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Trial registered on ANZCTR

Registration number
Ethics application status
Date submitted
Date registered
Date last updated
Type of registration
Retrospectively registered

Titles & IDs
Public title
Identifying the link between bone and muscle in older-adults : effects of exercise
Scientific title
Identifying the link between bone remodeling markers and muscle function and metabolism in older-adults : effects of exercise
Secondary ID [1] 295980 0
Nil known
Universal Trial Number (UTN)
Trial acronym
Linked study record

Health condition
Health condition(s) or problem(s) studied:
Low muscle mass 309513 0
osteoporosis 309516 0
Sarcopenia 309517 0
Condition category
Condition code
Musculoskeletal 308347 308347 0 0
Physical Medicine / Rehabilitation 308832 308832 0 0
Other physical medicine / rehabilitation
Metabolic and Endocrine 308833 308833 0 0
Other metabolic disorders

Study type
Description of intervention(s) / exposure
The study involves 2 phases. Phase 1 includes 2 visits: visit 1 and 2 (V1, 2) serves as baseline, screening and familiarisation prior to phase 2. Following phase 1, participants will be invited to phase 2. Phase 2 includes 3 separate testing conditions, blood sampling and optional muscle biopsy (none, 1 or 4). A portion of the muscle will be cultured, and stored for later analysis (described below). All visits will be performed by qualified and trained personnel.
Phase 1, Cross sectional study: two separate visits (V1, V2) performed in any order and up to 14days apart. Participants will attend the laboratory following overnight fast (10hrs) and visits approx. 3-4 hours duration.
V1; Following informed consent, participants will complete: Charlson comorbidity index for comorbidity burden, Nestle’ Mini-Nutritional Assessment and Falls Risk for Older People questionnaires. Height, weight will be measured and body mass index calculated. A 3-day dietary/physical activity log will be given, and returned (V2) to assess diet/physical activity, and to replicate similar diet for remainder visits.
(a) Blood sampling; A singular blood draw (30mL) from the antecubital vein for assay of circulating osteoprogenitor (COP) cells, serum osteocalcin (OC), undercarboxylated osteocalcin (ucOC) and a variety of cardio-metabolic health markers. COP cells analysis will be performed as we previously described. Quantification of OC/ucOC; Total serum OC will be measured using an automated immunoassay (Elecsys 170; Roche Diagnostics). Serum ucOC will be measured by the same immunoassay after absorption of carboxylated OC on 5mg/mL hydroxyl-apatite slurry, as previously performed by our group. Insulin, b-isomerized C-terminal telopeptides (b-CTx) and procollagen 1 N-terminal propeptide (P1NP); will be analysed using a Roche Hitachi Cobas e602 immunoassay analyser, according to the manufacturer’s guidelines. Hormones (PTH), lipids, glucose and insulin, inflammation markers (C-reactive protein, serum interleukin-6 (IL-6) and potentially other cardiovascular/health markers will be analysed according to hospital standards. Genetic analysis; Genomic data will be extracted from the venous blood samples (EDTA tubes) using a standard kit. Genetic variants will be analysed using Taq man R-T PCR high throughout gene analysis and sequence analysis, to sequence target genes that may be associated with bone (i.e. OC) and muscle health and exercise intolerance. A genome-wide analysis approach will be performed on collected samples with either illumine OmniExpress array chips or Infinium CoreExome-24 Kit. Mitochondrial genome will be sequenced using a Next Generation Sequencing with the Ion Platform (Life Technologies, Thermo Scientific) library sequencing method.
(b) Vascular/endothelial function; assessed by brachial artery flow-mediated dilatation (BAFMD) utilising ultrasound to capture images of brachial artery at baseline, during 5min occlusion and immediately after cuff release, for calculation of change in artery width post shear stress. Vascular stiffness assessed by measures of pulse wave velocity/reflection using applanation tonometry (SphygmoCor EXCEL system V1), a non-invasive diagnostic system for assessments of central blood pressure/pulse wave velocity (PWV). Pulse Wave Analysis (PWA): a cuff is placed on the upper arm (brachial artery) measuring pulsations (brachial) to produce central aortic pressure waveforms.
(c) Exercise capacity; VO2Peak assessed on a cycle ergometer with 12-lead electrocardiogram (ECG; Mortara, X-Scribe II, Milwaukee, WI). Initial intensity will be 10-30 W and increase by 10-30W×min-1 according to participant ability. The test will be terminated according to participants’ self-reported fatigue perception (RPE of 17) or clinical signs or symptoms.
(d) Familiarisation 1RM; Participants will perform a familiarisation session on leg press.
Visit 2;
(a) Body composition: a dual energy-X-ray absorptiometry (DXA) scan to assess total and regional lean body mass and BMD (total, neck of the femur and lumbar spine) used to define bone strength and fragility.
(b) Fat infiltration, bone microarchitecture: will be assessed by Peripheral Quantified Computer Tomography (pQCT). Participants will undergo pQCT imaging to quantify muscle mass, density and adipose infiltration. pQCT and DXA performed by appropriate expert personnel.
(c) Grip strength, Gait velocity; Grip strength measured using a hand dynamometer, less than 20kg for females and less than 30kgs for males will identify low muscle strength. A 4m gait velocity assessment will be performed using the instrumented walkway (GAITRite®) and/or by timing with a stop watch and less than 80cm/sec will determine reduced physical function. Grip strength and gait velocity thresholds are accepted as a measurement of sarcopenia.
(d) Physical Performance Test (PPT); includes 4 functional tasks; gait velocity assessment (above), up-and-go test, stair climbing power (SCP) and stair descending. All will be scored in time (s). The up-and-go test is a simple performance based assessment, requiring minimal equipment including; standard arm chair (approx. 46cm), 3-meter walkway, floor mark and stopwatch and performed as time (s) taken to rise from a seated position, walk 3 meters, turn, walk back to chair and sit. The SCP will consist of a rapid ascent of 10 stairs, where;
Stair Climbing Power equals: body weight (kg) x 9.8ms-2) x step height (m) x number of steps x time -1 (s-1)
The stair descent will be time to descend safely 10 stairs. Rest between ascent and descent will be 45s. 3 attempts will be given on each task (40-s rest intervals) and best time recorded. PPT score equals sum of the fastest times recorded for each.
(e) maximal strength; 1 repetition maximum (IRM) test on leg press will be performed, defined as the heaviest weight lifted once, with proper technique and without compensatory movements. Results will guide prescription for the acute resistance exercise (RE). Leg Muscle Quality (LMQ); shown to decrease with age is described as the amount of force a muscle group can produce per unit of muscle mass. (Leg strength (1RM), leg lean mass (DXA) Calculated as;
LMQ equals: leg strength (kg) / L leg lean mass (kg) + R leg lean mass (kg)
Phase 2: Acute exercise; randomised, controlled, crossover (V3, 4, 5); examining effects of acute aerobic (AER) and RE on bone/muscle metabolism and metabolic/CV risk (glucose, lipids, inflammation etc.). Phase two will be performed up to 14days following baseline testing. Participants will be randomised using sealed envelope (block allocation) to determine order of interventions; AER, RE and control (CTRL) (to prevent carry forward effects), performed by external personnel. Participants will perform each condition but in any order (randomised), and thus will serve as their own control. Each intervention is approx. 30mins duration and 3hrs total duration, visits performed 7 days apart. Participants will be under the direct supervision of the study coordinator, who is an AEP, and for all invasive measures under close supervision of the appointed medical doctor. In between visit, during the wash out period, participants will be asked to refrain from vigorous activity in preceding min. 24hours, and may or may not be requested to wash out of particular medications as advised by the medical doctor if electing for muscle biopsy. All of this information is managed and communicated to participants by study coordinater.
(a) Blood sampling; On arrival, a cannula will be inserted (as described above) and blood sampling at immediately post exercise (0mins), 30, 60 and 120mins to assess changes post exercise.
25mL sample will be taken immediately post exercise at 0mins, 30, 60 and 120min to observe changes in COP, OC and ucOC measures.
(b) Muscle biopsies; Participants elect to have none, 1 (at rest) or 4 (1 at rest a baseline for all interventions and 1 following each condition) muscle biopsies. from vastus lateralis under local anesthesia (xylocaine 1%) by percutaneous needle biopsy technique, modified to include suction. Excised tissue immediately snap frozen with liquid nitrogen and stored at -80degrees for later analysis. All muscle samples will be analysed for signalling proteins involved in muscle degradation/hypertrophy.
(c) interventions, randomised (V3, 4 and 5)
I. Acute CTRL: 30 mins rest.
II. Acute AER: 30 mins cycle ergometer 70-75% of HRPeak (based on GXT data).
III. Acute RE: 30mins of power exercises at 70-75% (pre-determined from 1RM) includes: leg press, 5 x 10 rapidly concentric (“as fast as possible”) and slow eccentric (4 second) reps and jumping sequences; 5 x 10 jumps with 2mins recovery between sets. Power training is effective to increase muscle strength, bone density and is safe for older-adults.
Baseline biopsy: In-vitro study: A portion of muscle sample obtained in V3 will be used for Cell culture: examining effect of different treatments (including, but not limited, ucOC) on human skeletal muscle myotubes. Markers of muscle degradation/ hypertrophy, see list below, and glucose uptake will be assessed.
Analysis of muscle sample: Muscle will be analysed for protein degradation pathways; ubiquitin-proteasome, autophagy-lysosome and caspase-3-mediated proteolytic pathways and protein synthesis; mammalian target of rapamyacin, mTOR. Other factors implicated in aging/pathways i.e. Smad3-signalling, TGF-beta, myostatin and growth and differentiation factor II will be assessed. We will investigate these pathways following 3 separate conditions. Protein extraction, Western blotting; specialised technique to detect specific proteins via gel electrophoresis to separate proteins by length of polypeptides or by 3D structure. Proteins are transferred to a membrane where using antibodies, specific proteins can be targeted.
Intervention code [1] 312566 0
Comparator / control treatment
Control - no exercise.
Control group

Primary outcome [1] 307640 0
Overall change in bone remodeling markers (osteocalcin, P1NP and b-CTx). These will be assessed in serum
Timepoint [1] 307640 0
Baseline and 0, 30, 60, 90 (primary endpoint) and 120 mins post exercise
Primary outcome [2] 307641 0
Expression of proteins associated with muscle hypertrophy/degradation (exploration, including mTOR), as measured by Western Blots, in human myotubes following osteocalcin and other treatments on in vitro.
Timepoint [2] 307641 0
0, 30, 60, 120mins (primary endpoint) and 24hrs and 72hrs post treatment
Primary outcome [3] 307642 0
Muscle signaling proteins (exploratory). This will be assessed via muscle biopsies
Timepoint [3] 307642 0
Baseline and 1 h post exercise
Secondary outcome [1] 352482 0
Genetic analysis. Exploratory outcome
Timepoint [1] 352482 0
Baseline blood only be used for baseline correlation
Secondary outcome [2] 352484 0
Vascular function, flow mediated dilatation (FMD), using ultrasound of the brachial artery.
Timepoint [2] 352484 0
Data will be collected at baseline only as it is specific for study 1.
Secondary outcome [3] 352487 0
Bone mineral density (DXA)
Timepoint [3] 352487 0
Baseline only, this is specific for Study 1.
Secondary outcome [4] 352488 0
Muscle strength, 1RM, will be assessed to characterise the participants
Timepoint [4] 352488 0
Assessment will be performed at baseline only as it is specific for Study 1.
Secondary outcome [5] 352489 0
Cell culture, in vitro, treatment with antiresorptive drugs. Proteins involved in muscle hypertrophy/degradation will be assessed. This is an exploratory outcome.
Timepoint [5] 352489 0
0, 30, 60, 120mins and 24hrs and 72hrs post treatment
Secondary outcome [6] 352490 0
Blood analysis for cardiometabolic health markers. This is an exploratory outcome.
Timepoint [6] 352490 0
Baseline and 0, 30, 60, 90 and 120 mins post exercise
Secondary outcome [7] 353179 0
Bone structure including cortical and trabecular bone using pQCT.
Timepoint [7] 353179 0
Baseline only as it is specific for Study 1.

Key inclusion criteria
Males and females aged >60 years. Females in particular will be required to be a minimum of 12 months post menopause
Minimum age
60 Years
Maximum age
No limit
Both males and females
Can healthy volunteers participate?
Key exclusion criteria
- Any fractures in the previous 3 months, or are currently undergoing a new osteoporotic treatment within 3months or have begun taking anti-resorptive medications within 3months.
- have diabetes mellitus or are taking hyperglycaemic medications. This is because of the close interaction and effects of osteocalcin and glucose metabolism.
- any haematological, myelodysplastic or myoproliferative disorder
- any bone malignancy
- taking warfarin of vitamin K supplementation or restriction
- a Body mass index greater than 40kg/m2
- Engagement in resistance exercise regime more than 2 sessions per week.

Additional criteria include:
- are unable to give informed consent independently, we will not include any persons who are unable to give independent informed consent for safety reasons, particularly as we take some invasive measures.
- pregnancy, it is remains unclear the effects of maximal exercise whilst during pregnancy, as such for safety reasons we will not include pregnant women.
- unable to understand English, this could potentially be a safety concern if unable to communicate during some of the maximal exertion testing visits, and for the acute exercise bout.

Study design
Purpose of the study
Allocation to intervention
Randomised controlled trial
Procedure for enrolling a subject and allocating the treatment (allocation concealment procedures)
Allocation is concealed. To determine the order of the treatments (aerobic exercise, resistance exercise or control - no exercise). sealed opaque envelopes will be used.
Methods used to generate the sequence in which subjects will be randomised (sequence generation)
Allocation concealment. The person responsible for the randomisation, is not involved in the project. Each volunteer has its own envelop with 3 notes inside (aerobic, resistance and control). The person will withdrawn one note at a time and the order of the interventions will be determined by the order of the drew.
Masking / blinding
Open (masking not used)
Who is / are masked / blinded?

Intervention assignment
Other design features
Not Applicable
Type of endpoint(s)
Statistical methods / analysis

Recruitment status
Date of first participant enrolment
Date of last participant enrolment
Date of last data collection
Sample size
Accrual to date
Recruitment in Australia
Recruitment state(s)

Funding & Sponsors
Funding source category [1] 300575 0
Commercial sector/Industry
Name [1] 300575 0
Exercise & Sports Science Australia : Tom Penrose Community Service Grant
Address [1] 300575 0
Locked Bag 4102, Ascot, QLD 4007
Country [1] 300575 0
Primary sponsor type
Victoria University
Victoria University,
PO Box 14428,
Melbourne, VIC 8001
Secondary sponsor category [1] 300066 0
Name [1] 300066 0
Address [1] 300066 0
Country [1] 300066 0

Ethics approval
Ethics application status
Ethics committee name [1] 301364 0
Melbourne Health Human Research Ethics Committee
Ethics committee address [1] 301364 0
Office for Research
South West
300 Grattan Street
Parkville Victoria, 3050
Ethics committee country [1] 301364 0
Date submitted for ethics approval [1] 301364 0
Approval date [1] 301364 0
Ethics approval number [1] 301364 0

Brief summary
The overall aim of the project is to explore the communication between bone and muscle in older-adults over the age of 60years and, whether older-adults with or without low muscle function respond differently to acute-exercise. We will explore how different type of exercise affect bone and muscle metabolism as well as identify potential targets for future treatments tp prevent muscle loss associated with ageing. The intervention include three studies: study 1: a cross-sectional study to explore the characteristics of older-adults with and without low muscle function. Study 2: Utilising a resting muscle sample, this study is an in-vitro cell culture study where we will grow the sample in the laboratory and then treat the sample with different drug treatments to examine directly how the muscle responds. Study 3: is a randomised, cross-over, controlled trial to examine responses to acute exercise under three different conditions: aerobic cycling exercise, resistance exercise (including leg press and jumping) and control (complete rest). This study will include blood sampling at rest and following exercise. In addition, optional muscle sampling after each condition will help us to examine the direct effect of the different exercise modes at the muscle. This project is important as a limited information on older-adults is available. This study will generate novel knowledge as it has the potential to identify new communication pathways between the bone and muscle with implications for future drug targets and the management of sarcopenia or sufferers at risk of/with reduced muscle function.
Trial website
Trial related presentations / publications
Public notes

Principal investigator
Name 86758 0
A/Prof Itamar Levinger
Address 86758 0
Victoria University,
PO Box 14428,
Melbourne, VIC 8001
Country 86758 0
Phone 86758 0
+61 03 99195343
Fax 86758 0
Email 86758 0
Contact person for public queries
Name 86759 0
Miss Casandra Smith
Address 86759 0
Victoria University,
PO Box 14428,
Melbourne, VIC 8001
Country 86759 0
Phone 86759 0
+61 03 83958173
Fax 86759 0
Email 86759 0
Contact person for scientific queries
Name 86760 0
A/Prof Itamar Levinger
Address 86760 0
Victoria University,
PO Box 14428,
Melbourne, VIC 8001
Country 86760 0
Phone 86760 0
+61 03 99195343
Fax 86760 0
Email 86760 0

No data has been provided for results reporting
Summary results
Not applicable