# Exercise as it relates to Disease/Treating osteosarcopenia through high-intensity resistance training. Is it the Holy Grail of treatment options?

This is a summary and critique of the journal article "Effects of High-Intensity Resistance Training on Osteopenia and Sarcopenia Parameters in Older Men with Osteosarcopenia—One-Year Results of the Randomized Controlled Franconian Osteopenia and Sarcopenia Trial (FrOST)." by Wolfgang Kemmler, Matthias Kohl, Michael Fröhlich, Franz Jakob, Klaus Engelke, Simon von Stengel and Daniel Schoene.

## What is the background to this research?

Osteosarcopenia is a syndrome which describes the co-existence of both osteoporosis and sarcopenia. Both are chronic health conditions and are most commonly associated with ageing. In simple terms, osteoporosis is a condition where bones have become brittle and more likely to fracture, whereas sacropenia is defined as the loss of muscle mass, strength and function. The combination of these two conditions significantly increases the risk of falls, fractures and mortality rates when compared to either condition alone.
There is a significant body of evidence to support the use of resistance exercise in patients with sarcopenia and it has been shown to have an important protective role in the development of osteoporosis. Yet, the evidence supporting it's use a treatment for reversing osteoporosis is not as strong.
The authors of this study argued previous research trials into the efficacy of resistance exercise as a treatment for osteoporosis contained several limitations (eg: short study duration and different aspects of exercise program design). Further to this, they cited a lack of research in male populations and in individuals with osteosarcopenia.

## Where is the research from?

The research presented in this paper is from the Franconian Osteopenia and Sarcopenia Trial or FrOST study. It was published in the Journal of Bone and Mineral Research. The lead author of the study, Wolfgang Kemmler, is a Professor at Friedrich-Alexander-University of Erlangen-Nürnberg in the Faculty of Medicine. He is a widely published author and his main areas of research include investigating the effects of different types of exercise on bone mineral density and body composition in different populations.
The research was supported by Kieser Training, a strength training company which provided the gym facilities and supervised participants.

## What kind of research was this?

The study was a clinical exercise study with a stratified randomised and balanced parallel group design. Participants in the study were allocated to either an exercise or control group (no exercise) and the design of the study ensured participants with different levels of skeletal muscle mass were equally represented in both the exercise and control groups. No stratification/grouping to account for differences in bone mineral density was mentioned.

## What did the research involve?

Participants for this study were recruited based on their participation in a previous study, the Franconian Sarcopenic Obesity (FranSO) study. They were all men aged 72 years or older who lived in community-based dwellings and who had osteosarcopenia. There were a number of additional eligibility criteria which are listed in full in the original paper.
Participants were allocated to either an exercise or control group. To control for differences in diet and the potential impact it might have on the outcomes being measured, both groups received dietary supplementation of protein, Vitamin D and calcium over the 12 months of the study. The exercise group undertook a 12 month supervised resistance training program two times a week. The training program was machine based and undertaken at a centrally located gym. The exercise program itself was comprehensive, consisting of 5 phases of 8 to 12 week blocks, with up to 18 exercises programmed per session.
The following table outlines the primary and secondary outcome measures used in the study.
* Primary Outcome Measure
* Integral bone mineral density at the lumbar spine determined by quantitative computed tomography at baseline and after 54 weeks.
* Secondary Outcome Measures
* Skeletal muscle mass index as determined by dual-energy X-ray absorptiometry at baseline and after 54 weeks.
* Bone mineral density at the total hip region of interest as determined by dual-energy X-ray absorptiometry at baseline and after 54 weeks.
* Maximum dynamic hip- and leg-extensor strength as determined by an isokinetic leg press at baseline and after 54 weeks.

## What were the basic results?

After 12 months of exercise the following were observed:
Primary Outcome:
* Bone mineral density at the lumbar spine was maintained in the exercise group while it decreased in the control group, resulting in a significant difference between the two groups.
Secondary Outcome/s:
* Skeletal muscle mass index increased significantly in the exercise group and decreased in the control group.
* Bone Mineral density at the hip did not change significantly in either the exercise or control group.
* The maximum dynamic strength of the hip and leg extensors was significantly higher for exercise group when compared to the control group.

## What conclusions can we take from this research?

Overall, this was a robust long term study which demonstrated resistance training can have the following benefits in elderly men with osteosarcopenia:
* help to maintain bone mineral density of the lumbar spine;
* increase skeletal muscle mass; and
* improve strength at the hip / leg extensors.
However, it's important to note the benefits of resistance training for elderly populations with sarcopenia is well established and are reflected in clinical guidelines for treatment of sarcopenia. Furthermore, the study found the lumbar bone mineral density of the exercise group was maintained, meaning they would still be defined as having osteopenia / osteoporosis. This suggests resistance exercise by itself was not enough to reverse osteoporosis in this population.

## Practical advice

Resistance training is an effective treatment option for sarcopenia and is an important tool for the prevention of osteopenia / osteoporosis.

## Further information/resources

Exercise and Sports Science Australia (ESSA) position statement on exercise prescription for the prevention and management of osteoporosis
Osteoporosis Australia
Centers for Disease Control and Prevention: Growing Stronger - Strength Training for Older Adults
Physical activity guidelines for older adults (Australia)

## References

* 1 2 3 4 5 Kemmler W, Kohl M, Fröhlich M, Jakob F, Engelke K, von Stengel S, Schoene D. Effects of High‐Intensity Resistance Training on Osteopenia and Sarcopenia Parameters in Older Men with Osteosarcopenia—One‐Year Results of the Randomized Controlled Franconian Osteopenia and Sarcopenia Trial (FrOST). Journal of Bone and Mineral Research. 2020 Apr 9.
* 1 2 3 Paintin J, Cooper C, Dennison E. Osteosarcopenia. British journal of hospital medicine. 2018 May 2;79(5):253-8.
* ↑ Akkawi I, Zmerly H. Osteoporosis: current concepts. Joints. 2018 Jun;6(2):122.
* ↑ Cruz-Jentoft AJ, Sayer AA. Sarcopenia. The Lancet. 2019 Jun 29;393(10191):2636-46.
* 1 2 3 Lozano-Montoya I, Correa-Pérez A, Abraha I, Soiza RL, Cherubini A, O’Mahony D, Cruz-Jentoft AJ. Nonpharmacological interventions to treat physical frailty and sarcopenia in older patients: a systematic overview–the SENATOR Project ONTOP Series. Clinical interventions in ageing. 2017;12:721.
* 1 2 3 Vlietstra L, Hendrickx W, Waters DL. Exercise interventions in healthy older adults with sarcopenia: a systematic review and meta‐analysis. Australasian journal on ageing. 2018 Sep;37(3):169-83.
* 1 2 3 Cruz-Jentoft AJ, Sayer AA. Sarcopenia. The Lancet. 2019 Jun 29;393(10191):2636-46.
* 1 2 Girgis CM, Mokbel N, DiGirolamo DJ. Therapies for musculoskeletal disease: can we treat two birds with one stone?. Current osteoporosis reports. 2014 Jun 1;12(2):142-53.
* ↑ Kemmler W, Shojaa M, Kohl M, von Stengel S. Exercise effects on bone mineral density in older men: a systematic review with special emphasis on study interventions. Osteoporosis International. 2018 Jul 1;29(7):1493-504
* ↑ Kemmler W, Weissenfels A, Teschler M, Willert S, Bebenek M, Shojaa M, Kohl M, Freiberger E, Sieber C, von Stengel S. Whole-body electromyostimulation and protein supplementation favourably affect sarcopenic obesity in community-dwelling older men at risk: the randomized controlled FranSO study. Clinical Interventions in Aging. 2017;12:1503.