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Guideline

General bone health maintenance and fracture prevention

Exercise

Exercise

Specific modalities of exercise have a preventive and therapeutic role to play in modifying both skeletal and non-skeletal risk factors for osteoporosis and osteoporotic fracture.

Progressive resistance training (also known as strength training or weightlifting) is an exercise modality in which muscles are exposed to a progressively greater load against a resistance (e.g., one’s own body weight or an external resistance such as free weights) and, in contracting to oppose this load, adapt by growing in size and strength. The muscle contractions and adaptations that occur create tension (strain) on bones that are associated with beneficial adaptations in bone density at skeletal sites attached to the trained muscle groups.

Weight-bearing impact exercises, which involve the skeleton supporting the weight of the body (‘load’) with an additional force (impact) imparted through the skeleton (e.g., jumping), are also an effective way to load and stimulate bones to maintain or increase bone density, structure, and strength.

Balance training in isolation does not improve BMD, although, if challenging, can reduce falls risk (refer also to Section 2.2). Other kinds of exercise, such as walking and non-weight-bearing activities (e.g., cycling and swimming) have minimal effects on BMD and no significant effects on falls risk in RCTs, and may increase (e.g., walking) the risk of fracture, especially in those with poor balance, frailty, and sarcopenia.

Recommendation 17

Grade

Exercises recommended to reduce fracture risk:
• Muscle resistance (strength) training should be regular (at least twice a week), moderate–vigorous and progressive.
• Weight-bearing impact exercises should be performed most days (at least 50 moderate impacts) and include moderate-to-high loads in a variety of movements in different directions.
• Balance training activities should be challenging.
Limit prolonged sitting (sedentary behaviour).

B

Recommendation 18

Grade

Exercise programs for very frail older institutionalised people and those with a high vertebral fracture risk should be supervised, modified and tailored to minimise the potential to increase the risk of falls, injury and vertebral fractures.

C

Recommendation 19

Grade

Prescribe extended and supervised exercise therapy, including targeted resistance and challenging balance training, after hip fracture to improve mobility, strength and physical performance and to reduce the risk of falls.

B

Recommendation 20

Grade

Evidence for the benefits of exercise after vertebral and non-hip fractures is limited, but suggests supervised resistance training will build bone once a fracture has healed to the same extent as in non-fractured patients. For people with a vertebral fracture, exercises to strengthen back muscles, enhance flexibility and improve posture, as well as to reduce falls risk, should be considered.

D

Moderate- to high-impact weight-bearing activities (jumping, hopping) and progressive resistance (strength) training are most effective for increasing or maintaining BMD.1–4 There is minimal evidence of benefit for low-intensity resistance or low-impact weight-bearing aerobic exercises, such as walking and cycling.4,5 High-velocity resistance training (or power training), in which the concentric (pushing) phase of the exercise for lower limb exercises is performed rapidly, has been shown to provide further benefit to BMD when added to traditional resistance training and to improve lower limb muscle power.6,7 Muscle power represents the ability of muscle to produce force quickly and this form of training can not only stimulate bone adaptation via rapid muscle contractions, but also reduce falls risk since it can improve movement speed (e.g., ability to step quickly when balance is perturbed). Moderate- to high-impact exercises, such as jumping, may be considered where the risk of fracture is low (e.g., in people without osteoporosis) and there are no contraindications (e.g., joint problems, severe balance impairment). Examples of weight-bearing impact exercises which are moderate-to-high impact that may benefit BMD and strength, include marching/stomping, stair climbing, jumping, hopping, dancing, tennis, basketball, and netball.

The dose (volume) of exercise required to elicit skeletal adaptations is specific to the modality and intensity of the exercise chosen. Short, intermittent bouts of moderate- to high- impact weight-bearing exercise (1-2 minute bouts that include 50 impacts e.g., 5 sets of 10 impacts per session) are more beneficial to increase or maintain BMD than one longer, less-intense or low-impact session.8,9 Weight-bearing impact exercises should be performed on most days of the week and include multidirectional or diverse movements to stimulate bone adaptation.9 Resistance training requires two to three sets of 8–10 repetitions at moderate to high intensity (progress to 70–85% of peak muscle strength) that include exercises targeting major muscle groups attached to the hip and spine (about eight exercises per session) and performed at least twice per week.9 Resistance training may be prescribed using machines or free weights in which the loads (weights) are increased progressively over time. This is referred to as ‘progressive overload’, a critical training principle to elicit skeletal adaptations over time. For optimal skeletal benefits, progressive resistance training should be performed in combination with moderate- to high-impact exercises.1,3,10

Exercise for preventing falls needs to include high challenging balance and functional training (e.g., exercises should be undertaken while standing and challenge balance; that is, place the person at the edge of their balance or functional ability, and incorporate activities relevant to everyday functional tasks).11,12 The greatest benefits in reducing falls risk are observed following individualised and supervised programs that include stepping and multimodal balance and functional training programs performed two to three times per week (dose of ≥3 hours per week) for at least four months.12 Examples of challenging balance exercises include standing with the feet close together, standing on one leg, tandem walking, figure-8 walking, stepping exercises, backwards or sideways walking, ‘exergames’ and tai chi. Effective programs have been designed so that older people can undertake balance training safely unsupervised at home or in centre-based classes.

Caution is advised to avoid or minimise rapid, repetitive, weighted and end-range forward flexion or twisting of the spine in those with spinal osteoporosis or a history of vertebral fractures. In people with spinal osteoporosis or a history of vertebral fractures, emphasis should be placed on exercises to strengthen back muscles (focusing on muscle endurance at a low intensity) to improve posture and support the spine. Challenging balance training should be undertaken in safe settings, initially under supervision. Important muscle groups to target include back extensors, abdominals, shoulder stabilisers, triceps, hip extensors, hip abductors, knee extensors, plantar and dorsiflexors.

The goals of exercise in the treatment of osteoporotic hip fracture focus on the modifiable, non-skeletal contributors to weakness, frailty, falls and functional dependency, including muscle strength and power, balance, gait stability, poor appetite, depression, cognitive impairment, social isolation, and polypharmacy (e.g., by substituting exercise for sedatives and antidepressants).

Evidence Statement

Specific kinds of exercise maintain BMD or reduce bone loss associated with ageing and menopause. The effects of exercise on BMD are modest and site specific.4,8 The most effective exercises include high-force, high-velocity, moderate- to high-impact, intermittent stimuli and novel directions of movement involving muscles that are attached to bones susceptible to fragility fracture (vertebrae, hip, femur, pelvic, ankle, wrist). Multimodal exercise programs that include progressive resistance training combined with moderate- to high-impact weight-bearing exercise generally provide the greatest skeletal benefit in older adults.1–4,8 Non-weight-bearing aerobic activities such as swimming and cycling may be associated with low BMD.13 Simple walking does not prevent bone loss, osteoporosis or fracture.5 In fact, walking alone has been shown to increase fracture risk in postmenopausal women and men.14,15 Lower-intensity resistance training or low-impact training is less effective for eliciting beneficial skeletal effects at the hip and spine.2

Although fracture has been the primary outcome in few exercise RCTs to date, there is evidence from several reviews and meta-analyses16–19 that exercise may reduce the risk of osteoporotic fracture, particularly if it includes resistance training or multimodal robust exercise regimens.

No exercise regimens have been shown to reduce recurrent hip fracture. There is evidence that extended exercise therapy added to usual care is safe and effective after hip fracture, and results in improved mobility, strength and physical performance.20,21 Exercise may play a role both in rehabilitation from the osteoporotic fracture itself and in the prevention of additional fractures, and is often combined with other multidisciplinary care strategies.20 High-intensity progressive resistance training, in combination with other treatments for frailty and mobility impairment, such as balance training, nutritional support and treatment for depression, has resulted in reduced nursing home admission and overall mortality in a hip fracture cohort,22 as well as improved strength, nutritional status and depressive symptoms. In contrast, various hip fracture rehabilitation strategies that included no exercise or only low-intensity exercise have had mixed or minimal impact on short- or long-term rehabilitative outcomes.23,24

Robust data on exercise after vertebral fracture are limited. A Cochrane review of nine trials in individuals with a history of vertebral fracture reported insufficient evidence to determine the effects of exercise on incident fractures, falls or adverse events, but there was some moderate-quality evidence that exercise can improve physical performance and very-low-quality evidence (data from some individual trials) reporting benefits for pain and quality of life.25 An earlier systematic review of nine trials also reported modest benefits of exercise for strength and balance without increases in pain, but no consistent or high-quality evidence for quality of life, BMD, recurrent fractures or other outcomes.24 There is some evidence that physiotherapy and exercise after upper extremity fracture may reduce pain and upper limb function,26 although few high-quality trials exist. A systematic review of 31 controlled trials of exercise after ankle fracture reported that commencing exercise after surgery in a removable brace or splint significantly improved activity limitation, but also led to a higher rate of adverse events (RR 2.61; 95% CI: 1.72–3.97), whereas most other approaches were ineffective.27

  • The most important components of the exercise prescription for the prevention of osteoporosis are moderate- to high-intensity progressive resistance training in combination with weight-bearing impact exercise and challenging balance training.
  • Exercise programs should be individualised to a person’s needs, abilities and interests. People with osteoporosis should be encouraged to ‘do more’ and not ‘less’ in terms of exercise. It is important that healthcare professionals adopt a positive and encouraging approach to exercise that does not create a sense of fear.
  • Particularly when the individual has not undertaken recent physical activity, exercise programs should commence at a low level and be continuously progressive to reach target volumes and intensities as muscle strength and function improve. A physiotherapist or exercise physiologist can assist in developing the most appropriate program, providing education on safe and effective training techniques, increasing motivation and ongoing monitoring of benefits.
  • Limiting rapid, repetitive, weighted and end-range forward flexion or twisting of the spine during daily activities and the inclusion of back extension strengthening exercises may minimise the risk of vertebral fractures, as well as exacerbation of pain from spinal osteoarthritis. In the presence of existing spinal osteoporosis or vertebral fracture, it is important to provide clear instructions and advice on safe and correct lifting techniques for day-to-day moving and when lifting, moving and transitioning in and out of exercises.
  • Avoid flexion and internal rotation movements in those with a total hip replacement.
  • Individuals with arthritis may need to modify exercises in terms of modality, intensity, range of motion or extent of weight-bearing exercise to prevent exacerbation of joint symptoms. Seated resistance training exercise is preferable to weight-bearing aerobic exercise or higher-impact activities for bone health in those with significant degenerative joint disease or instability, at least until joint and muscle health is improved or stabilised.
  • To reduce falls risk, prescribe challenging balance or multimodal programs that include resistance training prior to promotion of ambulation if gait and balance are impaired.
  • Optimise lighting, visual and hearing aids, safety of the exercise environment, climate conditions and footwear in all exercise settings and exercise at times of day when sedation from medications or fatigue are at a minimum and cognition and mood are optimal.
  1. Kemmler W, Shojaa M, Kohl M, von Stengel S. Effects of different types of exercise on bone mineral density in postmenopausal women: A systematic review and meta-analysis. Calcif Tissue Int 2020;107(5):409–39.
  2. Kistler-Fischbacher M, Weeks BK, Beck BR. The effect of exercise intensity on bone in postmenopausal women (Part 2): A meta-analysis. Bone 2021;143:115697.
  3. 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.
  4. 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;8(1):47.
  5. 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.
  6. Stengel SV, Kemmler W, Pintag R, et al. Power training is more effective than strength training for maintaining bone mineral density in postmenopausal women. J Appl Physiol (1985) 2005;99(1):181–88.
  7. Reid KF, Fielding RA. Skeletal muscle power: A critical determinant of physical functioning in older adults. Exerc Sport Sci Rev 2012;40(1):4–12.
  8. Allison SJ, Poole KE, Treece GM, et al. The influence of high-impact exercise on cortical and trabecular bone mineral content and 3D distribution across the proximal femur in older men: A randomized controlled unilateral intervention. J Bone Miner Res 2015;30(9):1709–16.
  9. Beck BR, Daly RM, Singh MA, Taaffe DR. Exercise and Sports Science Australia (ESSA) position statement on exercise prescription for the prevention and management of osteoporosis. J Sci Med Sport 2017;20(5):438–45.
  10. Zhao R, Zhang M, Zhang Q. The effectiveness of combined exercise interventions for preventing postmenopausal bone loss: A systematic review and meta-analysis. J Orthop Sports Phys Ther 2017;47(4):241–51.
  11. Sherrington C, Fairhall NJ, Wallbank GK, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev 2019;1(1):CD012424.
  12. Sherrington C, Michaleff ZA, Fairhall N, et al. Exercise to prevent falls in older adults: An updated systematic review and meta-analysis. Br J Sports Med 2017;51(24):1750–58.
  13. Abrahin O, Rodrigues RP, Marçal AC, Alves EA, Figueiredo RC, de Sousa EC. Swimming and cycling do not cause positive effects on bone mineral density: A systematic review. Rev Bras Reumatol Engl Ed 2016;56(4):345–51.
  14. Ebrahim S, Thompson PW, Baskaran V, Evans K. Randomized placebo-controlled trial of brisk walking in the prevention of postmenopausal osteoporosis. Age Ageing 1997;26(4):253–60.
  15. Nikander R, Gagnon C, Dunstan DW, et al. Frequent walking, but not total physical activity, is associated with increased fracture incidence: A 5-year follow-up of an Australian population-based prospective study (AusDiab). J Bone Miner Res 2011;26(7):1638–47.
  16. Zhao R, Bu W, Chen X. The efficacy and safety of exercise for prevention of fall-related injuries in older people with different health conditions, and differing intervention protocols: A meta-analysis of randomized controlled trials. BMC Geriatr 2019;19(1):341.
  17. Howe TE, Shea B, Dawson LJ, et al. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database Syst Rev 2011;(7):CD000333.
  18. Zhao R, Feng F, Wang X. Exercise interventions and prevention of fall-related fractures in older people: A meta-analysis of randomized controlled trials. Int J Epidemiol 2017;46(1):149–61.
  19. Kemmler W, Häberle L, von Stengel S. Effects of exercise on fracture reduction in older adults: A systematic review and meta-analysis. Osteoporos Int 2013;24(7):1937–50.
  20. Auais MA, Eilayyan O, Mayo NE. Extended exercise rehabilitation after hip fracture improves patients’ physical function: A systematic review and meta-analysis. Phys Ther 2012;92(11):1437–51.
  21. Chudyk AM, Jutai JW, Petrella RJ, Speechley M. Systematic review of hip fracture rehabilitation practices in the elderly. Arch Phys Med Rehabil 2009;90(2):246–62.
  22. Singh NA, Quine S, Clemson LM, et al. Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: A randomized controlled trial. J Am Med Dir Assoc 2012;13(1):24–30.
  23. Sherrington C, Tiedemann A, Cameron I. Physical exercise after hip fracture: An evidence overview. Eur J Phys Rehabil Med 2011;47(2):297–307.
  24. Dusdal K, Grundmanis J, Luttin K, et al. Effects of therapeutic exercise for persons with osteoporotic vertebral fractures: A systematic review. Osteoporos Int 2011;22(3):755–69.
  25. Gibbs JC, MacIntyre NJ, Ponzano M, et al. Exercise for improving outcomes after osteoporotic vertebral fracture. Cochrane Database Syst Rev 2019;7(7):CD008618.
  26. Bruder A, Taylor NF, Dodd KJ, Shields N. Exercise reduces impairment and improves activity in people after some upper limb fractures: A systematic review. J Physiother 2011;57(2):71–82.
  27. Lin CW, Moseley AM, Refshauge KM. Effects of rehabilitation after ankle fracture: A Cochrane systematic review. Eur J Phys Rehabil Med 2009;45(3):431–41.
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