Home based exercise programme for knee pain and knee osteoarthritis: randomised controlled trial.

OBJECTIVES: To determine whether a home based exercise programme can improve outcomes in patients with knee pain. DESIGN: Pragmatic, factorial randomised controlled trial of two years' duration. SETTING: Two general practices in Nottingham. PARTICIPANTS: 786 men and women aged >/=45 years with self reported knee pain. INTERVENTIONS: Participants were randomised to four groups to receive exercise therapy, monthly telephone contact, exercise therapy plus telephone contact, or no intervention. Patients in the no intervention and combined exercise and telephone groups were randomised to receive or not receive a placebo health food tablet. MAIN OUTCOME MEASURES: Primary outcome was self reported score for knee pain on the Western Ontario and McMaster universities (WOMAC) osteoarthritis index at two years. Secondary outcomes included knee specific physical function and stiffness (scored on WOMAC index), general physical function (scored on SF-36 questionnaire), psychological outlook (scored on hospital anxiety and depression scale), and isometric muscle strength. RESULTS: 600 (76.3%) participants completed the study. At 24 months, highly significant reductions in knee pain were apparent for the pooled exercise groups compared with the non-exercise groups (mean difference -0.82, 95% confidence interval -1.3 to -0.3). Similar improvements were observed at 6, 12, and 18 months. Regular telephone contact alone did not reduce pain. The reduction in pain was greater the closer patients adhered to the exercise plan. CONCLUSIONS: A simple home based exercise programme can significantly reduce knee pain. The lack of improvement in patients who received only telephone contact suggests that improvements are not just due to psychosocial effects because of contact with the therapist.

Lack of effect of supplementation with essential fatty acids on bone mineral density in healthy pre- and postmenopausal women: two randomized controlled trials of Efacal v. calcium alone.

Randomized controlled trials of the effects of the dietary supplement Efacal (Scotia Pharmaceuticals Plc, Guildford, Surrey, UK) v. Ca only on total body bone mineral density (BMD) and markers of bone turnover were conducted in healthy pre- and postmenopausal women separately. Total daily dose for 12 months for the Efacal groups was: Ca 1.0 g, evening primrose oil 4.0 g and marine fish oil 440 mg; and for the control groups was: Ca 1.0 g. Reported compliance was better than 90% in both age groups. For the forty-three premenopausal women (age range 25-40 years), initial mean total body BMD values were similar for Efacal and control groups and both groups showed highly significant mean increases of about 1%; however, there were no significant between-group differences for the changes in BMD or markers of bone turnover. For the forty-two postmenopausal women (age range 50-65 years), initial mean total body BMD values were again well-matched across treatment groups. Both Efacal and control groups showed highly significant decreases in total body BMD of about 1%, but again there were no significant between-group differences in total body BMD or markers of bone turnover. Possible confounding variables such as initial total body BMD were explored but had no effect on the outcome in either age group. Nail quality improved in both age groups and in both Efacal and control groups. Again, there was no significant difference between treatment groups. No evidence was found to support a beneficial effect of Efacal on BMD in these women.

Habitual physical activity and bone mineral density in postmenopausal women in England.

BACKGROUND: Reduced levels of physical activity have been found to be associated with an increased risk of osteoporotic fracture in a number of epidemiological studies, and intervention studies have shown beneficial effects of exercise regimes on bone mineral density. It is not yet established, however, which specific forms of customary physical activity are most strongly associated with bone mineral density in postmenopausal women. METHODS: A cross-sectional study was conducted in 580 postmenopausal women, aged 45-61 years, resident in Nottingham, England. The participants completed a detailed interviewer-administered activity questionnaire. Physical activity was assessed as total hours of participation per week in activities including housework, walking, gardening and sports. Stair-climbing and self-reported walking pace were also reported. Bone mineral density measurements were made using dual energy x-ray absorptiometry, measurements at five sites were used in analysis. RESULTS: The strongest associations between the activity measures and bone mineral density were for stair-climbing and walking pace, which both gave statistically significant positive associations at the trochanter hip site and the whole body. In women reporting a fairly brisk or fast walking pace, bone mineral density at the proximal femur was also significantly and positively associated with the frequency of walking at least a mile. There were no significant associations with aggregate measures of total customary physical activity. CONCLUSIONS: This study has identified two forms of physical activity, namely stair-climbing and brisk walking which are associated with increased bone mineral density at the hip and whole body in postmenopausal women. Both are feasible forms of activity for promoting to middle-aged women.

Pre- and postmenopausal women have different bone mineral density responses to the same high-impact exercise.

The effects of a vertical jumping exercise regime on bone mineral density (BMD) have been assessed using randomized controlled trials in both pre- and postmenopausal women, the latter stratified for hormone replacement therapy (HRT). Women were screened for contraindications or medication likely to influence bone. The premenopausal women were at least 12 months postpartum and not lactating; the postmenopausal women had been stable on, or off, HRT for the previous 12 months and throughout the study. BMD was measured blind using dual-energy X-ray absorptiometry at the spine (L2-L4) and the proximal femur. The exercise consisted of 50 vertical jumps on 6 days/week of mean height 8.5 cm, which produced mean ground reactions of 3.0 times body weight in the young women and 4.0 times in the older women. In the premenopausal women, the exercise resulted in a significant increase of 2.8% in femoral BMD after 5 months (p < 0.001, n = 31). This change was significantly greater (p < 0.05) than that found in the control group (n = 26). In the postmenopausal women, there was no significant difference between the exercise and control groups after 12 months (total n = 123) nor after 18 months (total n = 38). HRT status did not affect this outcome, at least up to 12 months. It appears that premenopausal women respond positively to this brief high-impact exercise but postmenopausal women do not.

Longitudinal changes in selected physical capabilities: muscle strength, flexibility and body size.

OBJECTIVES: first, to record, in a representative sample of older men and women, longitudinal changes in (i) maximal voluntary strength of the handgrip muscles, (ii) maximal range of movement in the shoulder joint and (iii) body weight and skeletal size; second, to explore associations between the changes in muscle strength and both customary physical activity and health outcomes. DESIGN: longitudinal analyses of survivors measured at baseline, and 4-year and 8-year follow-ups. PARTICIPANTS: 350 survivors of a random sample originally aged 65 and over. RESULTS: over 8 years average loss of body weight was slight but significant at about 2 kg (less than 5%). Loss of shoulder range was negligible, while loss of muscle strength was significant at about 40 N (less than 2% per year). Demispan remained stable across all three points of measurement. These mean values concealed substantial variation in the rate of loss of strength, which was twice as fast in the older groups, especially in the women. These losses could not be attributed to worsening health, although this was observed. All the respondents had at least two chronic health problems at the 8-year stage. For the changes in handgrip strength, reduced reported habitual use of the handgrip muscles and increased symptoms of anxiety and depression were significant independent covariates in addition to age and time (all P < 0.0001). CONCLUSION: there are significant independent associations between the loss of muscle strength in old age and both decline in physical activity and increase in depression scores. This is strongly suggestive of causal links and confirms the need to encourage physical activity and control depression in order to maintain strength and function in old age.

Relations between compressive axial forces in an instrumented massive femoral implant, ground reaction forces, and integrated electromyographs from vastus lateralis during various 'osteogenic' exercises.

A subject, who had undergone surgery to replace one hip joint and the proximal half of the femur with an instrumented titanium implant, performed brief exercises whilst simultaneous measurements were made of compressive axial force in the implant using short-range wireless telemetry, ground reactions using a Kistler force plate, and electromyographic activity of the vastus lateralis (VL) and erector spinae (ES) muscles using surface electrodes. Recordings were made barefoot and wearing 'trainers'. The exercises (slow jumping in counter movement style, fast continuous jumping, and jogging on the spot) have been found effective in controlled interventions for increasing bone mineral density in women. The implant forces were 250-400% BW. The values were about twice the magnitude of the ground reaction forces and significantly correlated with them for both peak force and its rate of rise but their relative magnitudes varied depending on mode of activity (jumping or jogging). Implant forces were significantly related to the muscle activity; in multiple regression analysis implant forces during take off from slow jumps VL contributed significantly in addition to the ground reaction (98% total explained variance). There was more activity in VL during jumping than jogging for the same implant force which may explain why jumping appears to be more osteogenic than jogging for the femur. For the same ground reaction, wearing trainers increased both the magnitude of the compressive loading of the femur and its rate of rise.

Effects of hormone replacement therapy on muscle performance and balance in post-menopausal women.

1. A randomized controlled trial of the effect of oral hormone replacement therapy plus calcium compared with calcium alone on balance, muscle performance and falls was conducted over 48 weeks in 116 post-menopausal women (aged 45-70 years), all of whom had suffered a distal radial fracture during the previous 3 months. Treatment was with Prempak C or Premarin 0.625 mg in the test group with 1 g calcium daily (Sandocal) in both groups. Measurements were made of balance, assessed as sway, leg extensor power and self-paced walking speed, at 12-week intervals over 24 weeks. Hand grip strength was measured every 12 weeks for 48 weeks, and falls in the preceding 12 weeks were recorded at each visit. 2. There was no relation between initial levels of oestradiol and any other variable assessed, except body mass. Levels of follicle-stimulating hormone in the test group were in the premenopausal range. There was no significant change attributable to hormone replacement therapy at any time point in any of the outcome variables. The only significant difference was an increase of 4.2% (95% confidence interval 0.7-7.6%) in leg extensor power in the control group (calcium alone) compared with the group treated with hormone replacement therapy. 3. Of the total group, 37% fell again during the year, with three patients suffering a further fracture. Frequent fallers swayed significantly more often than the others, but there was no evidence that their muscle strength was poorer or that the group treated with hormone replacement therapy fell less frequently. 4. Hormone replacement therapy did not increase muscle performance, improve balance or reduce falls over a year in middle-aged women.

Postexercise heart rates and pulse palpation as a means of determining exercising intensity in an aerobic dance class.

OBJECTIVE: To establish the accuracy of the traditional method of measuring the intensity of exercise in aerobic dance classes, that is, intermittent pulse palpation performed during a brief cessation of activity. METHODS: A short wave telemetry system was used to record heart rates during a class in a group of 12 healthy women aged 26 (SD 6) years. Subjects palpated their pulses for 10 s following high and low intensity exercise [78(8)% and 69(9)% of mean predicted maximum heart rate respectively]. Recorded exercising heart rates, averaged over 60 s preceding pulse palpation [ExHR(rec)], were compared with the recorded postexercise heart rates averaged over the 10 s palpation period [PostExHR(rec)] and with the palpated counts (PalpHR). Differences were assessed using Student's t test and Wilcoxon signed rank test. RESULTS: Differences between ExHR(rec) and PostExHR(rec) following high and low intensity exercise [3(6) beats.min-1 and 5(7) beats.min-1 respectively] were not significant. However, the wide variation between subjects means that a postexercise heart rate is unreliable as a measure of individual exercise intensity. PalpHR was significantly lower than ExHR(rec) (P < 0.01). Every individually palpated count underestimated the exercising heart rate (range 9 to 95 beats.min-1). CONCLUSIONS: While postexercise heart rate adequately represents the exercise heart rate for a group, the individual variation is too wide for this to be a useful measurement.

Lack of variation in muscle strength with menstrual status in healthy women aged 45-54 years: data from a national survey.

Isometric handgrip, quadriceps muscle strength and leg extensor power were assessed as part of a large representative survey of adult men and women in England. The gender ratios for these muscle strength measurements did not differ across age groups, which ranged from 25 to 65 years. Data from a subsample of women who were aged between 45 and 54 years and free of major health problems or current gynaecological problems (n = 299) and were analysed to see if there were differences in the muscle measurements according to reported menstrual status. Analysis of variance was used to compare four subgroups of women as follows: those who were still menstruating regularly (n = 89), those who had stopped altogether (n = 92), those who were irregular (n = 33) and those on hormone replacement therapy (n = 15). No significant differences were found between these subgroups in any of the three muscle measurements, body mass, fat-free mass (derived from four skinfolds), body mass index, or customary activity levels. There was a significant age difference of 2 years between two subgroups. After having controlled for this, using analysis of covariance, the outcome was not changed. These women were also compared with men in the same age range; the women had about 60% of the strength of the men and a highly significant difference remained after controlling for fat-free mass in all subgroups. No evidence was found for an ergogenic effect of the high oestrogen status conferred by natural menstruation or hormone replacement therapy.

Longitudinal weight changes over four years and associated health factors in 629 men and women aged over 65.

OBJECTIVES: (1) To assess changes in body weight longitudinally over 4 years in a representative group of men and women aged over 65 years, living in their own homes. (2) To assess whether initial weight (or weight in proportion to skeletal size) was associated with health 4 years later. (3) To assess whether any changes found in body weight were associated with changes in physical or mental health. (4) To compare the cross-sectional age-related changes in weight found in the initial survey with the longitudinal changes found over 4 years. DESIGN: A large randomised age-stratified survey using a structured questionnaire and measurements of body weight and demispan (for skeletal size), with a 4-year follow-up. SETTING: The survey was conducted in the respondents' own homes. SUBJECTS: 958 subjects age over 65 years, who were recruited from the Nottingham general practitioners' lists, took part in the initial survey; 629 of these subjects completed the second survey 4 years later. RESULTS: (1) The mean 4-year change in body weight was a small but significant loss; in women (n = 385) it was 1.56kg (P <0.001, 95% CI 1.02-2.10) and in men (n = 244) 0.85kg (P = 0.010, 95% CI 0.21-1.49). (2) Initial weight did not predict mortality, new morbidity nor health 4 years later. (3) There were no robust associations between weight change ans either absolute measures of physical health or changes in these measures. (4) The longitudinal change in weight was similar to that predicted by the cross-sectional data. CONCLUSIONS: (1) Ageing, in old age, is associated with loss of body weight, but with a large intra-individual variation. (2) Neither initial body weight nor the change, was associated with mortality or morbidity over 4 years in a large representative sample of old people living in their own homes in a food-rich country.

Weight-bearing exercise and ground reaction forces: a 12-month randomized controlled trial of effects on bone mineral density in healthy postmenopausal women.

The effects of brief daily exercise on bone mineral density (BMD) were assessed in a randomized controlled trial in 44 healthy postmenopausal women using weight-bearing exercise in a regimen adapted from osteogenic protocols reported in animal studies. BMD was assessed masked using dual energy X-ray absorptiometry at 0, 6, and 12 months. The sites assessed were the proximal femur (neck, Ward's triangle, and trochanter) and the lateral spine (L2-3) to assess the effects of the exercise, and the radius (ultradistal and 33% distal) as a marker for systemic effects. The test group was required to perform 50 "heel drops" daily at home (raising the body weight onto the toes and then letting it drop to the floor keeping the knees and hips extended) and to attend a weekly class of mixed exercises, which included some high-impact activity. The control group also attended a weekly exercise class run by the same teacher, which included only low-impact activity, and did flexibility exercises at home daily. The ground reaction forces (as a ratio of body weight) during heel drops were 2.5 to 3.0 N/N, with a rate of rise of 50-100 kN/sec. A patient with an instrumented femoral implant allowed comparison of compressive axial forces in the shaft of the proximal femur with the ground reaction forces, and these appeared to be transmitted undamped to the shaft of the femur. Initial analysis of BMD in the women showed no significant increases after 12 months of exercise at any site in either group, and the groups did not differ significantly from each other in this respect. Proximity to menopause was not associated with rapid bone loss, and in those who were more than 6 years postmenopausal, there was evidence for a maintenance effect of the exercise in the test group. Compliance (83%) and increases in leg extensor power (15%) were similar in both groups, and when they were combined, BMD was maintained at the trochanter but fell significantly at the radius (p < 0.001).

Changes in bone mineral density associated with dietary-induced loss of body mass in young women.

1. Moderately overweight, premenopausal women were assessed for bone mineral density of the total body, lumbar spine and proximal femur before and after 6 months of modest dietary restriction (minimum 4800 kJ/day). The aim was to evaluate the effect of loss of body mass on bone mineral density. 2. Dietary assessment included two analyses of 3 day weighed food intakes, one before and the other after 4 months of dietary restriction. Energy and calcium intakes were significantly reduced by 27% and 5%, respectively. The change in calcium intake was negatively and significantly related to initial levels of calcium intake. 3. A significant mean loss of 3.4 +/- 3.1 kg in body mass was achieved mainly in the first 3 months of the study; it was accompanied by significant losses at 6 months in bone mineral density in the total body of 0.7% and in the lumbar spine of 0.5%. There were no changes in the femur. 4. The change in bone mineral density in the total body was significantly related to the reduced absolute calcium intake, initial bone mineral density and loss of body mass. The change in bone mineral density in the spine was significantly related to the change in calcium intake. 5. These modest losses could be a threat in women with lower bone mineral density, and indicate the importance of maintaining a high intake of calcium during dietary restriction.

Increase in femoral bone density in young women following high-impact exercise.

Healthy premenopausal women were randomized into control and test groups; both exercised weekly in class and daily at home for a year. The test class did intermittent high-impact exercise; the control class did low-impact exercise. Bone density was assessed blind using dual energy X-ray absorptiometry at the femur (neck, Ward's triangle and trochanter) and at the lumbar spine (antero-posterior L1-4) on entry into the study, and again after 6 months (n = 27) and 12 months (n = 19). At 6 months the test group (n = 14) showed a significant increase of 3.4% in trochanteric bone density (p = 0.01) and this was significantly different from control (p = 0.05). In the second 6 months the control group was crossed over to high-impact exercise and showed a significant increase of 4.1% in trochanteric density (n = 7) while the original group maintained their improvement relative to baseline.

A comparison of the relation between oxygen uptake and heart rate during different styles of aerobic dance and a traditional step test in women.

The oxygen uptake and heart rate in various styles of dance and in a graded step test have been compared in ten healthy women aged [mean (SD)] 34 (5) years. Dance was choreographed into progressively more energetic sequences typical of community classes, and videotaped. Oxygen uptake was assessed using a respirometer carried in a back-pack. Each of the two tests (dance and step) took 15-20 min and measurements were made in randomised balanced order on the same day. The mean oxygen costs of dance ranged from 1.29 l.min-1 for low impact style to 1.83 l.min-1 for high impact style with arm work; mean heart rates were 135 and 174 beats.min-1 respectively. Low impact dance raised heart rates above 60% of predicted maximum and so would provide training; during high impact dance recorded heart rates sometimes exceeded recommended safe limits. The addition of arm work significantly increased heart rates in both high and low impact dance but when oxygen pulses for each style of dance were compared no significant differences attributable to arm work were found. Moreover calculated differences between oxygen uptakes in stepping and dance at the same heart rates (those recorded during dance) were not significant for any of the four styles. Analysis of variance confirmed that neither arm work nor impact contributed significantly to the differences, so there was no evidence that these forms of dance change the normal relation between heart rate and oxygen uptake found in dynamic activities with large muscle groups such as stepping.