect changes in bone density, weighted by sample size, ranged from -17.10 to 17.30% (mean, 0.27%; 95% confidence interval, 0.16-0.37%). When analyzed separately, sample weighted decreases of approximately -0.51 and -0.86% were found for exercise and nonexercise groups, respectively. Larger effects were observed when groups that did not measure bone density specific to the site loaded and groups that received some type of supplementation (calcium or hormone replacement therapy) were deleted from the model (mean change, 0.76%; 95% confidence interval, 0.6-0.93). Both aerobic and strength training enhanced regional bone mineral density (mean change: aerobic, 1.62% and 95% confidence interval, 1.12-2.12; strength, 0.65% and 95% confidence interval, 0.48-0.83). In conclusion, metaanalytic review of included studies suggests that exercise may slow the rate of bone loss in postmenopausal women. However, it is premature to form strong conclusions regarding the effects of exercise on regional bone mineral density in postmenopausal women. A need exists for additional, well designed studies on this topic before a recommendation can be made regarding the efficacy of exercise as a nonpharmacologic therapy for maintaining and/or increasing regional bone mineral density in postmenopausal women. (C) Williams & Wilkins 1998. All Rights Reserved.
Article
This study was designed to assess the effects of 18 months of resistance exercise on regional and total bone mineral density (BMD) and soft tissue lean mass (STL) in premenopausal women aged 28–39 randomly assigned to an exercise or control group. Twenty-two exercise and 34 control subjects completed the 18-month training study. All subjects were previously inactive and untrained women. Initial, 5-, 12- and 18-month assessments were made of total and regional BMD and total and regional STL using dual energy X-ray absorptiometry. All subjects consumed a 500 mg/day elemental calcium supplement throughout the study. Initial Ca intake without supplement averaged 1,023 mg/day in total sample. Serum levels of bone osteocalcin and dietary assessments using 12 randomly assigned days of diet records were also completed. Muscular strength was assessed from both 1 repetition maximum (RM) testing of 10 weightlifting exercises and by peak torque for hip abduction/adduction and knee extension/flexion. Training increased strength by 58.1% based on 1 RM testing and by 33.8% based on isokinetic testing at 18 months versus baseline. BMD increased significantly above baseline at the lumbar spine for the exercise group at 5 months (2.8%), 12 months (2.3%), and 18 months (1.9%) as compared with controls. Femur trochanter BMD increased significantly (p < 0.05) in the exercise group at 12 months (1.8%) and 18 months (2.0%) but not at 5 months (0.7%) as compared with controls. No changes in total BMD, arm BMD, or leg BMD were found. There was a 20% increase in BGP in the exercise group as compared with controls at 5 months and this difference was maintained throughout the study. For STL, significant increases for total, arm, and leg were found at 5, 12, and 18 months for the exercise group versus control ranging from 1–6% over baseline. These results support the use of strength training for increasing STL and muscular strength with smaller but significant regional increases in BMD in the premenopausal population.
Article
Osteoporosis is widely viewed as a major public health concern, but the exact magnitude of the problem is uncertain and likely to depend on how the condition is defined. Noninvasive bone mineral measurements can be used to define a state of heightened fracture risk (osteopenia), or the ultimate clinical manifestation of fracture can be assessed (established osteoporosis). If bone mineral measurements more than 2 standard deviations below the mean of young normal women represent osteopenia, then 45% of white women aged 50 years and over have the condition at one or more sites in the hip, spine, or forearm on the basis of population-based data from Rochester, Minnesota. A smaller proportion is affected at each specific skeletal site: 32% have bone mineral values this low in the lumbar spine, 29% in either of two regions in the proximal femur, and 26% in the midradius. Although this overall estimate is substantial, some other serious chronic diseases are almost as common. More importantly, low bone mass is associated with adverse health outcomes, especially fractures. The lifetime risk of any fracture of the hip, spine, or distal forearm is almost 40% in white women and 13% in white men from age 50 years onward. If the enormous costs associated with these fractures are to be reduced, increased attention must be given to the design and implementation of control programs directed at this major health problem.
Article
A substantial body of cross-sectional data and a smaller number of intervention trials generally justify optimism that regular physical activity benefits the skeleton. We conducted an 8 month controlled exercise trial in a group of healthy college women (mean age = 19.9 years) who were randomly assigned to a control group or to progressive training in jogging or weight lifting. We measured the following variables: bone mineral density (BMD) of the spine (L2-4) and right proximal femur using dual-energy x-ray absorptiometry, dynamic muscle strength using the 1-RM method, and endurance performance using the 1.5 mile walk/run field test. A total of 31 women completed the 8 month study. For women completing the study, compliance, defined as the percentage of workout sessions attended, was 97% for the runners (range 90-100%) and 92% (range 88-100%) for the weight trainers. Body weight increased by approximately 2 kg in all groups (p less than 0.05). Weight training was associated with significant increases (p less than 0.01) in muscle strength in all muscle groups. Improvement ranged from 10% for the deep back to 54% for the leg. No significant changes in strength scores were observed in the control or running groups. Aerobic performance improved only in the running group (16%, p less than 0.01). Lumbar BMD increased (p less than 0.05) in both runners (1.3 +/- 1.6%) and weight trainers (1.2 +/- 1.8%). These results did not differ from each other but were both significantly greater than results in control subjects, in whom bone mineral did not change.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
A group of 68 premenopausal women participated in a controlled 12 month exercise program. Two groups were matched according to age, body size (body mass index), and typical activity level. Data collection included bone mineral density (BMD) of the lumbar spine with dual-photon absorptiometry and of the os calcis with single-photon absorptiometry, lean body mass, urinary calcium/creatinine, and urinary gammacarboxyglutamic acid (Gla). Subjects wer given a daily 500 mg supplement of elemental calcium. There was no significant difference between groups in terms of diet, in urinary calcium/creatinine or Gla, or in lean body mass. The weight lifting group had a nonsignificant increase in mean lumbar BMD of 0.81% and the control group exhibited a nonsignificant decrease of 0.5%. However, a paired t-test revealed a significant difference between the matched pairs in percentage change in lumbar BMD. The os calcis showed no significant change in the means in either group or as matched pairs. The relatively small change seen as a result of this modified Nautilus exercise program may prevent moderate weight lifting from being a practical answer for osteoporosis, even in a highly motivated population
Article
The effect of exercise on bone mass is unclear. To determine the skeletal effect of weight-bearing exercise in premenopausal women, we prospectively evaluated the effects of a weight-training program on lumbar spine bone mass in 10 women (mean +/- SEM, 36.2 +/- 1.3 yr) and compared the results with those in 7 sedentary women (40.4 +/- 1.6 yr). None of the women had previously participated in a weight-training program, and all ingested a 500-mg calcium supplement each day throughout the study. Axial loading and balance of large muscle groups were emphasized. Individual strength increased by 57 +/- 8% over 9 months. Despite the increase in muscle strength, lumbar spine bone density in the exercising women decreased by 2.90% at 4.5 months and 3.96% at 9 months (P = 0.01). In contrast, there was no change in lumbar density in the controls over the 9-month period. We conclude that short term weight training at this frequency and intensity decreases vertebral bone mass in premenopausal women.
Article
This study investigated the efficacy of 4 years of exercise intervention in deterring bone loss in middle-aged women, and is a correction and extension of previously published data. Sixty-two control subjects (mean age 50.8) and 80 exercise subjects (mean age 50.1) completed a 4-year study. Subjects exercised three times a week, 45 minutes per session. Bilateral radius, ulna, and humerus bone mineral content (BMC) and width (W) were measured on each subject 11 times over the 4-year period. The two groups did not differ initially in age, height, or weight, but the control group had a greater maximum VO2 (ml/kg/min) than the exercise group. Slopes and intercepts of the bone variables vs. time were determined for each subject, and these values were used for between-group comparisons of loss. The control group BMC and BMC/W declined significantly in all three bones in both arms. The exercise group rate of decline was significantly less than that of the control group for 12 of the 18 bone variables. The greatest effect of the exercise intervention was on the ulna and radius. Exercise subjects lost significantly less than control subjects in left and right ulna and radius BMC and BMC/W, and left ulna and radius W. Lesser differences between groups were observed in the humerus. BMC and W loss rates of the left humerus were reduced in the exercise group, with no difference between exercise and control subjects in the other humerus variables. To determine if menopausal status influenced the response to exercise, we analyzed the difference between groups for premenopausal and postmenopausal subjects separately. Regardless of menopausal status, exercise subjects had lower bone loss rates than control subjects. In both premenopausal and postmenopausal subjects, exercise reduced bone loss significantly for 10 of the 18 bone variables. It can be concluded that physical activity significantly reduces bone loss in the arms of middle-aged women.