Evidence on physical activity and osteoporosis prevention ...Methods We conducted a systematic review investigating the asso-ciation between physical activity and osteoporosis preven-tion

REVIEW Open Access

Evidence on physical activity andosteoporosis prevention for people aged65+ years: a systematic review to informthe WHO guidelines on physical activityand sedentary behaviourMarina B. Pinheiro1,2* , Juliana Oliveira1,2, Adrian Bauman3, Nicola Fairhall1,2, Wing Kwok1,2 andCatherine Sherrington1,2

Abstract

Background: Various physical activity interventions for prevention and treatment of osteoporosis have beendesigned and evaluated, but the effect of such interventions on the prevention of osteoporosis in older people isunclear. The aim of this review was to investigate the association between physical activity and osteoporosisprevention in people aged 65 years and above.

Methods: A systematic review was conducted and searches for individual studies were conducted in PubMed (January2010 to March 2020) and for systematic reviews were conducted in PubMed, Embase, CINAHL and SPORTDiscus(January 2008 to July 2020). Records were screened according to the following eligibility criteria: i) population: adultsaged 65 years and older; ii) exposure: greater volume, duration, frequency, or intensity of physical activity; iii)comparison: no physical activity or lesser volume, duration, frequency, or intensity of physical activity; iv) outcome:osteoporosis related measures (e.g., bone mineral density). The methodological quality of included studies wasassessed and meta-analysis summarised study effects. The GRADE approach was used to rate certainty of evidence.

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* Correspondence: [email protected] for Musculoskeletal Health, The University of Sydney and SydneyLocal Health District, Sydney, Australia2School of Public Health, Faculty of Medicine and Health, The University ofSydney, Sydney, AustraliaFull list of author information is available at the end of the article

Pinheiro et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:150 https://doi.org/10.1186/s12966-020-01040-4

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Results: We included a total of 59 studies, including 12 observational studies and 47 trials. Within the included trials, 40compared physical activity with no intervention controls, 11 compared two physical activity programs, and six investigateddifferent doses of physical activity. Included studies suggest that physical activity interventions probably improve bonehealth among older adults and thus prevent osteoporosis (standardised effect size 0.15, 95% CI 0.05 to 0.25, 20 trials,moderate-certainty evidence, main or most relevant outcome selected for each of the included studies). Physical activityinterventions probably improve lumbar spine bone mineral density (standardised effect size 0.17, 95% CI 0.04 to 0.30, 11trials, moderate-certainty evidence) and may improve hip (femoral neck) bone mineral density (standardised effect size 0.09,95% CI − 0.03 to 0.21, 14 trials, low-certainty evidence). Higher doses of physical activity and programs involving multipleexercise types or resistance exercise appear to be most effective. Typical programs for which significant intervention impactswere detected in trials were undertaken for 60+ mins, 2–3 times/week for 7+ months. Observational studies suggested apositive association between long-term total and planned physical activity on bone health.

Conclusions: Physical activity probably plays a role in the prevention of osteoporosis. The level of evidence is higher foreffects of physical activity on lumbar spine bone mineral density than for hip. Higher dose programs and those involvingmultiple exercises and resistance exercises appear to be more effective.

Keywords: Physical activity, Osteoporosis, Bone mineral density, Older people, Review

BackgroundOsteoporosis is a major public health problem and is char-acterised by micro-architectural deterioration of bone tis-sue and low bone mineral density (BMD) which leads toreduced bone strength, increased bone fragility and a con-sequent increase in risk of skeletal fractures [1, 2]. Osteo-porosis is known as a ‘silent disease’ as it is frequentlyundiagnosed until a symptomatic fracture occurs - usuallyat an older age [3]. The most common clinical manifesta-tions of osteoporosis are fractures of the hip, vertebrae orwrist, with incidence increasing with age. Osteoporoticfractures are responsible for excess morbidity, mortality,reduction in quality of life, institutionalization and eco-nomic costs [1, 4–7]. For instance, in the UK it is esti-mated that fragility fractures cost the NHS £4.4 billion peryear [8] and in the USA osteoporosis cost US$57 billion in2018 with this figure projected to grow to over US$95 bil-lion yearly by 2040 [9]. In light of worldwide increases inlife expectation as well as the burden placed by osteopor-osis fractures on societies, health systems and individuals,effective osteoporosis prevention strategies are essential.Low bone mass is recognised as an important risk fac-

tor for fracture and therefore, a key target for osteopor-osis prevention [1]. It is thought that disuse andinactivity generates unloading of the skeletal systemresulting in reduced bone mass. Conversely, physical ac-tivity is thought to stimulate bone growth and preservebone mass. Physical activity is an umbrella term that in-cludes leisure time physical activity (exercise, sport), ac-tivities of daily living, household tasks and work [10].The benefits of physical activity for healthy ageing arewell established [11, 12] and various physical activity in-terventions for prevention and treatment of osteoporosishave been designed and evaluated. Various guidelinesrecommend engagement in physical activity for the

management of osteoporosis [1], including for olderpeople [13], however the effects of such interventions inolder people who have not been diagnosed with osteo-porosis i.e., in osteoporosis prevention have not beensummarised. A summary of the evidence in this field iscrucially important to enable specific recommendationson physical activity engagement for osteoporosis preven-tion to be made.Previous reviews investigating the association between

physical activity and osteoporosis prevention have onlyfocused on specific types of physical activity, such as ex-ercise [14–18], walking [19, 20], or sport [21], singlebody parts [22], male [15, 23] or female [14, 17, 20], andmost were not specifically focused on older people orprevention. To address this evidence gap, and provide acomprehensive summary of the evidence in the field, weconducted a review investigating the effect of physicalactivity for prevention of osteoporosis in older people[24]. Given the worldwide low levels of physical activity,particularly pronounced in older people [25], a summaryof the evidence on the effects of physical activity on theprevention of osteoporosis is important to inform publichealth initiatives and planning.This review aimed to investigate the association be-

tween physical activity and osteoporosis prevention inolder people (aged 65 years and above). The questionswere: i) What is the association between physical activityand osteoporosis prevention in older people (> 64 yearsold)? ii) Is there a dose response association (volume,duration, frequency, intensity) between physical activityand prevention of osteoporosis? iii) Does the associationvary by type or domain of physical activity? The focuswas on primary prevention studies i.e., studies in thegeneral community rather than studies in those withexisting osteoporosis.

Pinheiro et al. International Journal of Behavioral Nutrition and Physical Activity (2020) 17:150 Page 2 of 53

MethodsWe conducted a systematic review investigating the asso-ciation between physical activity and osteoporosis preven-tion in older people. This review was commissioned bythe World Health Organization (WHO) to assist theGuideline Development Group (GDG) develop the guide-lines on physical activity and sedentary behaviour (2020)[26, 27]. It was submitted to the GDG for their consider-ation as they formulated their recommendations. TheGDG decided on the scope of the guideline, the PICO(Population, Intervention, Comparison, Outcome) ques-tion, and the search strategy. The GDG initially requestedan umbrella review (review of reviews). However, since noeligible reviews were found we included individual studiesthat were reported in the reviews identified by the searchfor reviews conducted in PubMed. To ensure that import-ant studies were not missed, we conducted an additionalsearch for individual studies and reviews after submissionof the report. This manuscript includes the initial WHOreport results as well as the expanded search results. Wefollowed the preferred reporting items for systematic re-views and meta-analyses (PRISMA) guidelines [28, 29],and the PRISMA study flow diagram was used to docu-ment the screening process.

Data source and searchA search for existing systematic reviews was conductedin PubMed for reviews published from 2008 up to No-vember 2019 (Additional file 1, A). An expanded searchwas conducted in PubMed for individual studies pub-lished from January 2010 to March 2020 (Additional file1, B). A second expanded search was conducted inPubMed and three additional databases (CINAHL,Embase, SPORTDiscus) for reviews published from 2008up to July 2020 (Additional file 1, C).

Study selectionTwo reviewers screened all titles and abstracts to iden-tify studies that addressed the present research ques-tions. The full text of each study that potentially met theinclusion criteria was obtained and independentlyassessed for eligibility by two reviewers. Any disagree-ments were discussed and when consensus could not bereached, the eligibility of the study was decided followingdiscussion with a third reviewer. We also searched foradditional studies in the reference lists of eligible papersand relevant systematic reviews known by the team. Allstudies were selected according to eligibility criteriabelow and additional details on eligibility criteria can befound in Additional file 1, D.

PopulationWe included studies investigating adults aged 65 yearsand older. Studies that included younger participants

were included if the mean age minus one standard devi-ation was more than 64 years and/or if participants metthe age criteria at follow-up. Studies that recruited par-ticipants on the basis of having osteoporosis at baselinewere excluded. We followed the WHO definition ofosteoporosis on the basis of BMD measurement relativeto reference values of young adults of the same sex [2].No restriction was applied to participants’ health statusor setting.

ExposureThe exposure of interest was any volume, duration, fre-quency, or intensity of physical activity. Studies whereparticipants received multiple interventions were onlyincluded if the only difference between the groups wasthe physical activity intervention. We excluded studiesthat only used physical activity as a confounding variableas well as studies of multimodal interventions wherephysical activity was not the main component, or thatdid not present data on physical activity separately.

ComparisonWe included studies that had no physical activity orlesser volume, duration, frequency, or intensity of phys-ical activity as a comparator.

OutcomeOur outcome of interest was osteoporosis, including butnot limited to BMD from any location (e.g., neck offemur, spine), bone mineral content (BMC), calciumbone index, cortical bone density, and bone qualityindex. We excluded studies that had fracture as an out-come in the absence of a bone mass measure.

Study designWe initially searched for systematic reviews and meta-analyses. Since we did not find any eligible systematic re-view, we identified reviews that included potentially eli-gible studies and screened all potential studies againstour questions. The expanded search was targeted at in-dividual studies that could have been missed by the ini-tial search for reviews. We included individual studies(instead of reviews) that had the following study designs:randomised controlled trials, quasi-randomised con-trolled trials, prospective cohort studies, and retrospect-ive cohort studies. We excluded cross-sectional andbefore-and-after studies.We only included studies published with full-text in

English and published in peer-reviewed journals. We ex-cluded grey literature, including unpublished data, ab-stracts, and conference proceedings.


Data extraction and quality assessmentOne reviewer extracted information into standardisedforms and a second reviewer checked all data. We ex-tracted quantitative estimates for all outcome measuresrelevant to osteoporosis reported by the includedstudies.

Physical activity classificationWe used the Prevention of Falls Network Europe (Pro-FaNE) taxonomy to classify the physical activity and ex-ercise programs in the included trials (Additional file 2)[30]. The programs were classified as primarily involvingthe following exercise categories: i) gait, balance, coord-ination and functional task training (referred to as ‘bal-ance and functional exercises’ for simplicity); ii)strength/resistance training (including power training;using resistance so referred to as ‘resistance exercises’);iii) flexibility; iv) three-dimensional (3D) exercise (withTai Chi or dance subcategories); v) general physical ac-tivity (e.g., walking programs); vi) endurance; vii) otherkinds of exercise. The taxonomy allows for more thanone type of exercise to be delivered within a program.We also considered whether the exercise explicitly in-cluded bone loading (e.g., hopping or heel drops) and in-cluded this category (i.e., bone loading) as “other kindsof exercise”.

Quality assessmentWe assessed the methodological quality of the rando-mised controlled trials and quasi-randomised trials usingthe PEDro scale with total scores ranging from 0 to 10[31, 32]. We assessed the methodological quality of ob-servational studies using a modified version of the Qual-ity in Prognosis Studies (QUIPS) tool [33] adapted tostudies of risk factors. The tool contains six domainsand each is categorised as low, moderate or high risk ofbias based on explicit criteria (Additional file 3). Overallrisk of bias was considered ‘low’ if four or more domains(including study confounding) were rated as low risk ofbias; otherwise, the overall risk of bias was considered‘high’. Two reviewers assessed the risk of bias independ-ently; discrepancies were resolved by a third reviewer.Using the Grading of Recommendations Assessment,

Development and Evaluation (GRADE) framework [34],we examined the quality of primary research andassessed the overall quality of evidence as ‘high’, ‘moder-ate’, ‘low’ or ‘very low’ in terms of presence and extentof four factors: risk of bias, inconsistency, imprecision,and publication bias. We did not consider the indirect-ness criterion because we only included similar studiesin terms of population, intervention, comparator andoutcome [35]. The quality of the evidence was rated foreach outcome. Briefly, we downgraded the evidence byone level for limitation of study design if > 50% of

included trials had a PEDro score < 6/10 [36]. We down-graded the evidence for imprecision if the total numberof participants was less than 400 across all studies in-cluded in the meta-analysis [37]. We considered the re-sults inconsistent if the heterogeneity between trials waslarge (I2 > 50%) or if there was wide variation of point es-timates across the included studies [38]. We assessedpublication bias (small study effect) by visual inspectionof funnel plots and by performing a sensitivity analysiswhere we excluded studies with a small sample size (<50 participants) and we considered whether their re-moval impacted the pooling of results [39].

Data synthesis and analysisWe pooled data from all relevant randomised controlledtrials comparing physical activity with a control groupfor the main outcome of each trial. We also performedtwo additional analyses according to the two most com-monly reported outcomes across the included studies.Within each analysis we performed subgroup analysesaccording to the physical activity classification, as perProFaNE taxonomy. When data were available for morethan one time-point, we extracted data from the timepoint closest to the end of the intervention. Mean esti-mates were extracted in the following hierarchical order:mean difference, change score and final score [40].Where a trial included more than one interventiongroup, we included each intervention in a separate com-parison and divided the number of participants in thecontrol group accordingly to avoid double counting par-ticipants in the analyses [40]. We did not include thequasi-randomised trials and the trials investigating clin-ical populations in the meta-analysis.We calculated the standardised mean difference

(Hedges’ g) and 95% confidence interval (CI) and usedrandom effects meta-analysis models as we consideredthat a range of true effects was likely but also undertooksensitivity analyses using fixed effect models. Hedges’ gwas calculated using a combination of data format in-cluding mean difference, pre- and post score or changescore data (as per individual study’s availability) and wasstandardised using the post-test score standard deviationwhere available. We used Comprehensive Meta-Analysis(Version 3, Biostat, Englewood NJ).We undertook meta-regression to investigate the im-

pact of different doses and types of physical activity in-terventions and study quality using Stata metan andmetareg commands (Version 15, College Station, TX).For meta-regression we classified programs with 7800total minutes (i.e., 150 mins × 52 weeks) or more as highdose programs. Type of physical activity interventionwas coded according to the presence of ProFaNE tax-onomy categories outlined above: balance/function, boneloading, resistance, multiple exercise and combination of


multiple and resistance exercise types. We explored theimpact of study methodological quality by undertakingmeta-regression to compare effects in trials with PEDroscores equal or greater than 6 or below 6.

ResultsInitial searchThe initial search for systematic reviews and meta-analyses did not identify sufficient evidence to answerthe review questions. We screened the full texts of 36 re-views and no eligible reviews were found (Fig. 1). Themain reasons for exclusion were reviews including youn-ger participants (n = 34), participants with osteoporosisat baseline (management instead of prevention, n = 12),and not investigating whole body physical activity (e.g.,whole body vibration, n = 7).Amongst the 36 reviews which had their full text

screened, 25 reviews included potentially eligible studiesand their full texts were identified and assessed by tworeviewers. We used the same eligibility criteria, but norestriction was applied for publication year of individualstudies. We found 36 studies (trials and observationalstudies) investigating the association between physicalactivity and prevention of osteoporosis (34 identifiedfrom the reviews and 2 from hand searching) [41–76].

Expanded search for individual studiesThe expanded search yielded 772 records and the fulltexts of 92 records were screened (Fig. 1). A total of 24studies met the eligibility criteria, 23 identified viaPubMed search and one via hand searching. Out of the24 studies identified, five had already been included inthe WHO report [42, 47, 66, 68, 71]. Therefore, the ex-panded search found 19 additional studies [77–95].

Expanded search for systematic reviewsThe expanded search for systematic reviews identified atotal of 366 reviews. We screened the full texts of 58 re-views and no eligible reviews were found (Fig. 1).Amongst the 58 reviews which had their full textscreened, 30 reviews included potentially eligible individ-ual studies and after assessing their full text we included4 additional studies [96–99], resulting in a total of 59studies included in this manuscript. The included studieswere published between 1980 and 2020. There were 39randomised controlled trials, 8 quasi-randomised trialsand 12 observational studies (8 prospective and 4 retro-spective studies). There were three cases where resultsfrom the same study were reported across multiple arti-cles [53, 77, 81, 94, 96], all of which were included inthis review as they reported results for different follow-up timepoints.

ExposureWithin the included trials, 40 compared physical activitywith a control intervention (Table 1); 11 compared twophysical activity programs (Table 2); six trials (Table 3)and eight observational studies (Table 4) investigateddifferent doses of physical activity. A total of 12 observa-tional studies were included, seven investigated totalphysical activity, one leisure-time physical activity (exer-cise, transportation and sport), and five planned physicalactivity (four exercise and one sport-tennis) (Table 4).The included trials comprised a wide range of physical

activity and exercise modalities. Following the ProFaNEtaxonomy, most studies (n = 19) investigated more thanone category of exercise (classified as multiple); 11 stud-ies investigated balance and functional exercises, 12 re-sistance; five endurance; nine investigated a combinationof balance and functional exercise or resistance withbone loading; and one 3D exercises (Tai Chi).

Participant characteristicsMost included studies recruited from the general olderpopulation. Studies in which all participants had alreadybeen diagnosed with osteoporosis were excluded. Fourstudies excluded participants with osteoporosis at base-line [53, 93, 95, 96]. Three studies included participantson the basis of having some level of frailty [46, 73, 74];five articles reporting results from two studies includedonly participants with osteopenia [77, 81, 91, 92, 94];two studies included only obese participants [87, 88];two studies investigated prostate cancer survivors with-out osteoporosis [93, 95]; one study included partici-pants who had had surgical repair of a hip fracture nomore than 16 weeks prior to study entry [43]; and onestudy included participants with increased risk for fallsand fracture [90]. One study investigated lifelong tennisathletes. Twenty-eight studies included only womenwhereas six investigated only men. Five studies (reportedin 8 articles) included participants who were youngerthan 65 years at study entry, but met the age criteria atfollow-up [66, 77, 81, 86, 91, 92, 94, 98].

OutcomesThe included studies reported results for a range of dif-ferent outcomes (n = 32), and the most common oneswere measures of BMD and BMC. We performed anoverall assessment of the evidence according to thestudy’s main outcome. If the study did not specify amain outcome, we selected the outcome we consideredto be most relevant to the intervention (e.g., whole bodyfor exercises involving the whole body). We selectedlumbar spine in preference to hip when both were pre-sented, and the exercise was primarily undertaken in astanding position. Where exercises were mostly per-formed in non-standing positions (e.g., seated, supine)


Fig. 1 Flow chart of studies investigating physical activity and osteoporosis prevention in older people included in the WHO report (left size), inthe expanded search for individual studies (middle) and expanded search for systematic reviews (right side)


Table 1 Description of included studies comparing physical activity with a control intervention

ReferencePEDro score

StudydesignAllocated/Analysed

Participants (n,age mean (SD), %women, setting,health status)

InterventionPrimary exercisetype according toProFANEa

Controlb Outcomes Followup(mo)

Results

Allison 20135/10 [41]

RCT50/35

Setting:Community;United KingdomHealth status:HealthyA. High impactexercisen= 50(randomised); 35(analysed)Age: 69.9 (4.0)Female: 0%B. No exerciseContralateral leg ofeach participantwas used ascontrol

A. High impactunilateral exerciseprogramme (briefhopping exercisesessions)Frequency: 7 times/weekIntensity: 5 sets of 10multidirectional hopswith a 15s rest period.Encouragedparticipants tocontinue to hop ashigh and as fast asthey could.Session duration:~15 minDelivered by: NRDuration of theintervention (wks):52Primary exercisetype: Balance andfunction includingbone loading(multidirectionalhopping)

B. No exercisesperformed with thecontrol leg

1. Femoral neckBMD2. Trochanter BMD3. Total hip BMD4. Femoral neckBMC5. Trochanter BMC6. Total hip BMC

12 Final score (mean ±SD)1. Femoral neckBMDc

A. Exercise: 0.954 ±0.017B. Control: 0.945 ±0.0182. Trochanter BMDA. Exercise: 0.923 ±0.017B. Control: 0.923 ±0.0183. Total hip BMDA. Exercise: 1.030 ±0.017B. Control: 1.027 ±0.0184.Femoral neckBMCc

A. Exercise: 5.54 ±0.13B. Control: 5.49 ±0.145. Trochanter BMCA. Exercise: 16.45 ±0.54B. Control: 16.49 ±0.576. Total hip BMC:A. Exercise: 40.49 ±0.91B. Control: 40.35 ±0.97

dArmamento-Villareal 20127/10 [88]

RCT107/107

Setting:Community;United StatesHealth status:Obese older adultsA. Exercise groupn= 26Age: 70 (0.8)Female: 61%B. Diet group(weight loss)n= 26Age: 70 (0.8)Female: 65%C. Diet andexercisen= 28Age: 70 (0.8)Female: 57%D. Controln= 27Age: 69 (0.8)Female: 67%

A. Exercise Groupinvolving aerobicexercises, progressiveresistance training,and exercises toimprove flexibility andbalance.Frequency: 3 times/weekIntensity: aerobicdance: from 65% ofpeak heart rate to70%-85% of peakheart rate; resistance:from 1 to 2 sets at aresistance ofapproximately 65% ofone-repetition max-imum, with 8-12 repsto 2-3 sets at a resist-ance of 80% of one-repetition maximum,with 6 to 8 repsSession duration: 90minDelivered by: PhysicaltherapistDuration of theintervention (wks):52Primary exercise

D. Control - nointervention oradvice

1. Femoral neckBMD2. IntertrochanterBMD3. Femoral shaftBMD

12 Change (% ± SD)1. Femoral neckBMDA. Exercise: 1.00 ±0.76B. Diet: -2.09 ± 1.07C. Diet and exercise:-0.13 ± 0.91D. Control: -0.08 ±0.822. IntertrochanterBMDA. Exercise: 1.83 ±0.59B. Diet: -2.09 ± 1.06C. Diet and exercise:-1.06 ± 0.98D. Control: -0.18 ±0.733. Femoral shaftBMDA. Exercise: 1.83 ±0.59c

B. Diet: -2.47 ± 0.51C. Diet and exercise:-0.92 ± 0.83D. Control: 0.48 ±0.61


Table 1 Description of included studies comparing physical activity with a control intervention (Continued)






Results

type: Multiple(endurance plusflexibility plusresistance plus balanceand function)

Binder 20047/10 [43]

RCT90/78

Setting: Hospital;home careprogramme andcommunity; UnitedStatesHealth Status:People with arecent proximalfemur fractureA. PhysicalTherapy andexercise trainingn= 46(randomised); 46(analysed)Age: 80 (7)Female: 72%B. Control -Home exercisen= 44(randomised); 44(analysed)Age: 81 (8)Female: 77%

A. Supervised physicaltherapy and exercisetraining involvingflexibility, balance,coordination,movement speed andprogressive resistanceexercises.Frequency: 3 times/weekIntensity: theresistance trainingstarted from 1-2 setsof 6-8 reps each exer-cise at 65% of 1RM;progressed to 8-12reps 3 sets at 85%-100% of initial 1-RM.Session duration: 45to 90 minDelivered by: PhysicaltherapistDuration of theintervention (wks):26Primary exercisetype: Multiple(balance/function plusresistance)

B. Low-intensityhome exerciseprogramme

1. Whole bodyBMD2. Hip BMD

6 Final score (mean ±SD)1. Whole body BMDA. Physical therapyand exercisetraining: 1.03 ± 0.13B. Home exerciseprogramme: 1.00 ±0.112. Hip BMDA. Physical therapyand exercisetraining: 0.64 ± 0.18B. Home exerciseprogramme: 0.69 ±0.12No significant groupx time effects

Blumenthal19916/10 [44]

RCT101/84

Setting: NR;United StatesHealth status:HealthyA. AerobicTrainingn= 33(randomised)B. Yoga andflexibilityn= 34(randomised)C. Controln= 34(randomised)Age (wholesample): 67 (range:60-83)Female: NR

A. Aerobic training:Endurance traininginvolving bicycleergometry, briskwalking/jogging, andarm ergometry.Frequency: 3 times/weekIntensity: 70% heartrate reserveSession duration: 60minDelivered by: NRDuration ofintervention (wks):16Primary exercisetype: EndurancetrainingB. Yoga: Supervisednon-aerobic yogaprogramme.Frequency: at least 2times/weekIntensity: NRSession duration: 60minDelivered by: NRDuration ofintervention (wks):

C. Waiting listcontrol: did notreceive any form oftreatment and wereinstructed not tochange theirphysical activityhabits andspecifically not toengage in anyaerobic exercise forthe 4-month period.

1. Distal radiusBMD (mg/ cm2)

4, 8, 14 1. Distal radius BMD:no between-groupdifferences.Quantitativeestimates notreported forbetween-groupcomparisons.Sub-analysis wasperformedcomparingparticipants whodecided to continueto exercise or notfor men and womenseparately(randomisation wasbroken for thisanalysis):Female:Mean ± SD at eightmonths:Females whocontinued theprogramme: 0.7 ±0.2Females whodiscontinued theprogramme: 0.8 ±0.1








Results

16Primary exercisetype: Balance andfunction

Mean ± SD atfourteen months:Females whocontinued theprogramme: 0.7 ±0.3Females whodiscontinued theprogramme: 0.9 ±0.2MenMean ± SD at eightmonths:Men who continuedthe programme: 1.2± 0.2Men whodiscontinued theprogramme: 1.1 ±0.2Mean ± SD atfourteen months:Men who continuedthe programme: 1.4± 0.4Men whodiscontinued theprogramme: 1.0 ±0.3Between-groupdifference: p







Results

De Jong20005/10 [46]

RCT217/143

Setting:Community;NetherlandsHealth status:People with frailtyand BMI ≤ 25A. Exercisen= 55(randomised); 36(analysed)Age: 76.5 (4.6)Female: 69%B. Controln= 44(randomised); 33(analysed)Age: 78.8 (6.7)Female: 67%C. Exercise +nutritionn= 60(randomised); 39(analysed)Age: 79.8 (5.8)Female: 74%D. Nutritionn= 58(randomised); 35(analysed)Age: 79.6 (5.0)Female: 69%

A. Supervised group-based exerciseprogramme involvingmuscle strength, co-ordination, flexibility,speed, endurance withuse of ropes, weightsand elastic bands.Frequency: 2 times/weekIntensity: Moderate tohigh; 7 of a 10-pointBorg scaleSession duration: 45minDelivered by: Skilledteachers andsupervisorDuration of theintervention (wks):17Primary exercisetype: Balance andfunction

B. Socialprogrammeinvolving creativeand social activitiesas well aseducational sessions.

1. Whole bodyBMD

4.5 Change score (meanchange ± SD)1. Whole body BMDA. Exercise: 0.000 ±0.022B. Control: -0.003 ±0.018C. Combinationgroup: 0.003 ± 0.023D. Nutrition group:0.006 ± 0.014No between-groupdifferences in therelevant compari-sons to this review(ie, exercise vs con-trol and combin-ation vs nutrition)

Duckham20156/10 [47]

RCT319/283

Setting: Generalpractice; UnitedKingdomHealth status:HealthyA. Home basedexercise (OEP)n= 88(randomised); 75(analysed)Age: 71.4 (4.9)Female: 68%B. Communitybased exercise(FaME)n= 105(randomised); 94(analysed)Age: 71.8 (5.5)Female: 60%C. Control: Usualcaren= 126(randomised); 114(analysed)Age: 72.2 (5.5)Female: 54%

A. OEP: Homeexercise programmeconsisting of legstrengthening, balanceexercise, and walking.Frequency: 3sessions/week ofhome exercise; at least2 sessions/week ofwalkingIntensity: Walkingmoderate paceSession duration: 30min/home exercisesession, and 30 min/walking sessionDelivered by: Trialresearch staff in theone-off trainingDuration of theintervention (wks):24Primary exercisetype: Balance andfunctionB. FaME: Falls andexercise managementprogramme involvingprogressive resistancetraining, flexibilitytraining, functionalfloor skill and adaptedTai Chi. Additionally,FaME intervention

C. Usual careParticipants notoffered the FaME orOEP programmes

1. Femoral neckBMD2. Trochanter BMD3. Total hip BMD4. Upper neckBMD5. Lumbar spineBMD6. Distal radiusBMD7. Whole bodyBMD8. Whole bodyBMC

6 Mean difference(95% CI)1. Femoral neckBMDA. OEP: -0.003 (-0.011to 0.005)B. Communitybased: -0.002 (-0.010to 0.005)2. Trochanter BMDA. OEP: -0.005 (-0.032to 0.022)B. Communitybased: 0.000 (-0.025to 0.026)3. Total hip BMDA. OEP: -0.008 (-0.034to 0.019)B. Communitybased: 0.003 (-0.022to 0.028)4. Upper neck BMDA. OEP: 0.003 (-0.018to 0.023)B. Communitybased: 0.006 (-0.013to 0.026)5. Lumbar spineBMDA. OEP: 0.003 (-0.012to 0.019)B. Communitybased: 0.005 (-0.010to 0.020)








Results

included homeexercise based on EOPand walking.Frequency: 3-5 times/week [One exerciseclass, two home exer-cise session and atleast two sessions ofwalking per week]Intensity: walking atmoderate paceSession duration: 60min/exercise class; 30min/home exercisesession; 30 min/walking sessionDelivered by: Posturalstability instructorDuration of theintervention (wks):24Primary exercisetype: Balance andfunction

6. Distal radiusA. OEP: 0.001 (-0.008to 0.010)B. Communitybased: -0.009 (-0.018to -0.000)c

7. Whole body BMDA. OEP: 0.003 (-0.002to 0.008)B. Communitybased: -0.003 (-0.007to 0.002)8. Whole body BMCA. OEP: 0.8 (-22.0 to23.6)B. Communitybased: -6.6 (-27.9 to14.7)

Englund20055/10 [48]

RCT48/40

Setting:Community;SwedenHealth status:HealthyA. Exercise(COMB)n= 24(randomised); 21(analysed)Age: 72.8 (3.6)B. Controln= 24(randomised); 19(analysed)Age:73.2 (4.9)Female: 100%

A. Supervised exerciseprogramme involvinga combination ofstrengthening, aerobic,balance andcoordination exercisesFrequency: 2 times/weekIntensity: 2 sets of 8-12 reps (strengtheningexercise)Session duration: 50minDelivered by:PhysiotherapistDuration of theintervention (wks):47Primary exercisetype: Multiple(balance and functionplus resistance plusendurance)

B. No training 1. Lumbar SpineBMD2. Femoral neckBMD3. Trochanter BMD4. Ward’s triangleBMD5. Whole bodyBMD6. Arms BMD7. Whole bodyBMC

12 Mean difference(95% CI) (on %changes)1. Lumbar spineBMD: 2.1 (-0.4 to 3.4)2. Femoral neckBMD: 0 (-3.8 to 2.6)3. Trochanter BMD:3.4 (-1.2 to 7.3)4. Ward's triangleBMD: 2.2 (1.8 to12.9)c

5. Whole body BMD:0.1 (-1.3 to 2.2)6. Arms BMD: 0 (-1.9to 2.8)7. Whole body BMC:1.3 (-0.3 to 3.1)

Helge 20145/10 [50]

RCT27/23

Setting:Community;DenmarkHealth status:HealthyA. Football groupn= 9 (randomised);9 (analysed)Age: 68.0 (4.0)B. Resistancetrainingn= 9 (randomised);8 (analysed)Age: 69.1 (3.1)C. Controln= 8 (randomised);6 (analysed)

A. Football group:Supervised progressivefootball trainingFrequency: 1.7 (0.3)times/week (range:1.2-2.2)Intensity: 82% ofmaximum heart rate(range 64 to 90%)Session duration: 45to 60 minDelivered by: NRDuration of theintervention (wks):52Primary exercisetype: Balance and

C. Inactive control 1. Whole bodyBMD2. Right femoralneck BMD3. Left femoralneck BMD4. Right femoralshaft BMD5. Left femoralshaft BMD6. Total rightproximal femurBMD7. Total leftproximal femurBMD

12 Final score (mean ±SE)1. Whole body BMDA. Football: 1.211 ±0.036B. Resistance: 1.225± 0.024C. Control: 1.268 ±0.0302. Right femoralneck BMDA. Football: 0.921 ±0.034B. Resistance: 1.000± 0.042C. Control: 1.008 ±0.063








Results

Age: 67.4 (2.7)Female: 0%

function (football)B. Resistancetraining: Progressiveresistance training forcore and upper andlower bodyFrequency: 1.9 (0.2)times/week (range:1.4-2.2)Intensity: started from3 sets of 16-20 RM to4 sets of 8 RMSession duration: 45to 60 minDelivered by: NRDuration of theintervention (wks):52Primary exercisetype: Resistance(seated)

3. Left femoral neckBMDA. Football: 0.939 ±0.034B. Resistance: 1.006± 0.036C. Control: 1.018 ±0.0434. Right femoralshaft BMDA. Football: 1.156 ±0.042B. Resistance: 1.229± 0.056C. Control: 1.254 ±0.0595. Left femoral shaftBMDA. Football: 1.143 ±0.043B. Resistance: 1.229± 0.057C. Control: 1.282 ±0.0456. Total rightproximal femur BMDA. Football: 0.982 ±0.031B. Resistance: 1.066± 0.048C. Control: 1.083 ±0.0487. Total left proximalfemur BMDA. Football: 0.989 ±0.031B. Resistance: 1.069± 0.048C. Control: 1.117 ±0.041

Jessup 20035/10 [52]

RCT18/16

Setting:RetirementCommunity;United StatesHealth Status:HealthyA. Multi-componentinterventionn= 9 (randomised);8 (analysed)Age: 69.1 (2.8)B. Controln= 9 (randomised);8 (analysed)Age: 69.4 (4.2)Female: 100%

A. Supervised exerciseprogramme involvingresistance training,load-bearing walkingwith use of weightsvest, stair-climbing,and balance training.Frequency: 3 times/weekIntensity: 8-10 reps of50% of 1RM, pro-gressed to 75% of1RM (resistancetrainingSession duration: 60to 90 min exercisetraining session; 30 to45 min walkingDelivered by: Co-investigator and/or re-search assistantDuration of theintervention (wks):32 weeksPrimary exercise

B. Control 1. Femoral neckBMD2. Lumbar spineBMD

8 Change score(ANCOVA, p-value)1. Femoral neckBMDA. Exercise: 1.7B. Control: -0.04F (1, 15) = 7.38, P=0.0162. Lumbar spineBMDA. Exercise: 0.11B. Control: -0.003F (1, 15) = 2.70, P=0.121Final score (mean ±SD)1. Femoral neckBMDA. Exercise: 0.74 ±0.05B. Control: 0.74 ±0.132. Lumbar spineBMDA. Exercise: 0.88 ±








Results

type: Multiple(balance and functionplus resistance plusendurance)

0.08B. Control: 1.14 ±0.32

Karinkanta2007¶7/10 [53]

RCT149/144

Setting:Community;FinlandHealth Status:healthy andexcludedparticipants withosteoporosisA. Balance-jumping trainingn=37(randomised); 35(analysed)Age: 72.9 (2.3)B. Resistancetrainingn= 37(randomised);37(analysed)Age: 72.7 (2.5)C. CombinedBalance-jumpingand resistancetrainingn= 38(randomised); 36(analysed)Age: 72.9 (2.2)D. Controln= 37(randomised); 36(analysed);Age: 72.0 (2.1)Female: 100%

A. Balance-jumpingtraining: Balancetraining includingstatic and dynamicbalance exercise,agility training, impactexercises and changesof direction exercise.Intensity: NRPrimary exercisetype: Balance andfunction includingbone loading (jumps)B. Resistancetraining: Tailoredprogressive resistancetraining programmefor large musclegroups.Intensity: Initially 2sets of 10-15 reps atintensity 50-60% of1RM, progressed to 3sets of 8-10 reps at 75-80% of 1RM. Rate ofperceived exertion:above 18 out of 20Primary exercisetype: ResistanceC. CombinedBalance-jumping andresistance training: Acombination of A & Bon alternate weeks.Primary exercisetype: Multiple(balance and functionplus resistance)For all exercise groups:Frequency: 3 times/weekSession duration: 50minDelivered by: ExerciseleadersDuration of theintervention (wks):52

D. Control: maintaintheir pre-study levelof physical activityduring the 12-month trial

1. Femoral neckBMC2. Distal tibiatrabecular density(mg/cm3)

12 Final score (mean ±SD)1. Femoral neckBMCA. Balance: 2.73 ±0.40B. Resistance: 2.71 ±0.33C. Combined: 2.65 ±0.29D. Control: 2.67 ±0.442. Distal tibiatrabecular density(mg/cm3)A. Balance: 224 ± 34B. Resistance: 219 ±26C. Combined: 215 ±39D. Control: 226 ± 33

eKarinkanta2009¶5/10 [98]

RCT149/126

Setting:Community;FinlandHealth Status:Healthy andexcludedparticipants withosteoporosisA. Balancejumping traininggroupn= 37

A. Balance-jumpingtraining: Balancetraining (static anddynamic), agilitytraining, impactexercises and changesof direction exercise.Intensity: NRPrimary exercisetype: Balance andfunction includingbone loading (jumps)

D. Control: maintaintheir pre-study levelof physical activity

1. Femoral necksection moduls (Z)(mm3)2. Tibia midshaftdesnity-weightedpolar sectionmodulus (BSI)(mm3)

24 % Mean differencecompared to control(95% CI)1. Femoral neck ZA. Balance: 3.6 (-0.8to 8.2)B. Resistance: 3.5(-0.8 to 8.1)C. Combined: 0.3(-4.0 to 4.8)2. Tibia midshaft BSIA. Balance: 0.2 (-1.1








Results

(randomised); 33(analysed)Age: 72.9 (2.3)B. Resistancetraining groupn= 37(randomised); 34(analysed)Age: 72.7 (2.5)C. Combinedresistance andbalance jumpingtraining groupn= 38(randomised); 32(analysed)Age: 72.9 (2.2)D. Non-trainingcontrol groupn= 37(randomised);27(analysed)Age: 72.0 (2.1)Female: 100%

B. Resistance training:Tailored progressiveresistance for largemuscle groups.Intensity: Initially 2sets of 10-15 reps atintensity 50-60% of1RM, progressed to 3sets of 8-10 reps at 75-80% of 1RM. Rate ofperceived exertion:above 18 out of 20Primary exercisetype: ResistanceC. CombinedBalance-jumping andresistance training: Acombination of A & Bon alternate weeks.Primary exercisetype: Multiple(balance and functionplus resistanceincluding boneloading)For all exercise groups:Frequency: 3 times/weekSession duration: 50minDelivered by: ExerciseleadersDuration of theintervention (wks):52

to 1.6)B. Resistance: 0.3(-1.0 to 1.6)C. Combined:0.6(-0.7 to 1.9)

dKemmler2012§4/10 [94]

Quasi-randomisedtrial137/85

Setting:Community;GermanyHealth Status:OsteopeniaA. Exercise groupn= 86(randomised); 41(analysed)Age: 55.0 (3.4)B. Control-notrainingn= 51(randomised); 44(analysed)Age: 55.8 (3.1)Female: 100%

A. Supervised groupclass that includeswarm-up/ endurance,jumping and resist-ance exercise + hometraining that includesrope skipping, isomet-ric exercises, elasticbelt and stretchingexercisesFrequency: Supervisedgroup classes: 2 times/week; home training 2times/week(supervised groupclasses: 3 times/week;home training 1 time/week in the year 4and 5)Intensity:Aerobic dance: 70% to85% maximum heartrate and peak groundreaction forces (GRF)at approximately 3 to4 times bodyweight;Multilateral jumping: 4sets of 15 reps andGRF at approximately4 times of

B. No training:maintain own’shabitual lifestyle

1. Lumbar spine(L1-L4) BMD2. Femoral neckBMD

144 Mean difference(95% CI)1. Lumbar spineBMD0.030 (0.011 to0.049)c

2. Femoral neckBMD0.024 (0.009 to0.039)c








Results

bodyweight;Resistance: from 1 to 4sets, 4 to 12 reps, 70%to 90% 1 RM (2 to 3minute-rest) to 2 to 3sets, 20 to 25 reps,50% to 55% 1 RM (1to 2-minute rest)Session duration: 60to 65 min/ supervisedgroup session;20 min/home trainingsessionDelivered by:Certified trainersDuration ofintervention (wks):49 to 50 weeks/yearthroughout the 12yearsPrimary exercisetype: Multiple(endurance plusresistance with boneloading)

dKemmler2016§4 /10 [93]


Setting:Community;GermanyHealth status:OsteopeniaA. Exercise groupn= 86(randomised); 39(analysed)Age: 55.0 (3.5)B. Control-notrainingn= 51(randomised); 28(analysed)Age: 56.0 (3.0)Female: 100%

A. Supervised groupclass (aerobic danceexercise, jumping andresistance exercise) +Home training (ropeskipping, isometricand dynamicresistance exercise andstretching/ flexibilityexercise) five monthsafter study startedFrequency:Year 4 and 5:supervised groupclasses: 3 times/week;home training 1 time/weekAll other years:supervised groupclasses: 2 times/week;home training 2times/weekIntensity:Aerobic dance: 70% to85% maximum heartrate and 2 to 3bodyweight peakground reaction forces(GRF)Multilateral jumping: 4sets of 15 reps at GRFof 3 to 4.5bodyweightResistanceexercise: from 1 to 4sets of 4 to 12 reps atintensity of 70% to90% 1 RM (2- to 3-minute rest) to 2 to 3sets of 20 to 25 repsat an intensity of 50%

B. No training –maintain presentlifestyle

1. Lumbar spineBMD2. Total hip BMD

192 Absolute meandifference betweengroups (95% CI)1. Lumbar spineBMDPeriod 1 (baseline toyear 4): 2.37 (0.97 to3.77)c

Period 2 (year 5 toyear 8): 0.81 (0.15 to-1.76)Period 3 (year 8 toyear 12): 0.78 (0.03to -1.58)Period 4 (year 12 toyear 16): 0.75 (0.12to 1.38) c

2. Total hip BMDPeriod 1 (baseline toyear 4): 0.92 (0.24 to-2.08)Period 2 (year 5 toyear 8): 0.81 (0.12 to1.92)c

Period 3 (year 8 toyear 12): 0.16 (0.59to -0.91)Period 4 (year 12 toyear 16): 1.15 (0.08to 2.22) c








Results

to 55% 1 RM (1- to 2-minute rest)Session duration: 60to 65 min/ supervisedgroup session; 20 to25 min/home trainingsessionDelivered by: NRDuration ofintervention (wks):49 to 50 weeks/yearthroughout the 16yearsPrimary exercisetype: Multiple(endurance plusresistance with boneloading)

dKim 20186 /10 [95]

Pilot RCT51/41

Setting:Outpatientdepartment of ahospital; SouthKoreaHealth status:Diagnosis of StageI to III prostatecancer receivingandrogendeprivationtherapy withoutosteoporosisA. Home-basedexercise interven-tion for prevent-ing osteoporosis(HEPO)interventionn= 26(randomised); 23(analysed)Age: 70.5 (5.0)B. Control-stretching exer-cise (STR)n= 25(randomised); 18(analysed)Age: 71.0 (5.5)Female: 0%

A. Home-based exer-cise (HEPO). A coreprogram (weight-bear-ing exercise and resist-ance exercise) +optional program(stabilization/ balanceexercise and circuit re-sistive calisthenics).Two 30-minute educa-tion sessions with aworkbook precededthe start of the exer-cise and ten 15-minute sessions oftelephone counsellingFrequency: 3 to 5times/weekIntensity: The weight-bearing goal involvedat least 150 minutesper week ofmoderate-intensitywork, starting at an in-tensity of 11 to 12 onthe rate of perceivedexertion scale and in-creasing for 6 monthsto 13 to 15.The resistance exerciseprotocol started atfree weight andgradually increased toloads of 10% of bodyweight.Session duration:~40 minDelivered by: ExercisephysiologistDuration of theintervention (wks):24Primary exercisetype: Resistance withbone loading

B. Whole bodystretching exercise(STR)

1. Lumbar spine(L1-L4) BMD2. Femoral neckBMD3. Total hip BMD

6 Change score (mean± SD)1. Lumbar spine (L1-L4) BMDA. HEPO: -0.027 ±0.007B. STR: -0.031 ±0.0082. Femoral neckBMDA. HEPO: -0.014 ±0.007B. STR: -0.015 ±0.0083. Total hip BMDA. HEPO: -0.008 ±0.006B. STR: -0.011 ±0.006








Results

Kohrt 19973/10 [55]


Setting: NR;United StatesHealth Status:HealthyA. Groundreaction forcestrainingn= 14(randomised); 12(analysed)Age: 66.0 (1.0)B. Joint reactionforces trainingn= 13(randomised); 9(analysed)Age: 65.0 (1.0)C. Controln= 12(randomised); 9(analysed)Age: 68.0 (1.0)Female: 100%

A. Ground reactionforces training:Individualised exercisetraining focusing onactivities that involvedground-reactionforces, such as walk-ing, jogging and/orstair climbing.Frequency: 3 to 5times/week Intensity:60-70% to 80-85%maximum heart rateSession duration: 30-45 minutes/dayDelivered by: NRDuration of theintervention (wks):36Primary exercisetype: Multiple(balance and functionplus endurance plusflexibility)B. Joint reactionforces training:Individualised exercisetraining includingactivities that involvedjoint-reaction forces,such as weightliftingand rowing.Frequency: 3 to 5sessions/weekIntensity:Weightlifting: 2-3 setsof 8-12 reps; Rowing:60-70% to 80-85% ofmaximum heart rateSession duration: NRfor the total sessionduration; however;rowing took 15 to 20minDelivered by: NRDuration of theintervention (wks):36Primary exercisetype: Multiple(resistance plusendurance plusflexibility)

C. No exercise 1. Whole bodyBMD2. Lumbar spineL2–L4 BMD3. Femoral neckBMD4. Trochanter BMD5. Ward’s BMD6. Ultra-distal wristBMD7. One-third distalwrist BMD

12 Between-groupanalysis relative tocontrol1. Whole body BMDA. Ground reaction:p < 0.05B. Joint reaction: p <0.012. Lumbar spine L2–L4 BMDA. Ground reaction:p < 0.05B. Joint reaction: p <0.013. Femoral neckBMDA. Ground reaction:p < 0.01B. Joint reaction: nodifference4. Trochanter BMDA. Ground reaction:no differenceB. Joint reaction: nodifference5. Ward’s BMDA. Ground reaction:p < 0.01B. Joint reaction: p <0.056. Ultra-distal wristBMDA. Ground reaction:no differenceB. Joint reaction: nodifference7. One-third distalwrist BMDA. Ground reaction:no differenceB. Joint reaction: nodifferenceQuantitativeestimates were notreported (chancescores are providedin a graph)

dKorpelainen2010‡7/10 [96]

RCT160/100

Setting:Community;FinlandHealth status:Women with hipand radiusosteopeniaA. Exercise groupn= 84(randomised); 55(analysed)Age: 72.7 (1.1)

A. Supervised balance,leg strength, andimpact training andhome exerciseFrequency: 1 time/week of trainingsession; 1 time/day ofhome exercise trainingIntensity: NRSession duration: 60min/ supervisedsession, and 20 min/

B. Control 1. Femoral neckBMD2. Trochanter BMD3. Total proximalfemur BMD4. Femoral neckBMC5. Trochanter BMC6. Total proximalfemur BMC

48, 60,72

Mean difference(95% CI)1. Femoral neckBMDAt 4 year: 0.01 (-0.02to 0.03)At 5 year: 0.01 (-0.03to 0.02)At 6 year: 0.00 (-0.02to 0.02)2. Trochanter BMDAt 4 year: 0.01 (-0.02








Results

B. Control groupn= 76(randomised); 45(analysed)Age: 72.6 (1.2)Female: 100%

home exercisefollowing programDelivered by: PhysicaltherapistDuration of theintervention: 24weeks/yearPrimary exercisetype: Multiple(balance and functionplus resistance withbone loading)

to 0.03)At 5 year: 0.01 (-0.02to 0.03)At 6 year: 0.01 (-0.02to 0.04)3. Total proximalfemur BMDAt 4 year: 0.01 (-0.01to 0.04)At 5 year: 0.01 (-0.02to 0.03)At 6 year: 0.01 (-0.01to 0.04)4. Femoral neckBMCAt 4 year: -0.01 (-0.14to 0.11)At 5 year: -0.03 (-0.16to 0.09)At 6 year: -0.01 (-0.13to 0.11)5. Trochanter BMCAt 4 year: -0.22 (-0.87to 0.23)At 5 year: -0.30 (-0.51to 0.60)At 6 year: -0.25 (-0.78to 0.33)6. Total proximalfemur BMCAt 4 year: 0.01 (-1.56to 0.76)At 5 year: 0.01 (-1.72to 0.74)At 6 year: 0.01 (-1.68to 0.81)

dKorpelainen2006‡6/10 [79]

RCT160/136

Setting:Community;FinlandHealth status:Women with hipand radiusosteopeniaA. Exercise groupn= 84(randomised);69(analysed)Age: 72.9 (1.1)B. Control groupn= 76(randomised); 67(analysed)Age: 72.8 (1.2)Female: 100%

A. Supervised balance,jumping, and impactgroup trainingFrequency: 1 time/week of trainingsession; 1 time/day ofhome exercise trainingIntensity: NRSession duration: 60min/training session,and 20 min/hometrainingDelivered by: PhysicaltherapistDuration of theintervention (wks):24 weeks/year[exercise took place athome for other timesduring the year and intotal there were 72weeks supervisedgroup exercise] for 30months.Primary exercisetype: Multiple(balance and functionplus resistance withbone loading)

B. Control 1. Femoral neckBMD2. Trochanter BMD3. Total proximalfemur BMD4. Femoral neckBMC5. Trochanter BMC6. Total proximalfemur BMC7. Distal radiusBMD8. Ultradistalradius BMD

30 Mean difference(95% CI)1. Femoral neckBMD0.007 (-0.010 to0.024)2. Trochanter BMD0.011 (-0.014 to0.035)3. Total proximalfemur BMD0.004 (-0.021 to0.030)4. Femoral neckBMC-0.018 (-0.134 to0.100)5. Trochanter BMC0.043 (-0.514 to0.600)c

6. Total proximalfemur BMC-0.332 (-1.433 to0.769)7. Distal radius BMD-0.003 (-0.017 to0.011)8. Ultradistal radiusBMD








Results

-0.004 (-0.018 to0.008)

Kwon 20083/10 [56]

Quasi-randomisedtrial40/NR

Setting:Community; KoreaHealth status:HealthyA.Multicomponentinterventionn= 20(randomised)Age: 77.4 (2.56)B. Controln= 20(randomised)Age: 77.0 (3.33)Female: 100%

A. Combined trainingprogramme consistingof aerobic exercise,resistance training(free weights) andbalance exercise.Frequency: 3 times/weekIntensity:Aerobic exercises:started with 40-55%and up to 65-75%heart rate reserve;Resistance exercise: 8-12 reps at 75% of 1RMSession duration: 60minDelivered by: NRDuration of theintervention (wks):24Primary exercisetype: Multiple(balance and functionplus endurance plusresistance)

B. Control 1. Whole bodyBMD2. Lumbar (L2-L4)spine BMD3. Femoral neckBMD4. Ward’s triangleBMD5. Greatertrochanter BMD

6 Final score (mean ±SD)1. Whole body BMDA. Exercise: 0.92 ±0.07B. Control: 0.88 ±0.052. Lumbar (L2-L4)spine BMDA. Exercise: 0.85 ±0.15B. Control: 0.85 ±0.103. Femoral neckBMDA. Exercise:0.68 ±0.12B. Control: 0.70 ±0.074. Ward’s triangleBMDA. Exercise: 0.48 ±0.10B. Control: 0.46 ±0.085. Greater trochanterBMDc

A. Exercise: 0.59 ±0.05B. Control: 0.58 ±0.12

Lau 19924/10 [57]

RCT60/50

Setting: Hostel;Hong KongHealth Status:HealthyA. Exercise groupand placebocalciumsupplementationn= 11 (analysed)Age: mean age(range): 79 (76-81)B. Calciumsupplementationn= 12 (analysed)Age: meanage(range): 75 (72-79)C. Calciumsupplementationand exercisen= 15 (analysed)Age: meanage(range): 76 (73-80)D. Controln= 12 (analysed)Age: mean age(range): 75 years(71-78)Female: 100%

A. Supervised exerciseinvolving moving theupper trunk whilestanding.Frequency: 4 times/weekIntensity: Submaximalexertion effortSession duration: 15minDelivered by: NRDuration of theintervention (wks):40Primary exercisetype: Balance andfunction

Control 1. Femoral neckBMD2. Wards triangleBMD3.Intertrochantericarea BMD4. Lumbar spine(L2-L4) BMD

10 Change score (%;mean, 95% CI)1. Femoral neckBMDA. Exercise: -6.6 (-12to 0.8)B. Control: -1.1 (-7.4to 5.3)C. Supplement: -3.5(-9 to 1.8)D. Supplement andexercise: 5.0 (-0.77 to10)2. Wards triangleBMDA. Exercise: -6.0 (-15to 3.2)B. Control: -2.4 (-10to 5.9)C. Supplement: 2.5(-5.9 to 11)D. Supplement andexercise: 17 (3 to 31)3.Intertrochantericarea BMDA. Exercise: 0.1 (-6.5to 6.7)B. Control: 0.25 (-3.3to 3.8)C. Supplement: 2(-1.6 to 5.7)








Results

D. Supplement andexercise: 11 (1.3 to22)4. Lumbar spineBMDA. Exercise: -1.9 (-6.7to 2.8)B. Control: -2.5 (-6.5to 1.4)C. Supplement: -0.08(-5.2 to 5.1)D. Supplement andexercise: -1.1 (-3.7 to1.4)

Lord 19964/10 [58]

RCT179/138

Setting:Community,AustraliaHealth Status:HealthyA.Multicomponentexercisen= 90(randomised); 68(analysed)Age: 71.7 (5.4)B. Controln= 89(randomised); 70(analysed)Age: 71.5 (5.3)Female: 100%

A. Supervised group-based exerciseprogramme involvingaerobic exercise, bal-ance training,strengthening exercise,and stretching.Frequency: 2 times/weekIntensity: NRSession duration: 60minDelivered by:Instructors trained toprovide theprogrammeDuration of theintervention (wks):52 (only 42 weeks forexercise as there werebreaks in between)Primary exercisetype: Balance andfunction

No exercise 1. Femoral neckBMD2. Trochanter BMD3. Lumbar spine(L2-L4) BMD

12 Final score (mean ±SD) / Change score(mean % change ±SD)1. Femoral neckBMDA. Exercise: 0.791 ±0.122 / 1.52 ± 5.19B. Control: 0.776 ±0.110 / 3.12 ± 6.522. Trochanter BMDA. Exercise: 0.707 ±0.127 / 0.69 ± 4,64B. Control: 0.672 ±0.123 / 0.73 ± 5.283. Lumbar spine (L2-L4) BMDA. Exercise: 1.036 ±0.209 / 1.07 ± 2.59B. Control: 1.008 ±0.189 / 0.36 ± 3.91

Marques20115/10 [59]

RCT60/60

Setting:Community;PortugalHealth Status:HealthyA. Multi-componenttrainingn= 30 (randomisedand analysed)Age: 70.1 (5.4)B. Controln= 30 (randomisedand analysed)Age: 68.2 (5.7)Female: 100%

A. Progressivemulticomponentexercise trainingconsisting ofmoderate to highimpact weight-bearingactivities, endurance,balance exercise, andagility training.Frequency: 2 times/weekIntensity: Steppingexercise: at 120-125beats/min.Weight bearing andstrength exercise: from2 sets of 8 reps to 3sets of 15 repsSession duration: 60minDelivered by: Physicaleducation instructorsspecialised in physicalactivity for older adultsDuration of theintervention (wks):

B. Control 1. Femoral neckBMD2. Total femurBMD3. Trochanter BMD4. IntertrochantericBMD5. Lumbar spine(L1-L4) BMD


A. Exercise: 0.717 ±0.085B. Control: 0.671 ±0.0512. Total femur BMDA. Exercise: 0.832 ±0.104B. Control: 0.823 ±0.0583. Trochanter BMDA. Exercise: 0.628 ±0.081B. Control: 0.628 ±0.0344. IntertrochantericBMDA. Exercise: 0.989 ±0.148B. Control: 0.977 ±0.0755. Lumbar spine (L1-L4) BMD








Results

32Primary exercisetype: Balance andfunction with boneloading (heel drops)

A. Exercise: 0.868 ±0.094B. Control: 0.863 ±0.065

McCartney19953/10 [60]

RCT68/NR

Setting: NR;CanadaHealth status:HealthyA. Exercisen= 37(randomised)Age: 73 (3)Female: 54%B. Controln= 31(randomised)Age: 72 (3)Female: 74%

A. Progressiveresistance training forupper and lower body,and abdominals.Completed in as acircuit.Frequency: 2sessions/weekIntensity: 2 sets ofeach exercise at 50%of 1RM to 3 sets of80% 1RMSession duration: NRDelivered by: NRDuration of theintervention (wks):42 weeksPrimary exercisetype: Resistance

B. ControlOffered a supervisedwalking programme.Frequency: 2sessions/weekIntensity: lowSession duration:NRDelivered by: NRDuration of theintervention (wks):42 weeks

1. Lumbar spine(L2-4) BMD2. Whole bodyBMD3. Lumbar spine(L2-4) BMC4. Whole bodyBMC

10.5 No significantchanges in BMD andBMC as a result ofthe trainingprogramme.Quantitativeestimates notreported.

McMurdo19974/10 [61]

RCT118/92

Setting:Community;United KingdomHealth status:HealthyA. Exercise andcalciumsupplementationn= 44 (analysed)B. Calciumsupplementationn= 48 (analysed)Age: 64.5 (range60-73)Female: 100%

A. Exerciseprogramme involvingweight bearingexercise to music andcalciumsupplementation(1000 mg calciumdaily, as calciumcarbonate)Frequency: 3 times/weekIntensity: NRSession duration: 45minDelivered by: NRDuration of theintervention (wks):30 (three 10-weekterms)Primary exercisetype: Balance andfunction

B. Taking calciumsupplementation(1000 mg calciumdaily, as calciumcarbonate)

1. Lumbar BMD2. Distal forearm(non-dominant)BMC3. Ultra distalforearm (non-dominant) BMC

24 Change score (mean% change ± 95% CI)1. Lumbar BMDA. Exercise andcalcium: -0.91 (-6.8to 5.0)B. Calcium: -2.65(-5.7 to 0.4)2. Distal forearm(non-dominant) BMCA. Exercise andcalcium: -2.18 (-3.0to -1.4)B. Calcium: -1.38(-2.2 to -0.6)3. Ultra distalforearm BMCc

A. Exercise andcalcium: 1.14 (-0.8 to3.1)B. Calcium: -2.6 (-4.6to -0.6)

eNichols19954/10 [99]

RCT34/28

Setting:Community;United StatesHealth status:Healthy and activeA. Weighttraining groupn=17(randomised); 9(analysed at 12-month)Age: 67.8(standard error: 1.6)B. Controln=17(randomised); 8(analysed at 12-month)

A. Supervised, isotonictraining (leg flexionand extension, backextension, trunkflexion, bench press,latissimus dorsi pull-down, shoulder pressand seated row)Frequency: 3 times/weekIntensity:Commenced with oneset of 10-12 reps at anintensity of 50% of1RM and progressedto three sets at 80% of1RM from third weekSession duration: NR

B. Contunue currentendurance exerciseprogram

1. Lumbar spine(L2-4) BMD2.Femoral neckBMD3. Trochanter BMD4. Total body BMD

12 Final score (mean ±SE)1. Lumnar spineBMDA. Weight training:1.025 ± 0.04B. Control: 1.012 ±0.032. Femoral neckBMDA. Weight training:0.776 ± 0.03B. Control: 0.772 ±0.023. Trochanter BMDA. Weight training:0.670 ± 0.02B. Control: 0.666 ±








Results

Age: 65.2 (1.2)Female: 100%

Delivered by: NRDuration of theintervention (wks):52Primary exercisetype: Resistance

0.034. Total body BMDA. Weight training:0.976 ± 0.02B. Control: 0.979 ±0.03

Paillard 20045/10 [62]

RCT21/21

Setting:Community;FranceHealth status:HealthyA. Walking groupn= 11 (randomisedand analysed)Age: 65.5 (2)B. Controln= 10 (randomisedand analysed)Age: 66.8 (2)Female: 0%

A. Individualised briskwalking programmeFrequency: 5 times/weekIntensity: Lactatethreshold (minimumheart rate: 131 beats/minute; maximumheart rate: 156 beats/minute)Session duration: 45to 60 minDelivered by: NRDuration of theintervention (wks):12Primary exercisetype: Endurance(walking)

B. Control 1. Hip BMD2. Whole bodyBMD

3 Final score (mean ±SD)1. Hip BMDA. Walking: 0.84 ±0.11B. Control: 0.95 ±0.122. Whole body BMDA. Walking: 1.06 ±0.11B. Control: 1.02 ±0.13

Park 20085/10 [63]

RCT50/50

Setting:Community; KoreaHealth status:HealthyA. Multi-componenttrainingn= 25 (randomisedand analysed)Age: 68.3 (3.6)B. Controln= 25 (randomisedand analysed)Age: 68.4 (3.4)Female: 100%

A. Exercise trainingincluding stretching,strength training,weight-bearing exer-cise, balance and pos-ture correctiontraining.Frequency: 3 times/weekIntensity: 65%-75% ofthe maximum heartrateSession duration: 60minDelivered by: NRDuration of theintervention (wks):48Primary exercisetype: Multiplebalance/ function plusendurance (weight-bearing)

B. Control 1. Femoral neckBMD2. Ward’s triangleBMD3. Trochanter BMD4. Lumbar spine(L2 to L4) BMD


A. Exercise: 0.857 ±0.078B. Control: 0.748 ±0.0632. Ward’s triangleBMDA. Exercise: 0.659 ±0.086B. Control: 0.576 ±0.0793. Trochanter BMDc

A. Exercise: 0.725 ±0.081B. Control: 0.677 ±0.0624. Lumbar spine (L2to L4) BMDA. Exercise: 1.059 ±0.082B. Control: 0.891 ±0.155

Pruitt 19954/10 [64]

RCT40/26

Setting:Community;AmericaHealthy status:HealthyA. High intensityresistancetrainingn= 15(randomised); 8(analysed)Age: 67.0 (0.5)B. Low intensityresistance

A. High intensityresistance training:High intensitysupervised resistancetraining comprisingexercises for upperand lower extremitieswith the use ofequipment.Intensity: 2 sets of 7reps at 80% 1RMPrimary exercisetype: ResistanceB. Low intensity

C. No training 1. Total hip BMD2. Femoral neckBMD3. Ward’s triangleBMD4. Lumbar spine(L2-L4) BMD

12 Change score (mean± SD)1. Total hip BMDA. High intensity:0.005 ± 0.014B. Low intensity:0.008 ± 0.012C. Control: 0.007 ±0.0102. Femoral neckBMDA. High intensity:-0.002 ± 0.154B. Low intensity:








Results

trainingn= 13(randomised); 7(analysed)Age: 67.6 (1.4)C. Controln= 12(randomised); 11(analysed)Age: 69.6 (4.2)Female: 100%

resistance training:Supervised resistancetraining comprisingexercises for upperand lower extremitiesusing equipment.Intensity: 3 sets of 14reps at 40% 1RMFor both A and B:Frequency: 3 times/weekSession duration: 50to 55 minDelivered by: NRDuration of theintervention (wks):52Primary exercisetype: Resistance

0.025 ± 0.008C. Control: 0.005 ±0.0193. Ward’s triangleBMDA. High intensity:0.018 ± 0.032B. Low intensity:0.022 ± 0.045C. Control: 0.008 ±0.0364. Lumbar spine (L2-L4) BMDA. High intensity:0.007 ± 0.018B. Low intensity:0.005 ± 0.027C. Control: 0.000 ±0.020

Rhodes 20005/10 [65]

RCT44/38

Setting:Community;CanadaHealth Status:HealthyA. Resistancetrainingn= 22(randomised); 20(analysed)Age: 68.8 (3.2)B. Controln= 22(randomised); 18(analysed)Age: 68.2 (3.5)Female: 100%

A. Supervisedprogressive resistancetraining comprisingexercises for largemuscle groups.Frequency: 3 times/weekIntensity: 3 sets of 8reps at 75 % 1 RMSession duration: 60minDelivered by:Professional lifestyleand fitness consultantsDuration of theintervention (wks):52Primary exercisetype: Resistance

B. No exerciseprogramme andwere instructed tomaintain theirnormal lifestylethroughout thestudy duration.

1. Femoral neckBMD2. Ward’s triangleBMD3. Trochanter BMD4. Lumbar spine(L2-L4) BMD5. Femoral neckBMC6. Ward’s triangleBMC7. Trochanter BMC8. Lumbar spine(L2-L4) BMC

12 Final score (mean ±SD)1. Femoral neckBMDA. Exercise: 0.83 ±0.12B. Control: 0.73 ±0.102. Ward’s triangleBMDA. Exercise: 0.70 ±0.11B. Control: 0.59 ±0.123. Trochanter BMDA. Exercise: 0.75 ±0.11B. Control: 0.67 ±0.114. Lumbar spine (L2-L4) BMDA. Exercise: 1.13 ±0.18B. Control: 1.01 ±0.175. Femoral neckBMCA. Exercise: 4.02 ±0.22B. Control: 3.48 ±0.196. Ward’s triangleBMCA. Exercise: 1.85 ±0.19B. Control: 1.51 ±0.187. Trochanter BMCA. Exercise: 9.04 ±0.33B. Control: 8.83 ±0.368. Lumbar spine (L2-L4) BMCA. Exercise: 45.86 ±2.7








Results

B. Control: 42.50 ±2.6

Rikli 19901/10 [67]


Setting: Localretirementcommunity; UnitedStatesHealth Status:HealthyA. Generalexercisen= 13(randomised); 10(analysed)Age: 72.2 (5.57)B. Generalexercise + weightn= 13(randomised); 10(analysed)Age: 71.6 (5.66)C. Controln= 11(randomised); 11(analysed)Age: 70.8 (8.43)Female: 100%

A. General exercise:Group-based aerobicexercise training forlarge muscle groups.Frequency: 3 times/weekIntensity: 60-70%maximum heart rateSession duration: 30to 50 minDelivered by: NRDuration of theintervention (wks):40Primary exercisetype: enduranceB. General exercise +weight: Group-basedaerobic exercise train-ing plus upper bodyprogressive resistancetraining. The resistancetraining was per-formed withoutsupervision.Frequency: 3 times/weekIntensity: 60-70%maximum heart ratefor aerobic activitiesSession duration: 50to 70 minDelivered by:AssistantsDuration of theintervention (wks):40Primary exercisetype: Multipleresistance plusendurance

C. No exercise 1. Distal radiusBMC/BW2. Distal radiusBMC

10 Change score (%)1. Distal radius BMC/BWc

A. General exercise:0.921B. General exerciseand weight: 1.734C. Control: -2.5772. Distal radius BMCc

A. General exercise:1.023B. General exerciseand weight: 1.743C. Control: -2.499

Sakai 20104/10 [68]

RCT94/84

Setting:Community, JapanHealth Status:HealthyA. Exercisen= 49(randomised); 47(analysed)Age: 68.3 (0.8)B. Controln= 45(randomised); 37(analysed)Age: 68.2 (0.5)Female: 100%

A. Home balanceexercises involvingunipedal standingexercise with theireyes open (single legstanding)Frequency: 3 sets/day;7 days/weekIntensity: NASession duration: 2min/setDelivered by: NA(home exercise)Duration of theintervention (wks):26Primary exercisetype: Balance/function

B. Usual activity 1. Femoral neckBMD2. Trochanter BMD3. IntertrochanterBMD4. Ward's triangleBMD5. Total hip BMD

6 % mean difference(p-value)1. Femoral neck: p=0.9932. Trochanter: p=0.8013. Intertrochanter: p=0.9684. Ward’s triangle p=0.0965. Total hip: p=0.889Change scorereported in a graph

Smith 19812/10 [70]

Quasi-randomisedtrial

Setting: Nursinghome; UnitedStates

A. Light-to-mildseated exercises in-cluding sideward leg

B. Placebo tabletsReceived 360 mg oflactose, 5mg of

1. Radius BMC 36 Change score (%)Radius BMCc

A. Exercise: 2.29%








Results

80/51 Health Status:HealthyA. Physicalactivity group +placebo tabletsn= 19(randomised); 12(analysed)Age: 82.9 (6.1)B. Control(placebo tablet)n= 26(randomised); 18(analysed)Age: 81.9 (7.4)C. Calcium andvitamin Dn= 17(randomised); 10(analysed)Age: 80.7 (4.8)D. Physicalactivity + calciumand vitamin Dn= 18(randomised); 11(analysed)Age: 84.3 (5.1)Female: 100%

spread, leg walk, run-ning in place, armcross, sideward bendand chair pull.Frequency: 3 times/weekIntensity: 70% of thesampled VO2 maxSession duration:30minDelivered by: NRDuration of theintervention (wks):156Primary exercisetype: Endurance(seated)

magnesium stearateand 80 mg ofmicrocrystallinecellulose in theplacebo tablets

D. Control: - 3.29%

eSnow 20003/10 [100]


Setting:Community;United StatesHealth status:HealthyA. Exercise groupn= 9 (randomisedand analysed)Age: 66.4 (1.7)B. Controln= 9 (randomisedand analysed)Age: 61.8 (2.5)Female:100%

A. Year1: 9-monthtraining (10 min ofwarm-up, 35 min oflower-body resistancetraining, includingstepping, squats, chairraises, forward lunges,lateral lunges and toeraises, using theweighted vest, 10-15min of cool-down ac-tivities. Jumping exer-cises were includedduring the fourthmonths of trainingwithout the weightedvestsYear 2-5 emphasiedmaintenance in lowerbody exercises utilisingthe weighted vest in-cluded more jumpsper class than year 1and encouraged useof the weighted vestwhile jumping.Frequency: 3 times/weekIntensity: 3 to 5 setsof 10 to 15 reps usingthe weight vest.Vest resistance setfrom 5% of bodyweight and wasgradually increased(approximaltey 1 to

B. Maintain andrecord their physicalactivity during thestudy and did notengage in weightedvest of jumpingactivity

1. Femoral neckBMD2. Trochanter BMD3. Total hip BMD

60 % change (mean ±SE)1. Femoral neckBMDc

A. Exercise group:1.54 ± 2.37B. Control: -4.43 ±0.932. Trochanter BMDc

A. Exercise group:-0.24 ± 1.02B. Control: -3.43% ±1.093. Total hip BMDc

A. Exercise group:-0.82 ± 1.04B. Control: -3.80% ±1.03%








Results

2% every 2 weeks)until 10% of bodyweight; Beyond 10%of body weight,resistance wasincreased at 0.5% to1% every 2 weeks.Session duration: 60Delivered by: NRDuration of theintervention (wks):260Primary exercisetype: Resistance withbone loading(jumping)

Taaffe 19964/10 [101]

RCT36/21

Setting:Community;United StatesHealth status:HealthyA. High intensityresistancetraining groupn= 12(randomised); 7(analysed)Age: 67.0 (0.2)B. Low intensityresistancetraining groupn= 13(randomised); 7(analysed)Age: 67.6 (0.5)C. Controln= 11(randomised); 7(analysed)Age: 69.6 (1.3)Female: 100%

Supervised exercisetraining targeted thighmuscle strengthincluding leg press,knee extension andknee flexion. Exercisesessions werebracketed by warm upand cool-downperiodsA. Intensity: 1 set of14 reps at an intensityof 40% 1RM and 2 setsof 7 reps at anintensity of 80% of1RMB. Intensity: 3 sets of14 reps at an intensityof 40% of 1RMFor both groupsFrequency: 3 times/weekSession duration: NRDelivered by: NRDuration of theintervention (wks):52Primary exercisetype: Resistance

D. Control 1. Middle third ofthe femur BMD2. Thigh BMD

12 Change score (mean% ± SEM)1. Middle third ofthe femur BMDc

A. High intensity:1.0± 1.0B. Low inteisty: -2.2± 0.5C. Control: -1.8 ± 0.62. NR

Taaffe 19995/10 [72]

RCT53/46

Setting:Community;United StatesHealth status:HealthyA. High-intensityresistance train-ing (1 day perweek)n= 14(randomised); 11(analysed)Age: 68.5 (3.6)Female: 36%B. High-intensityresistance train-ing (2 days perweek)n= 14

A, B & C. Supervisedresistance trainingtargeting the majorupper and lower bodymuscle groups.A. Frequency: 1 time/weekB. Frequency: 2times/weekC. Frequency: 3times/weekIntensity: Started at60% of the 1RM andgradually increase inintensity to 3 sets of 8reps at 80% of 1 RMSession duration: NRDelivered by: NRDuration of the

D. Control 1. Lumbar spine(L2-L4) BMD2. Total hip BMD3. Midradius BMD4. Total body BMC

6 Final score (mean ±SEM)1. Lumbar spine (L2-L4) BMDA. Resistance 1x/week: 1.025 ± 0.006B. Resistance 2x/week: 1.033 ± 0.006C. Resistance 3x/week: 1.032 ± 0.007D. Control: 1.041 ±0.0062. Total hip BMDA. Resistance 1x/week: 0.865 ± 0.010B. Resistance 2x/week: 0.866 ± 0.006C. Resistance 3x/week: 0.864 ± 0.010








Results

(randomised); 12(analysed)Age: 69.4 (3.0)Female: 29%C. High-intensityresistance train-ing (3 days perweek)n= 11 (randomised& analysed)Age: 71.0 (4.1)Female: 36%D. Controln= 14(randomised); 12(analysed)Age: 68.9 (3.6)Female: 43%

intervention (wks):24Primary exercisetype: Resistance

D. Control: 0.873 ±0.0103. Midradius BMDA. Resistance 1x/week: 0.605 ± 0.003B. Resistance 2x/week: 0.604 ± 0.003C. Resistance 3x/week: 0.608 ± 0.003D. Control: 0.601 ±0.0034. Total body BMCA. Resistance 1x/week: 2552 ± 15B. Resistance 2x/week: 2530 ± 14C. Resistance 3x/week: 2525 ± 14D. Control: 2536 ±14

Villareal 20034/10 [73]


Setting:Community;United StatesHealth status:Mild to moderatephysical frailty onhormonereplacementtherapyA. Supervisedmulti-componenttrainingn= 14 (randomisedand analysed)Age: 81 (3)B. Control: Homeexercisen= 14 (randomisedand analysed)Age: 81 (3)Female: 100%

A. Supervised exerciseprogramme involvingflexibility and balanceexercises, resistancetraining andendurance exercises.Frequency: 3 times/weekIntensity:Resistance training:from 1-2 sets of 8-12reps at 65% of 1RM to2-3 sets of 6-8reps at75–85% of 1RMEndurance: from 65–75 to 85–90% peakheart rateSession duration: 90to 120 minDelivered by: ExercisephysiologistsDuration of theintervention (wks):36 weeksPrimary exercisetype: Multiple(resistance plusbalance/function plusendurance)

B. Home exerciseprogrammefocusing onflexibilityFrequency: 2-3times/week

1. Total hip BMD2. Femoral neckBMD3. Trochanter BMD4. Lumbar spineBMD5. Whole bodyBMD

9 Change score (mean± SD)1. Total hip BMDA. Exercise: 0.003 ±0.011B. Control: 0.009 ±0.0114. Lumbar spineBMDc

A. Exercise: 0.034 ±0.022B. Control: 0.015 ±0.0225. Whole body BMDA. Exercise: 0.015 ±0.015B. Control: 0.002 ±0.015No quantitativeestimates reportedfor:2. Femoral neckBMD3. Trochanter BMD(There were nosignificant group-by-time interactioneffects)Results reported in agraph

Villareal 20044/10 [74]

RCT119/112

Setting:Community;United StatesHealth status:Mild-to-moderatephysical frailtyA. Exercisetraining (ET)n= 69(randomised); 65(analysed)Age: 83 (4)Female: 52%B. Home exercise

A. Supervised exerciseprogramme involvingflexibility and balanceexercises, resistancetraining andendurance exercises.Frequency: NRIntensity:Resistance training:started from 1-2 setsof 6-8 reps at 65-75%of 1RM to 3 sets of 8-12 reps at 85-100%1RM

B. Home exerciseprogrammefocusing onflexibility

1. Total hip BMD2. Femoral neckBMD3. Trochanter BMD4. Lumbar spine(L2-L4) BMD5. Whole BodyBMD

9 Final score (mean ±SD)1. Total hip BMDA. Exercise: 0.85 ±0.19B. Control: 0.75 ±0.152. Femoral neckBMDA. Exercise: 0.70 ±0.17B. Control: 0.63 ±0.113. Trochanter BMD








Results

(HOME)n= 50(randomised); 47(analysed)Age: 83 (4)Female: 55%

Endurance training:started from 15 minsat 65-75% of peakheart rate to 30 minsat 85-90% of peakheart rateSession duration: NRDelivered by: NRDuration of theintervention (wks):36Primary exercisetype: Multiple(resistance plusbalance/function plusendurance)

A. Exercise: 0.65 ±0.17B. Control: 0.58 ±0.124. Lumbar spine (L2-L4) BMDA. Exercise: 1.08 ±0.28B. Control: 0.97 ±0.235. Whole Body BMDA. Exercise: 1.09 ±0.18B. Control: 1.03 ±0.17

von Stengel20117/10 [78]

RCT151/141

Setting:Community;GermanyHealth Status:HealthyA. Conventionalmulticomponenttrainingn= 50(randomised); 47(analysed)Age: 68.6 (3)B. Wellnesscontroln= 51(randomised); 48(analysed)Age: 68.1 (2.7)Female: 100%

A. Training sessionsconsisting of aerobicdancing; progressivecoordination andbalance training;functional gymnasticsand isometric strengthtraining; andprogressive upperbody exercises.Additionally,participants wererequested to carry outa home trainingsession.Frequency: 4 times/week [i.e. 2 controlledtraining session/week;2 home exercise/week]Intensity:Dance aerobic: 70–80% maximum heartrate;Functional gymnasticsand isometricstrength: 6-10s of max-imum exertion and20-30s of active rest;Upper body exercise: 3sets 15 repsSession duration: 60min/training session;20 min/home trainingsessionDelivered by:Certified instructorsDuration of theintervention (wks):72Primary exercisetype: Multiple(balance/function, plusflexibility plusresistance plusendurance (dance)

B: Low intensitywellnessprogramme thatincludeslight physicalexercises and arelaxationprogrammeFrequency: 1 time/weekIntensity: LightSession duration:NRDelivered by: NRDuration of theintervention (wks):72(10 weeks oftraining wereintermitted by abreak of 10 weeksand the trainingcycle was repeatedthroughout 72weeks)

1. Total hip BMD2. Lumbar spine(L1-L4) BMD

18 Mean difference(95% CI):1. Total hip BMD:0.002 (-0.007 to0.012)2. Lumbar spine:0.015 (0.001 to0.029)c

dWinters-Stone 2014

RCT51/43

Setting:Community;

A. Progressive,moderate-intensity

B. FLEX Control:Whole body

1. Lumbar spine(L1-L4) BMD

12 Final score (mean ±SD)








Results

7/10 [97] United StatesHealth Status:Prostate cancersurvivors receivingandrogendeprivationtherapy withoutosteoporosisAge: 70.2A. Progressive,moderate-intensity resist-ance + impacttraining (POWIR)n=29(randomised);24(analysed)B. Control-flexibility training(FLEX)n= 22(randomised); 12(analysed)Female: 0%

resistance for upperand lower body + im-pact training consistedof two footed jumpsfrom the group to atarget height 1” fromthe floor with a bent-knee landing withweighted vestsFrequency: 3 times/week (two supervisedclasses + one home-based session)Intensity: Lower bodytraining 1-2 sets of 8-12 reps from 0% to15% of the bodyweight. Upper bodytraining started from1-2 sets of 12-14 repsat 13-15 RM to 1-2sets of 8 to 10 reps at8-10RM. Jumpingstarted from 1-4 setsof 10 reps at 0-1%body weight to 9 to10 sets of 10 reps at10% body weightusing weighted vestSession duration: 60minDelivered by: Trainedexercise instructorsDuration of theintervention (wks):52Primary exercisetype: Resistance withbone loading

stretching andrelaxation

2. Total hip BMD3. Greatertrochanter BMD4. Femoral neckBMD

1. Lumbar spineBMDA. POWIR: 1.123 ±0.241B. FLEX: 1.094 ±0.1562. Total hip BMDA. POWIR: 0.956 ±0.135B. FLEX: 0.971 ±0.1293. Greater trochanterBMDA. POWIR: 0.776 ±0.131B. FLEX: 0.783 ±0.1124. Femoral neckBMDA. POWIR: 0.752 ±0.131B. FLEX: 0.791 ±0.098

Woo 20076/10 [75]

RCT180/176

Setting:Community; HongKongHeath status:HealthyA. Tai Chin=60(randomised); 58(randomised)Age: 68.2 yearsB. Resistancetrainingn= 60(randomised); 59(randomised)Age: 68.7 yearsC. No Treatmentn= 60(randomised); 59(randomised)Age: 68.1 yearsFemale: 50%

A. Tai Chi: 24-formsof Tai Chi using YangstyleFrequency: 3 times/weekIntensity: NRSession duration: NRDelivered by: NRDuration of theintervention (wks):52 weeksPrimary exercisetype: 3D (Tai Chi)B. Resistancetraining: Resistancetraining with the useof medium st

Documents

Evidence on physical activity and osteoporosis prevention ...Methods We conducted a systematic review investigating the asso-ciation between physical activity and osteoporosis preven-tion