Physical exercise is considered an effective means to stimulate bone osteogenesis in osteoporotic patients. The authors reviewed the current literature to define the most appropriate features of exercise for increasing bone density in osteoporotic patients. Two types emerged: (1)
According to the literature, the level of bone loss in a postmenopausal woman increases with age, respectively, with a loss of 0.6%, 1.1%, and 2.1% per year for the 60-69, 70-79, and> 80 age groups [
Therefore, there is considerable interest in defining the adequate dosage and characteristics of exercises to improve bone strength in osteoporosis, in order to develop appropriate guidelines, given the fact that economic and social costs appear to be in a progressive and constant growth in relation to the aging of the population [
In the past years, many studies [
However, it is still not clear which exercise is the best suited and how long it would take to obtain an appropriate result. For example, the SIOMMS guidelines [
The effects of exercise on bone tissue have gained an important contribution also from studies on sport athletes. Numerous publications have linked physical exercise, bone metabolism markers, and bone mineral density [
In clinical practice, however, the prescription of exercise in the elderly and osteoporotic patient must always be preceded by a careful evaluation: indeed, it is essential to define the type, intensity, and duration of a proposed program. The decision is based on the subject’s muscle strength, range of motion, balance, gait, cardiopulmonary function, comorbidities, bone density, and history of previous fractures, as well as the risk of falling [
Regarding aquatic exercise, a recent systematic review supports the evidence of a trend
Main search engines (PubMed, Cochrane Library, and Pedro) were explored using the keywords: exercise AND osteoporosis in title, resistance exercise AND osteoporosis, weight bearing exercise AND osteoporosis, vibration AND osteoporosis. The following filters were applied: articles in English language on humans aged 65 and over. The research took into account the existing systematic reviews and meta-analyses, focusing also on the individual articles included in the reviews. A subsequent selection regarding only exercise and primary osteoporosis, based on the titles and abstracts analysis of the articles, was performed.
Several critical issues in the evaluation of evidence, limiting in some way the conclusion of this review, were highlighted in the Cochrane reviews [
With regard to the
Forty-four systematic reviews were retrieved in PubMed using the keywords “exercise AND osteoporosis”, 15 using the keywords “resistance exercise AND osteoporosis”, 8 with “weight bearing exercise AND osteoporosis”, and 9 using “vibration AND osteoporosis”. Thirty-three systematic reviews were retrieved from Pedro and 1 Cochrane review from Cochran Library using the keywords “exercise AND osteoporosis”. Of these, once eliminated duplicates and papers not primarily focused on exercise and osteoporosis, 18 systematic reviews and meta-analyses were considered with respect to different type of exercise (Table
Systematic reviews and meta-analyses on Exercise and Osteoporosis.
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Gómez-Cabello A, Ara I, González-Agüero A, Casajús JA, Vicente-Rodríguez G. Effects of training on bone mass in older adults: a systematic review. Sports Med. 2012;1;42(4):301-25.[ | Walking provides a modest increase in the loads on the skeleton above gravity and, therefore, this type of exercise has proved to be less effective in osteoporosis prevention. Strength exercise seems to be a powerful stimulus to improve and maintain bone mass during the ageing process. Multi-component exercise programmes of strength, aerobic, high impact and/or weight-bearing training, as well as whole-body vibration (WBV) alone or in combination with exercise, may help to increase or at least prevent decline in bone mass with ageing, especially in postmenopausal women. |
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Nikander R, Sievänen H, Heinonen A, Daly RM, Uusi-Rasi K, Kannus P. Targeted exercise against osteoporosis: A systematic review and meta-analysis for optimising bone strength throughout life. BMC Med. 2010 Jul 21;8:47. [ | Epidemiological evidence suggests that moderate to vigorous physical activity performed three to four times per week is associated with considerably lower incidence of fragility fractures in both women and men. The findings from these studies also suggest that exercise regimens that include moderate- to high-magnitude impacts from varying loading directions may represent the optimal mode to enhance bone structure and strength. |
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Zehnacker CH, Bemis-Dougherty A. Effect of weighted exercises on bone mineral density in post-menopausal women. A systematic review. J Geriatr Phys Ther. 2007;30(2):79-88. [ | Weighted exercises can help in maintaining BMD in postmenopausal women and increasing BMD of the spine and hip in women with osteopenia and osteoporosis. The exercise program must be incorporated into a lifestyle change and be lifelong due to the chronic nature of bone loss in older women. |
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McMahon M. What impact does aquatic therapy have on bone density in postmenopausal women? If it has a positive or maintenance effect, what are the programme parameters that facilitate these outcomes? Aqualines 2017;29(1):8-21.[ | The majority of the studies reviewed support a trend showing that exercising in water can be useful in at least maintaining, or improving, various measures of bone mineral density (BMD). |
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Howe T, Shea B, Dawson LJ, Downie F, Murray A, Ross C, Harbour RT, Caldwell LM, Creed G. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database Syst Rev. 2011 Jul 6;(7):CD000333. [ | The most effective type of exercise intervention on bone mineral density (BMD) for the neck of femur appears to be non-weight bearing high force exercise such as progressive resistance strength training for the lower limbs. The most effective intervention for BMD at the spine was combination exercise programmes compared with control groups. Our results suggest a relatively small statistically significant, but possibly important, effect of exercise on bone density compared with control groups. |
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Polidoulis I, Beyene J, Cheung AM. The effect of exercise on pQCT parameters of bone structure and strength in postmenopausal women -- a systematic review and meta-analysis of randomized controlled trials. Osteoporos Int. 2012;23(1):39-51. [ | We conclude that exercise in postmenopausal women may decrease bone loss by maintaining cortical and trabecular volumetric BMD. |
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Martyn-St James M1, Carroll S. Meta-analysis of walking for preservation of bone mineral density in postmenopausal women. Plos one. 2008;43(3):521-31. [ | We conclude that regular walking has no significant effect on preservation of BMD at the spine in postmenopausal women, whilst significant positive effects at femoral neck are evident. However, diverse methodological and reporting discrepancies are apparent in the published trials on which these conclusions are based. Other forms of exercise that provide greater targeted skeletal loading may be required to preserve bone mineral density in this population. |
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Ma D, Wu L, He Z. Effects of walking on the preservation of bone mineral density in perimenopausal and postmenopausal women: a systematic review and meta-analysis. Menopause. 2013;20(11):1216-26. [ | Walking as a singular exercise therapy has no significant effects on BMD at the lumbar spine, at the radius, or for the whole body in perimenopausal and postmenopausal women, although significant and positive effects on femoral neck BMD in this population are evident with interventions more than 6 months in duration. |
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Bolam KA, van Uffelen JG, Taaffe DR. The effect of physical exercise on bone density in middle-aged and older men: a systematic review. Osteop Int. 2013;24(11):2749-62. [ | Regular resistance training and impact-loading activities should be considered as a strategy to prevent osteoporosis in middle-aged and older men. |
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Kelley GA, Kelley KS, Kohrt WM. Effects of ground and joint reaction force exercise on lumbar spine and femoral neck bone mineral density in postmenopausal women: a meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2012; 20;13:177. [ | The overall findings suggest that exercise may result in clinically relevant benefits to FN and LS BMD in postmenopausal women. |
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Chow TH, Lee BY, Ang ABF, Cheung VYK, Ho MMC, Takemura S. The effect of Chinese martial arts Tai Chi Chuan on prevention of osteoporosis: A systematic review. J Orthop Translat. 2017; 26;12:74-84. [ | TCC is beneficial to BMD and may be a cost-effective and preventive measure of osteoporosis. This beneficial effect is better observed in long-term TCC practice. |
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Sun Z, Chen H, Berger MR, Zhang L, Guo H, Huang Y. Effects of tai chi exercise on bone health in perimenopausal and postmenopausal women: a systematic review and meta-analysis. Osteoporos Int. 2016 Oct;27(10):2901-11. [ | Tai chi exercise may have benefits on bone health in perimenopausal and postmenopausal women, but the evidence is sometimes weak, poor, and inconsistent. |
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de Kam D, Smulders E, Weerdesteyn V, Smits-Engelsman BC. Exercise interventions to reduce fall-related fractures and their risk factors in individuals with low bone density: a systematic review of randomized controlled trials. Osteoporos Int. 2009;20(12):2111-25. [ | Exercise interventions for patients with osteoporosis should include weight-bearing activities, balance exercise, and strengthening exercises to reduce fall and fracture risk. |
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Martyn-St James M, Carroll S. A meta-analysis of impact exercise on postmenopausal bone loss: the case for mixed loading exercise programmes. Br J Sports Med. 2009; 43(12):898-908. [ | Mixed loading exercise programmes combining jogging with other low-impact loading activity and programmes mixing impact activity with high-magnitude exercise as resistance training appear effective in reducing postmenopausal bone loss at the hip and spine. Other forms of impact exercise appear less effective at preserving BMD in this population. However, diverse methodological and reporting discrepancies are evident in current published trials. |
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Varahra A, Rodrigues IB, MacDermid JC, Bryant D, Birmingham T. Exercise to improve functional outcomes in persons with osteoporosis: a systematic review and meta-analysis. Osteoporos Int. 2018;29(2):265-286. [ | A multicomponent exercise program of high-speed training combined with simulated functional tasks is promising to enhance functional outcomes. Due to substantial clinical heterogeneity of the target groups and specific demands of exercise modes, it is unclear which exercise program is optimal. |
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Zhao R, Zhao M, Xu Z. The effects of differing resistance training modes on the preservation of bone mineral density in postmenopausal women: a meta-analysis. Osteoporos Int. 2015; 26(5):1605-18. [ | Combined resistance exercise protocols appear effective in preserving femoral neck and lumbar spine BMD in postmenopausal women, whereas resistance-alone protocols only produced a nonsignificant positive effect. |
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Martyn-St James M, Carroll S. Effects of different impact exercise modalities on bone mineral density in premenopausal women: a meta-analysis. J Bone Miner Metab. 2010;28(3):251-67.[ | Exercise programmes that combine odd- or high-impact activity with high-magnitude resistance training appear effective in augmenting BMD in premenopausal women at the hip and spine. High-impact-alone protocols are effective only on hip BMD in this group. However, diverse methodological and reporting discrepancies are evident in published trials. |
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Xu J, Lombardi G, Jiao W, Banfi G. Effects of Exercise on Bone Status in Female Subjects, from Young Girls to Postmenopausal Women: An Overview of Systematic Reviews and Meta-Analyses. Sports Med. 2016;46(8):1165-82. [ | Combined-impact exercise protocols (impact exercise with resistance training) are the best choice to preserve/improve bone mineral density in pre- and postmenopausal women. Whole-body vibration exercises have no beneficial effects on bone in postmenopausal or elderly women. |
Systematic reviews and meta-analyses on Whole Body Vibration.
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Slatkovska L, Alibhai SM, Beyene J, Cheung AM. Effect of whole-body vibration on BMD: a systematic review and meta-analysis. Osteoporos Int. 2010;21(12):1969-80.[ | We found significant but small improvements in BMD in postmenopausal women and children and adolescents, but not in young adults. |
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Ma C, Liu A, Sun M, Zhu H, Wu H.Effect of whole-body vibration on reduction of bone loss and fall prevention in postmenopausal women: a meta-analysis and systematic review. J Orthop Surg Res. 2016; 17;11:24. [ | Low-magnitude whole-body vibration therapy can provide a significant improvement in reducing bone loss in the lumbar spine in postmenopausal women. |
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Merriman H, Jackson K. The effects of whole-body vibration training in aging adults: a systematic review. J Geriatr Phys Ther. 2009;32(3):134-45. [ | Some but not all of the studies in this review reported similar improvements in muscle performance, balance, and functional mobility with WBV as compared to traditional exercise programs. Bone studies consistently showed that WBV improved bone density in the hip and tibia but not in the lumbar spine. |
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Oliveira LC, Oliveira RG, Pires-Oliveira DA. Effects of whole body vibration on bone mineral density in postmenopausal women: a systematic review and meta-analysis. Osteoporos Int. 2016;27(10):2913-33. [ | Despite WBV presenting potential to act as a coadjutant in the prevention or treatment of osteoporosis, especially for BMD of the lumbar spine, the ideal intervention is not yet clear. Our subgroup analyses helped to demonstrate the various factors which appear to influence the effects of WBV on BMD, contributing to clinical practice and the definition of protocols for future interventions. |
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Fratini A, Bonci T, Bull AM. Whole Body Vibration Treatments in Postmenopausal Women Can Improve Bone Mineral Density: Results of a Stimulus Focussed Meta-Analysis. PLoS One. 2016;11(12):e0166774. [ | Whole body vibration treatments in elderly women can reduce BMD decline. However, many factors (e.g., amplitude, frequency and subject posture) affect the capacity of the vibrations to propagate to the target site; the adequate level of stimulation required to produce these effects has not yet been defined. |
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Lau RW, Liao LR, Yu F, Teo T, Chung RC, Pang MY. The effects of whole body vibration therapy on bone mineral density and leg muscle strength in older adults: a systematic review and meta-analysis. Clin Rehab. 2011;25(11):975-88.[ | Whole body vibration is beneficial for enhancing leg muscle strength among older adults. However, the review suggests that whole body vibration has no overall treatment effect on bone mineral density in older women. |
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Jepsen DB, Thomsen K, Hansen S, Jørgensen NR, Masud T, Ryg J. Effect of whole-body vibration exercise in preventing falls and fractures: a systematic review and meta-analysis. BMJ Open. 2017; 29;7(12):e018342. [ | Whole body vibration reduces fall rate but seems to have no overall effect on BMD or microarchitecture. |
One of the most common forms of aerobic training is walking, an exercise very well accepted by the older people, because it is harmless, self-managed, and easily practicable. The effects of
Furthermore, it is important to consider some parameters that can influence the effects of walking, such as walking speedily/slowly or strongly/weekly. Actually, there is evidence that an intervention of more than 6 months in duration can provide significant and positive effects on femoral neck BMD in peri- and postmenopausal women [
Some studies show how a brisk walking or jogging can have positive effects on hip and column BMD in women of menopausal age [
In comparing different types of physical exercises with controls, Howe [
Regarding Tai Chi, the issue is in increasing debate; recent literature [
Strength and resistance training are the most studied techniques to increase bone mass in the elderly. The rationale of these exercises lies in the mechanical stimulus indirectly produced on the bone [
Studies have examined the effect of strengthening the muscles of the upper limb and lower limb, rather than specific groups such as iliopsoas and spinal extensors. From the evidence gathered by Zehnacker et al. [
In relation to the hip, the exercise is effective on the greater trochanter if it involves the buttocks, on the lesser trochanter if it involves the iliopsoas, and on the Ward’s triangle if it involves the adductors and the hip extensors, according to the studies of Kerr et al. [
Similarly, Sinaki et al. [
In opposite opinion are Bemben et al. [
The multicomponent training consists of a combination of different exercises (aerobics, strengthening, progressive resistance, balancing, and dancing) and it is aimed at increasing or preserving bone mass. This implies that the same interventions are provided to all people, differently from multifactorial training, customized on the individual characteristics [
The association of several types of exercise is advised to the patients affected by osteoporosis with the goal to counter the reduction of bone mass [
However, diverse methodological and reporting discrepancies with respect to the proposed mix of exercises, the characteristics of patients with or without fractures, and the outcome measures seem relevant in determining the result of the exercise program. The revision of Gomez-Cabello et al. [
It is interesting to note from this review how the most challenging high impact exercise programs, such as jumping, are only effective when they are associated with other low-impact exercises. Bolan at al. [
Giangregorio et al. [
Xu et al. [
Also, in the review of studies analyzed by Marquez et al. [
The vibration of the entire body is a physiotherapy intervention based on the use of a high frequency mechanical stimulus generated by a vibrating platform (Whole Body Vibration or WBV) that activates the mechanoreceptors of the bone favoring osteogenesis. The results of the studies included in two systematic reviews [
To obtain these results, Dionello et al. [
Fratini et al. [
Conversely, a previous systematic review [
Although several exercise recommendations for individuals with osteoporosis have been proposed, reviews are often inconclusive, for the methodological variability emerging from the studies.
However, results from the Cochrane review [
The authors declare that they have no conflicts of interest.
This study was supported by the Erasmus Project “ACTLIFE-Physical activity the tool to improve the quality of life in osteoporosis people,” Grant Agreement n. 2017 – 2128 / 001 – 001.