With age, bone mass declines, and an accelerated loss of bone mineral density (BMD) occurs by 50 years of age [
POP treatment is a long-term process and may not 100% prevent the development or reverse the symptoms of the disease [
Available human, clinical, or community studies with a randomized controlled trial published in English or Chinese were included in this review. The participants consisted of patients with POP who had no thoracolumbar vertebral fracture and other complications such as heart, vein, lung, liver, and kidney as well as metabolic diseases and were not taking drugs affecting bone metabolism. The age and gender of the subjects were not limited. The included studies focused on the effect of kinesitherapy plus antiosteoporosis medications therapy as a kinesitherapy group compared with antiosteoporosis medications therapy as a control group for the BMD of POP (SOP and SMOP). Those which compared kinesitherapy alone with another exercise or any other antiosteoporosis intervention were excluded. The kinesitherapy should include weight-bearing, impact, resistance, endurance training, or a combination of these types of training, and only single-motion experiments will be ruled out. Health education can be added to all patients, and all inpatients can be given routine care. The outcomes included at least lumbar spine or femoral neck BMD.
The original research articles were obtained after a search of six electronic English and Chinese databases, which included PubMed, Science Citation Index (SCI), EMBASE, Chinese Scientific Journal Database (VIP), China National Knowledge Information (CNKI) database, and Wanfang from their inception to October 3, 2019. We used the following search strategy ([kinesitherapy OR exercise] AND osteoporosis AND bone mineral density) in all the English and Chinese databases.
Two reviewers (WSX and LSZ) independently screened and reviewed the title and abstract of the searched studies using NoteExpress V3.2.0.6992 software. The full text of the studies that potentially met the eligibility criteria was obtained, and any potentially relevant references were retrieved according to predefined eligibility criteria. The data were extracted by one reviewer (WSX) using the prepared forms and checked for accuracy by the second reviewer (LSZ). The details extracted from the eligible literature included the language of publication, participant characteristics, sample size, methodological information, participant demographics, experimental and control interventions (category, intensity, frequency, duration, and details of antiosteoporosis medication treatment), outcomes, and adverse effects [
The quality of the studies was independently evaluated by two reviewers (WSX and LSZ) using the Cochrane Collaboration’s tool for assessing the risk of bias [
Review Manager 5.2 software from the Cochrane Collaboration was applied for the data analysis. Statistical heterogeneity among the studies was assessed using a chi-square test or by calculating Higgins
A detailed screening flowchart depicting the generation of eligible articles is presented in Figure
Details of literature search and selection. SCI: Science Citation Index; VIP: Chinese Scientific Journal Database; CNKI: China National Knowledge Information database.
Table
The characteristics of all the trails.
Author, year | Participants (type, source, age, sample) | Duration (months) | Intervention | Outcomes | ||
---|---|---|---|---|---|---|
Kinesitherapy group | Control group | |||||
Iwamoto et al., 2001 [ | PMOP, unspecified, 53–77 years, 28 (KT: 8, CON: 20) | 24 | Brisk walking (1000 steps in the first 7 days, increase the step count by 30%/week) + gymnastic training (no details provided)) + CON | Calcium lactate (2.0 g, Qd) and 1 | Lumbar spine BMD | |
Shen, 2003 [ | POP, outpatient and inpatient, 45–80 years, 60 (KT: 30, CON: 30) | 3 | Aerobics, tai chi, dance, yangko, jogging, walking etc. (30–60 min/time, 5–7 times/week) + CON | Tonifying kidney granules (3 times/day, 1 dose/time) | Lumbar spine BMD | |
Zhu, 2007 [ | SOP, outpatient, 60–72 years, 96 (KT: 48, CON: 48) | 12 | Walking, jogging, tai chi (30–60 min/time, 3–5 times/week) + CON | Calcium (600 mg/d) | Lumbar spine BMD | |
Liu et al., 2007 [ | PMOP, outpatient, 48–61 years, 68 (KT: 36, CON: 32) | 6 | Draft movement, abdominal isometric exercises, flexion, and extension of the upper limbs (20 minutes each time, once every 3 days) + CON | Caltrate D (600 mg, Qd) | Lumbar spine BMD | |
Li et al., 2008 [ | PMOP, unspecified, 48–61 years, 70 (KT: 38, CON: 32) | 6 | Draft movement, abdominal isometric exercises, flexion, and extension of the upper limbs (20 min/time, once every four days) + CON | Ossotide injection (50 mg, Qd, 20 days in total) | Lumbar spine BMD | |
Liu et al., 2009 [ | SOP, outpatient service, 60–94 years, 60 (KT: 30, CON: 30) | 12 | Walking, jogging, tai chi (60 min/time, 1 time/day) + CON | Fosamax (10 mg, once a day) and calcium (600 mg/d) | Lumbar spine BMD | |
Liu and Wang, 2012 [ | SOP, unspecified, 60–81 years, 320 (KT: 162, CON: 158) | 12 | Tai chi and jogging (no less than 30 min/time, no less than 4 times/week) + CON | Calcium carbonate D3 (600 mg, Qd) | Lumbar spine BMD | |
Li et al., 2013 [ | SOP, hospital, 67 ± 4 years, 86 (KT:43, CON: 43) | 6 | Progressive lumbar dorsal muscle function exercise includes sitting training, swallow training and five-point support training (1-2 times/day) + CON | Lorelli calcium capsule (l capsules, 1 time/d for 2 consecutive months) | Lumbar spine BMD | |
Ming, 2013 [ | SOP, hospital, 60–78 years, 96 (KT: 48, CON: 48) | 12 | Walking, aerobics, running ,and tai chi (5 to 7 times a week for 45 to 60 minutes)+ CON | Calcium gluconate (20 ml/time, 3 times/day) and vitamin D (400 units, 2 times/day) | Lumbar spine BMD | |
Chen, 2015 [ | PMOP, clinic, 53– years, 57 (KT: 27, CON: 30) | 12 | Brisk walking (15–30 minutes), resistance strength exercises (15–20 minutes), and balance and flexibility exercises (simplify tai chi and five birds, 15–20 min) + CON | Alendronate (70 mg, Qd), caltrate D (600 mg, Qd), and alfacalcidol soft capsules (0.25 | Lumbar spine and femoral neck BMD | |
Dischereit et al., 2016 [ | PMOP, unspecified, 68 years, 42(KT: 25, CON: 17) | 24 | Endurance and strength training program (3 sessions once weekly, 65 min) + CON | Adequate calcium and vitamin D supplementation and bisphosphonate therapy | Lumbar spine and femoral neck BMD | |
Li et al., 2016 [ | PMOP, unspecified, 52–76 years, 188 (KT: 94, CON: 94) | 6 | Mainly includes walking, aerobics, running, and tai chi (30–60 min/time, more than 3 times/week) + CON | Caltrate D (1000 mg, Qd), derivatives, vitamin D, and raloxifene (1 pill, Qd) | Lumbar spine and femoral neck BMD | |
Chen, 2016 [ | PMOP, unspecified, 53–77 years, 65(KT:33, CON:32) | 6 | Brisk walking and tai chi (30–50 min/time, 2-3 times/week) + CON | Alendronate (70 mg,Qd), caltrate D (600 mg, Qd), and alfacalcidol soft capsules(0.25 | Lumbar spine BMD | |
Xu, 2017 [ | PMOP, unspecified, 51–67 years, 100 (KT:50, CON:50) | 6 | Aerobics, tai chi, and jogging (more than 30 min, more than 3 times/week) + CON | Calcine D (2 times/day, 2pills/time) + estrogen (1 time/day, 60 mg/time) | Lumbar spine and femoral neck BMD | |
Chang, 2017 [ | POP, unspecified, 60–79 years, 84 (KT: 42, CON: 42) | 12 | Aerobics, walking, swimming, jogging, and cycling (3–4 times, not less than 2 times, each exercise 30–60 minutes) + CON | Calcine D 600 (1 tablet once, 2 times a day) and health education | Lumbar spine BMD | |
Qi, 2017 [ | PMOP, community healthcare center, 45–65 years, 56 (KT:28, CON:28) | 12 | Aerobic exercise resistance group, load bearing, and stretching (30 min/time, 3–5 times/week, more than 1 h) + CON | Conventional treatment | Lumbar spine BMD | |
Wen, 2017 [ | POP, unspecified, 60–78 years, 96 (KT: 48, CON: 48) | 12 | Jogging, tai chi, etc. (daily) + CON | Routine prevention and taking medicine | Lumbar spine BMD | |
Liu and Yang, 2018 [ | POP, unspecified, 36–79 years, 80 (KT: 40, CON: 40) | 6 | Walking, fitness running, ballroom dancing, and swimming (at least 12 times a month, each time ≥30 min) + CON | Calcium and vitamin D3 | Lumbar spine BMD | |
Zheng et al., 2019 [ | POP, unspecified, 53–77 years, 84 (KT: 42, CON: 42) | 12 | Walking, jogging, alternate running, cycling, etc. (3 to 4 times per week, the minimum 2 times, 30–60 min) + CON | Calcium (300 mg/tablet, 2 times/d,1 tablet/time) | Lumbar spine BMD | |
Li et al., 2019 [ | PMOP, unspecified, 50–65 years, 52 (KT: 26, CON: 26) | 3 | Brisk walking (30 min, once a day, 4d/week) and resistance training (week 1, 2 weekly complete 1 set (15 times/set), and then add 1 set every 2 weeks) + CON | Calcium carbonate D3 (600 mg, 1 time/d), alfacalcidol soft capsule (0.5 g, 1time/d), and sodium alendronate (70 mg, 1 time/d/weeks) for 3 months | Lumbar spine and femoral neck BMD | |
Yan et al., 2019 [ | POP, unspecified, 53–77 years, 52 (KT: 26, CON: 26) | 6 | Flexible resistance exercise therapy to exercise the lumbar and dorsal muscles (5 times/week) + CON | Calcium carbonate D3 (600 mg), vitamin D3 (0.25 UG), health education, and routine nursing | Lumbar spine BMD |
PMOP, postmenopausal osteoporosis; POP, primary osteoporosis; SOP, senile osteoporosis; KT, kinesitherapy group; CON, control group; BMD, bone mineral density.
As shown in Figure
Risk of bias summary for each included study.
All the controls in the literatures were kinesitherapy plus antiosteoporosis drugs versus antiosteoporosis drugs. According to the duration of the intervention, the subgroups were divided into three groups based on an intervention duration of (1) less than 6 months; (2) 6 months; and (3) longer than 6 months.
Two trials [
Kinesitherapy plus antiosteoporosis medications versus antiosteoporosis medications on lumbar spine BMD (intervention duration < 6 months).
Ten studies [
Kinesitherapy plus antiosteoporosis medications versus antiosteoporosis medications on lumbar spine BMD (intervention duration = 6 months).
Eleven studies [
Kinesitherapy plus antiosteoporosis medications versus antiosteoporosis medications on lumbar spine BMD (intervention duration > 6 months).
Five trials [
Meta-analysis of femoral neck BMD.
POP is a worldwide health problem that primarily impacts postmenopausal women and senile individuals. Moreover, POP is often related to physical frailty, an increased risk of falls, substantial morbidity, mortality, and impairment in quality of life [
A total of 21 RCTs were included in this review, which showed that kinesitherapy had a favourable effect on lumbar spine and femoral neck BMD in patients with POP. Nevertheless, the interpretation and generalization of this systematic review and meta-analysis are subject to some limitations. According to the Cochrane Collaboration’s tool, low-quality evidence, which included studies with a high risk of bias, resulted in a high heterogeneity of the meta-analysis results and favoured the positive effect of kinesitherapy on BMD in patients with POP. There were eleven RCTs that did not report the random sequence generation, and the remaining RCTs were lacking detailed descriptions of randomization, which could result in selection bias. The performance bias was high since the blinding of participants and personnel was not implemented. In all of the included trials, whether the blinding of the outcome assessment was used or not is not mentioned except for one study which states explicitly that the blinding of the outcome assessment was not applied and the statistics of outcome operated by the author. Although one trial reported reasons for withdrawal and dropout, an intention-to-treat analysis was not performed in the data analysis phase for which attrition bias was inevitable. In addition, all of the study protocols from the trials could not be obtained. Furthermore, a specific exercise was not designed for the analysis, which suggests that such an analysis is problematic due to the diversity of interventions. Only five trials included the outcome of femoral neck BMD in the currently available studies; thus, the reliability of the treatment effects of kinesitherapy on femoral neck BMD is reduced. Therefore, more multicenter, larger sample, long-term, single-blind RCTs are required to assess the effect of kinesitherapy on BMD in patients with POP.
The meta-analyses in this study suggest that kinesitherapy plus antiosteoporosis medications can significantly improve lumbar spine BMD when the duration of intervention is longer than 6 months compared with antiosteoporosis medications alone in the current low-quality evidence. More high-quality evidence in the form of multicenter, larger sample, long-term, single-blind, randomized controlled trials is required to confirm the effect of kinesitherapy on BMD in patients with POP.
The authors have no conflicts of interest to declare.
This study was supported by the Youth Program of the Department of Education, Hunan Province, China (grant no. 17B246).