Specific kinds of exercise reduce bone loss associated with ageing and menopause. Exercise effects are modest and site-specific.2 The most effective exercises include high-force, high-velocity, 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). Progressive resistance training alone or combined with high impact weight-bearing exercise generally provide the greatest benefit in older adults.3,4 Non–weight-bearing aerobic activities such as swimming and cycling may be associated with low BMD.5 Simple walking does not prevent osteoporosis or fracture. Walking alone has in fact been shown to increase upper extremity fracture incidence in one study of postmenopausal women.6 Low intensity resistance training also has no significant effect on BMD.4
Although fracture has been the primary outcome in only one RCT to date, there is evidence from three meta-analyses4,7,8 that exercise may reduce the risk of osteoporotic fracture if it includes resistance training or multimodal robust exercise regimens (lower-extremity strength training, high-impact exercises, and weightbearing aerobic exercises).
No exercise regimens have yet 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.9,10 Exercise may play a role in both the rehabilitation from the osteoporotic fracture itself as well as the prevention of additional fractures, and is often combined with other multidisciplinary care strategies.9 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,11 as well as improved strength, nutritional status and depressive symptoms. By contrast, various hip-fracture rehabilitation strategies which included no exercise or only low-intensity exercise have had mixed or minimal impact on short- or long-term rehabilitative outcomes.12,13
Robust data on exercise after vertebral fracture are very limited. One systematic review of nine trials has 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.14 Physiotherapy or exercises for upper-extremity fractures have shown little benefit for clinical outcomes such a pain, range of motion or strength,15 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 (relative risk [RR]: 2.61, 95% confidence interval [CI]: 1.72–3.97), while most other approaches were ineffective.16