Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age

Recommendations

Exercise

Evidence statement

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

Grade: A

Recommendation 11
Individuals over 50 years of age without osteoporosis should participate regularly in progressive resistance training and balance training exercises. Resistance exercise should be regular (2–3 days per week), moderate–vigorous, progressive and varied to influence BMD and reduce fall and fracture risk.

Grade: A

Recommendation 12
Prescribe high-intensity progressive resistance and balance training to older adults with osteoporosis to prevent further bone loss and/or improve BMD, improve function, treat sarcopenia and decrease fall and fracture risk.

Grade: A

Recommendation 13
Prescribe extended exercise therapy, including resistance and balance training, after hip fracture to improve mobility, strength and physical performance. Evidence for the benefits of exercise after vertebral and non-hip fractures is limited.

Specific modalities of exercise have a preventive and therapeutic role to play in both skeletal and non-skeletal risk factors for osteoporosis and osteoporotic fracture. Resistance training (also known as strength training or weight lifting) is an exercise modality in which muscles are exposed to an uncustomary load, and in contracting to oppose this load grow in size and strength. This adaptation in muscle is associated with concomitant beneficial adaptations in bone structure, density and fracture resistance in skeletal sites attached to the trained muscle groups.

Balance training in isolation does not improve bone mineral density (BMD), although it reduces falls risk (see the section ‘Reducing the risk of falls’ earlier). Other kinds of exercise such as walking have minimal and inconsistent effects on BMD and no significant effects on falls risk in randomised controlled trials (RCTs), and may increase risk of fracture in those with poor balance and sarcopenia.

High-impact activities (jumping, skipping rope) and strength training are most effective for increasing BMD, and there is minimal evidence of benefit for low-impact weight-bearing aerobic exercises. High-velocity resistance training (power training) has been shown to provide further benefit when added to slow-velocity resistance training for BMD and muscle power. High-impact exercises such as jumping may be considered where the risk of fracture is thought to be low and there are no other contraindications (eg joint problems, severe balance impairment). Examples of weight-bearing aerobic exercises which are moderate-to-high impact that may benefit BMD and strength include jogging, tennis, volleyball, stair climbing and step aerobics.

Two short, intense exercise sessions separated by eight hours are better than one longer, less-intense session. The volume of exercise required is specific to the modality and intensity of the exercise chosen, and in general, is inversely proportional to the intensity of the exercise. Resistance training requires about three sets of eight repetitions at high intensity (approximately 80% of peak strength) for eight muscle groups for improvements in BMD (about 30 minutes per session, 2–3 days per week). Resistance training may be prescribed using machines or free weights that are increased over time as strength improves so that the desired intensity is maintained. High-impact exercise requires as little as 10 jumps, five days per week (1–2 minutes of exercise) alone or preferably integrated into other exercise regimens. In postmenopausal women, it is only effective when combined with resistance training and other activities.

Exercise for preventing falls needs to include medium-intensity to high-intensity balance training (ie exercises must be undertaken while standing and challenge balance), and be undertaken at a reasonable frequency and duration (ie for one hour, two times per week for six months).1 Examples of medium-to-high-intensity balance exercises include standing with feet close together, standing on one leg, tandem walking, stepping exercises, backward walking, ‘exer-games’ 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 regarding forward flexion and loading of the spine in those with spinal osteoporosis. Balance training should be undertaken in safe settings under supervision initially. Important muscle groups include back extensors, triceps, hip extensors, hip abductors, knee extensors, plantars and dorsiflexors.

The goals of exercise in the treatment of osteoporotic hip fracture should be focused on the modifiable, nonskeletal 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 (eg by substituting exercise for sedatives and antidepressants).

  • The most important components of the exercise prescription are high-intensity resistance training and progressive balance training.
  • Exercise programs should be individualised to the person’s needs, abilities and interests.
  • 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 fitness improves. 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.
  • Avoidance of back-flexion exercises or flexed postures during daily activities and inclusion of back extension exercises may minimise the risk of vertebral fractures as well as exacerbation of pain from osteoarthritis in the spine. In the presence of existing spinal osteoporosis or vertebral fracture, avoid forward flexion and twisting movements involving the spine and stooped postures during sitting and activities of daily living (eg bowling, golf, gardening, vacuuming, picking up objects).
  • 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 balance and resistance training prior to promotion of ambulation if gait and balance are impaired.
  • Optimise lighting, visual and hearing aids, safety of 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. Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close JC. Effective exercise for the prevention of falls: A systematic review and meta-analysis. J Am Geriatr Soc 2008;56(12):2234–43.
  2. Nikander R, Sievanen 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;8:47.
  3. 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.
  4. Howe TE, Shea B, Dawson LJ, et al. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database Syst Rev 2011;7:CD000333.
  5. Nagle KB, Brooks MA. A systematic review of bone health in cyclists. Sports Health 2011;3(3):235–43.
  6. Ebrahim S, Thompson P, Baskaran V, Evans K. Randomized placebo-controlled trial of brisk walking in the prevention of postmenopausal osteoporosis. Age Ageing 1997;26(4):253–60.
  7. Kemmler W, Haberle L, von Stengel S. Effects of exercise on fracture reduction in older adults: A systematic review and metaanalysis. Osteoporos Int 2013;24(7):1937–50.
  8. 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 2016:1–13.
  9. 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.
  10. 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.
  11. 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.
  12. Rajashulakshana R, Haslinda B, Maria A, Nazri J, Nur Raudhah A. Does orthogeriatric model of care improve the outcome of patients with hip fractures? A systematic review. Singhealth Proceedings 2010;19 Suppl 2:S321.
  13. Sherrington C, Tiedemann A, Cameron ID. Physical exercise after hip fracture: An evidence overview. Eur J Phys Rehab Med 2011;47(2):297–307.
  14. 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.
  15. Bruder A, Taylor N, Dodd KJ, Shields N. Physiotherapy for the rehabilitation of upper limb fractures in adults: A systematic review and meta-analysis. Physiotherapy (United Kingdom) 2011:eS163.
  16. 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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