High Intensity High Impact for Bone Losses in Menopause?

Episode #489 Is offsetting bone losses in menopause with high impact safe? Is it recommended? Aren’t you more prone to fractures? This episode explores the recent research in honor of Menopause Awareness Month (and Osteoporosis Day October 20, 2021). If you’re trying to prevent, if you’ve been diagnosed, or if you’ve got younger women in your life who need this information NOW to be better prepared than we could have known to be… this is for you.

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Bone Losses in Menopause

Average bone loss is 1.5% per year for the spine and 1.1% – 1.4% for the femoral neck in the first 4-5 years post menopause.

Losses slow slightly after this and then increase again in latter decades.

Just 6 months into the pandemic research began to emerge about the long-term health effects of short-term muscle loss. The possible devasting disability includes sarcopenia and osteoporosis both, as well as increases in risk of obesity. A combined loss of muscle, strength, bone, with or without increased body fat sets up females specifically for avoidable negative health effects.

Osteoporosis & Exercise

Exercise is recommended but often with poor and non-specific guidelines for having the most benefit. The purpose of this post is to:

  • Present the continuum of activity results on bone mineral density
  • Present other valuable components of exercise
  • Support prioritization of exercise time for readers
  • Consider a variety of exercises (and non-exercise) interventions and their results
  • Integrating safety

Optimal exercise interventions are those favoring a mechanical stimulus on bone both through antigravity loading and the stress exerted on muscles. Two types of activity for osteoporosis prevention and post-diagnosis therapeutic effects:

  • Weight-bearing activities
  • Strength/Resistance exercises

What is weight-bearing activity?

Defined as any activity one performs on one or more feet. Technically, however it would also include activity weight bearing on the upper body as in a downward facing dog. Where bone density is concerned, there are levels of weight-bearing. Standing in tree pose is weight bearing. Using an elliptical is weight bearing. Neither of those however has any striking force involved as when there is a heel strike in walking. The greater the strike the greater the force to bone.

What is resistance exercise?

Technically, resistance exercise is anything that provides additional overload to the muscle (and bone) beyond activities of daily living. Resistance exercise includes use of machine and free weights, body weight, tubing, bands, even water exercise or swimming is viewed as resistance training. Each activity falls along a continuum of benefits.

As you might guess, use of machine or free weights will surpass swimming or water exercise for bone density benefits. Use of weight training also surpasses benefits from bands and tubing. Though use of bands and tubing may be a first step, an only option depending on access to dumbbells, or machine weights, or support lateral movements unachievable from free-weights alone, the application of heavy resistance is most beneficial and more closely mimics activity of daily life.

Of the two activities for osteoporosis prevention and therapeutic effects, strength/resistance exercise have the greatest benefit. This is due to the overload and what is referred to as Minimal Effective Stress (MES).

Minimum Effective Stress

Walking alone does not improve bone mass. It may have a limited contribution to slowing bone losses. The limit to benefits of walking occurs due to an effect called Minimal Effective Stress. For example, if you walk 2 or 3 miles several times a week, neither walking more days a week or walking 4 or 5 miles offers more bone benefit. You’re already adapted to the stress of your own body weight. What would potentially change or increase bone benefit would be jogging or adding a weighted vest during the walk. (Note: not handheld weights).

Similarly, with jogging, once you can jog or run, you don’t get greater benefits by running longer or more frequently. In fact, long distance runners who find low body fat, low body weight, may be at greater risk for low bone density. Older runners who do no resistance training with heavy weight are prone to fractures as much (or more if lower body weight) as general population.

It’s Not All Bone Strength

There is also more than the strength of the bone and of the muscle in consideration of activity. As aforementioned, the balance or stability-enhancing benefit of an activity also plays a part in reducing risk of falls. Where heavy resistance exercise is not possible, lighter weight and balance activities alone will still be beneficial, though not to bone, to improved stability and balance. It’s important that balance is specific to balance practice. Agility, balance and coordination don’t come from strength alone, but must be practiced.

For anyone seeking bone density and muscle strength, exercise selection should match those goals.

For anyone limited by conditions, injuries, or access, a greater emphasis should be placed on balance and stability, each of which require less equipment.

In either case, balance and agility/reaction skills are specific and need to be trained. They aren’t just added benefits from strength training.

The Research

Women in menopause transition are susceptible to muscle and bone losses that lead to sarcopenia and osteoporosis, respectively. That makes them more prone to falls, fractures, and then increasing bedrest and instability leading to frailty and early death.

How Much Muscle is Typically Lost?

Traditionally, loss of muscle can be about 8% per decade beginning at age 30. There’s an annual decline in total body LM during 4 to 5 years of the menopausal transition accelerates. The rapid acceleration of losses over a short period of time sets of alarms. If this isn’t countered with sufficient resistance training during that time, or mitigated soon after, it leads to a cascade of events including bone losses.  

The accelerated losses do slow again after the surge in early post menopause. Yet, in another decade or more they again accelerate to nearly 1% annual decline in leg LM among women between the ages of 70 and 79.

Start at the Beginning

The early research for exercise in osteoporosis prevention and treatment was conservative. The list of contraindications for those diagnosed with osteoporosis was long or at least limiting. Recent studies however, explore the intensity of exercise that does more than slows bone losses in favor of that which -even after menopause- where once thought game over, bone density can be improved.

Conservative Start

Early research scared many women who may have been avid exercise enthusiasts with a passion for downhill skiing or golf, into thinking they couldn’t potentially participate any longer. It suggested they suddenly come with a “fragile” label and are resigned to light and safe exercise.

One particular study in the Clinical Interventions in Aging journal I’ve spoke of before but bears mentioning as I kick off this section of a review of studies suggests otherwise. Post- diagnosis, there are considerations, and you have unique needs. You can however, and possibly should, find high intensity exercise that will start and wisely progress that includes both high impact weight bearing exercise and high intensity weight training.

That is, includes jumping, as well as heavy weight training. A study intended to be 18 months long was cut short by Covid at 13 months when supervision was no longer possible in March 2020, revealed even without getting to the most intense phase of the program, bone density was improved. In addition, compliance was high, injuries were non-existent. 

12-month high impact programs

Significantly better results were found in women who did high impact exercise and medication and dietary changes than medication and dietary changes alone. High impact- jumping, hopping, explosive movements was safe and effective

24-week aerobic dance programs

Another study in Medicine published in 2019 showed 3 times per week high impact exercise with women not taking HRT, improved bone density.

Site-Specific Benefits

High intensity exercise is a more effective stimulus for lumbar spine BMD than low or moderate intensity, but not femoral neck BMD, however, the latter finding may be due to lack of power in the exercises performed.

Additional Proof for High Intensity High Impact for Bone Losses in Menopause

A 2020 study published in the International Journal of Behavioral Nutrition and Physical Activity looked at women 65 and older. For them too higher doses of activity and particularly those involving resistance training are significantly more effective.

Let’s talk about dose where exercise for bone density is concerned. It’s important to know increasing frequency beyond 2-3 times a week is not the best way to increase volume. The better application of volume is increased amount of resistance, and increased sets. This will result in a decreased number of repetitions.

While muscle can benefit from greater repetitions (performed with smaller weights), bone cannot. If you are able to lift heavy (defined as reaching fatigue in 10 or fewer repetitions) you will have the most bone benefits.

Recent Research is Most Specific

While you may choose to believe that yoga, that pilates, that walking improves bone density, you’ll want to keep this in mind. In a review of literature including 75 articles, published from 1989 to 2019, results were too variable to conclude exercise effects on osteoporosis. This is proof that some protocols DO and some DO NOT benefit bone density.

This makes the statement, “something is better than nothing” questionable if you have a specific goal. You can’t do your boyfriend’s, your daughters, or your best friend’s exercise program and expect the specific results you want without checking the match for your priorities.

What we need is an exercisematch.com so you can sort through the prolific options and be sure that if your goal is bone density, or weight loss, or reducing arthritic pain, you are doing the right exercise to match this goal and any limitations. Flipping50’s mission is to make this a little easier for you.

Other Health Benefits

High intensity aerobic activity in a small co-hort of post menopausal women increased HDL, decreased body fat, and improved VO2 (cardiovascular fitness) but did nothing to lean muscle mass. Now, at first glance this is good. At second you might not think entirely. Even with a loss of body fat, because of the decrease in overall weight, metabolism will be lower. Without adjustments in dietary intake ultimately weight regain is likely.

A 2018 study in the Journal of Bone Mineral Research employed a protocol of high intensity loads (5 reps to fatigue x 5) for 4 different exercises, including high impact drop jumps. This study too had a high compliance level, one/100 adverse effects (low back spasm), and positive bone density improvements.

Yoga Poses for Bone Density

Some holes in the yoga study make it difficult to discern if the yoga was exclusively responsible for bone density improvement. There wasn’t enough control in the activity and habits of the participants. Monthly gain in BMD was significant in spine (0.0029 g/cm2, P = .005) and femur (0.00022 g/cm2, P = .053). At 22, 22, and 24 months, respectively, 72, 81, and 83 of these subjects reported mean gains of 0.048, 0.088, and 0.0003 g/cm2 per month which is the equivalent 1.152 (22 mos) and .0072 (24 mos).

Compare to 24 weeks strength training that include 3.1 ± 4.6%. There’s a significant difference both in results.

Yoga and Pilates for Bone Density

A 2021 study published in PLoS One showed only non-significant results on BMD. Benefits do occur for balance and stability. As a means of risk reduction from fall-related fractures there is value in these activities. What we each need to do is determine what is our realistic time spend and co-create a program based on the most influential exercises for each of our unique goals. It is possible to create a program that is inclusive of the high intensity strength training, the high impact (where a wise choice) activity, and the balance and stability building movements. This doesn’t have to mean many and separate sessions weekly. Minutes of balance and stability work regularly can be included in warm ups and cool downs.

Whole Body Vibration for Bone Density

Best indicated for the frail unable to perform other resistance exercises. For greatest effectiveness must contain a component of strength training. There is a degree of improvement in balance and stability from WBV. However, the biggest benefit is from resistance training combined with WBV, not in performing WBV alone. The additional benefit if the platform is available is worth it. The investment in the equipment for home, may not be the best or wisest use of time.

There you have it. This summary of recent bone losses and menopause research (provided during Menopause Awareness Month) is intended to get you pointed in the right direction for your exercise journey.

References Mentioned:

28 Day Kickstart

Fitness Trainers & Health Coaches MasterClass

Ageless Woman Summit

Stop the Menopause Madness Summit

References:

  1. Kirwan R, McCullough D, Butler T, Perez de Heredia F, Davies IG, Stewart C. Sarcopenia during COVID-19 lockdown restrictions: long-term health effects of short-term muscle loss. Geroscience. 2020 Dec;42(6):1547-1578. doi: 10.1007/s11357-020-00272-3. Epub 2020 Oct 1. PMID: 33001410; PMCID: PMC7528158.
  2. Sipilä S, Törmäkangas T, Sillanpää E, et al. Muscle and bone mass in middle-aged women: role of menopausal status and physical activity. J Cachexia Sarcopenia Muscle. 2020;11(3):698-709. doi:10.1002/jcsm.12547
  3. Hettchen M, von Stengel S, Kohl M, Murphy MH, Shojaa M, Ghasemikaram M, Bragonzoni L, Benvenuti F, Ripamonti C, Benedetti MG, Julin M, Risto T, Kemmler W. Changes in Menopausal Risk Factors in Early Postmenopausal Osteopenic Women After 13 Months of High-Intensity Exercise: The Randomized Controlled ACTLIFE-RCT. Clin Interv Aging. 2021 Jan 11;16:83-96. doi: 10.2147/CIA.S283177. PMID: 33469276; PMCID: PMC7810823.
  4. Ilinca, Ilona & Avramescu, Taina & Shaao, Mirela & Rosulescu, Eugenia & Zavaleanu, Mihaela. (2010). The role of high – impact exercises in improve bone mineral density in postmenopausal women with osteopenia or osteoporosis. Citius Altius Fortius. 27.
  5. Yu, Pei-An MDa,b; Hsu, Wei-Hsiu MD, PhDa,b,c; Hsu, Wei-Bin PhDb; Kuo, Liang-Tseng MDa,b; Lin, Zin-Rong PhDd; Shen, Wun-Jer MDe; Hsu, Robert Wen-Wei MDa,b,c,∗ The effects of high impact exercise intervention on bone mineral density, physical fitness, and quality of life in postmenopausal women with osteopenia, Medicine: March 2019 – Volume 98 – Issue 11 – p e14898doi: 10.1097/MD.0000000000014898
  6. 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;143:115697. doi: 10.1016/j.bone.2020.115697. Epub 2020 Dec 24. PMID: 33357834.
  7. Pinheiro, M.B., Oliveira, J., Bauman, A. et al. Evidence on physical activity and osteoporosis prevention for people aged 65+ years: a systematic review to inform the WHO guidelines on physical activity and sedentary behaviour. Int J Behav Nutr Phys Act17, 150 (2020). https://doi.org/10.1186/s12966-020-01040-4
  8. https://www.frontiersin.org/articles/10.3389/fphys.2020.00652/full
  9. https://www.frontiersin.org/articles/10.3389/fragi.2021.667519/full
  10. Watson, S.L., Weeks, B.K., Weis, L.J., Harding, A.T., Horan, S.A. and Beck, B.R. (2018), 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: 211-220. https://doi.org/10.1002/jbmr.3284
  11. Lu YH, Rosner B, Chang G, Fishman LM. Twelve-Minute Daily Yoga Regimen Reverses Osteoporotic Bone Loss. Top Geriatr Rehabil. 2016;32(2):81-87. doi:10.1097/TGR.0000000000000085
  12. Fernández-Rodríguez R, Alvarez-Bueno C, Reina-Gutiérrez S, Torres-Costoso A, Nuñez de Arenas-Arroyo S, Martínez-Vizcaíno V. Effectiveness of Pilates and Yoga to improve bone density in adult women: A systematic review and meta-analysis. PLoS One. 2021;16(5):e0251391. Published 2021 May 7. doi:10.1371/journal.pone.0251391

 

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