Exercise for preventing and treating osteoporosis in ... · Exercise for preventing and treating...

Exercise for preventing and treating osteoporosis in

postmenopausal women (Review)

Howe TE, Shea B, Dawson LJ, Downie F, Murray A, Ross C, Harbour RT, Caldwell LM,

Creed G

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2011, Issue 7

http://www.thecochranelibrary.com

Exercise for preventing and treating osteoporosis in postmenopausal women (Review)

Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . .

6BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

18DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

26CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

88DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 1.1. Comparison 1 Any exercise versus control, Outcome 1 Total number of fractures. . . . . . . . . 95

Analysis 1.2. Comparison 1 Any exercise versus control, Outcome 2 Bone mineral density % change: spine. . . . 96

Analysis 1.3. Comparison 1 Any exercise versus control, Outcome 3 Bone mineral density % change: femoral neck. . 97

Analysis 1.4. Comparison 1 Any exercise versus control, Outcome 4 Bone mineral density % change: Ward’s triangle. 98

Analysis 1.5. Comparison 1 Any exercise versus control, Outcome 5 Bone mineral density % change: hip. . . . . 99

Analysis 1.6. Comparison 1 Any exercise versus control, Outcome 6 Bone mineral density % change: trochanter. . . 100

Analysis 1.7. Comparison 1 Any exercise versus control, Outcome 7 Bone mineral content % change: spine. . . . 101

Analysis 1.8. Comparison 1 Any exercise versus control, Outcome 8 Bone mineral content % change: femoral neck. . 102

Analysis 2.1. Comparison 2 Static weight bearing exercise versus control, Outcome 1 Bone mineral density % change:

hip. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

Analysis 3.1. Comparison 3 Dynamic weight bearing exercise low force versus control, Outcome 1 Bone mineral density %

change: spine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103


change: femoral neck. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104


change: trochanter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104


change: Ward’s triangle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105


change: wrist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

Analysis 3.6. Comparison 3 Dynamic weight bearing exercise low force versus control, Outcome 6 Bone mineral density

mean regression slope % change: wrist. . . . . . . . . . . . . . . . . . . . . . . . . . 106

Analysis 3.7. Comparison 3 Dynamic weight bearing exercise low force versus control, Outcome 7 Fractures. . . . 107

Analysis 4.1. Comparison 4 Dynamic weight bearing exercise high force versus control, Outcome 1 Bone mineral density

% change: spine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108


% change: hip. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109


% change: mid femur. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109


% change: proximal tibia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

Analysis 4.5. Comparison 4 Dynamic weight bearing exercise high force versus control, Outcome 5 Calcium bone index %

change: trunk and upper thighs. . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

iExercise for preventing and treating osteoporosis in postmenopausal women (Review)



% change: trochanter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111


% change: femoral neck. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Analysis 4.8. Comparison 4 Dynamic weight bearing exercise high force versus control, Outcome 8 Bone mineral content

% change: spine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

Analysis 4.9. Comparison 4 Dynamic weight bearing exercise high force versus control, Outcome 9 Bone mineral content

% change: femoral neck. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Analysis 4.10. Comparison 4 Dynamic weight bearing exercise high force versus control, Outcome 10 Bone mineral

content % change: wrist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114


content % change: ankle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114


content % change: tibia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115


% change: total body. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

Analysis 4.14. Comparison 4 Dynamic weight bearing exercise high force versus control, Outcome 14 Volumetric bone

density % change: tibial trabecular. . . . . . . . . . . . . . . . . . . . . . . . . . . 116

Analysis 4.15. Comparison 4 Dynamic weight bearing exercise high force versus control, Outcome 15 Volumetric bone

density % change: tibial cortical. . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

Analysis 4.16. Comparison 4 Dynamic weight bearing exercise high force versus control, Outcome 16 Fractures. . . 117

Analysis 5.1. Comparison 5 Non-weight bearing exercise low force versus control, Outcome 1 Bone mineral density %

change: spine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117


change: total hip. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118








change: total body. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

Analysis 6.1. Comparison 6 Non-weight bearing exercise high force versus control, Outcome 1 Bone mineral density %

change: spine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121


change: total hip. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122








change: total body. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

Analysis 7.1. Comparison 7 Combination versus control, Outcome 1 Bone mineral density % change: spine. . . . 126

Analysis 7.2. Comparison 7 Combination versus control, Outcome 2 Bone mineral density % change: total hip. . . 127

Analysis 7.3. Comparison 7 Combination versus control, Outcome 3 Bone mineral density % change: trochanter. . 128

Analysis 7.4. Comparison 7 Combination versus control, Outcome 4 Bone mineral density % change: total body. . 129

Analysis 7.5. Comparison 7 Combination versus control, Outcome 5 Calcium bone index % change: trunk and upper

thighs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

Analysis 7.6. Comparison 7 Combination versus control, Outcome 6 Bone mineral density % change: neck of femur. 130

Analysis 7.7. Comparison 7 Combination versus control, Outcome 7 Bone mineral density % change: Ward’s triangle. 131

iiExercise for preventing and treating osteoporosis in postmenopausal women (Review)


Analysis 7.8. Comparison 7 Combination versus control, Outcome 8 Bone mineral density % change: arms. . . . 132

Analysis 7.9. Comparison 7 Combination versus control, Outcome 9 Fractures. . . . . . . . . . . . . . 132

Analysis 8.1. Comparison 8 Dynamic weight bearing exercise high force plus HRT versus HRT, Outcome 1 Bone mineral

density % change: proximal tibia. . . . . . . . . . . . . . . . . . . . . . . . . . . . 133


density % change: hip. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133


density % change: mid femur. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134


density % change: spine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134


density % change: trochanter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135


density % change: femoral neck. . . . . . . . . . . . . . . . . . . . . . . . . . . . 135


density % change: total body. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136

Analysis 9.1. Comparison 9 Non-weight bearing exercise high force plus bisphosphonates versus bisphosphonates, Outcome

1 Bone mineral density % change: spine. . . . . . . . . . . . . . . . . . . . . . . . . 136


2 Bone mineral density % change: hip. . . . . . . . . . . . . . . . . . . . . . . . . . 137


3 Bone mineral density % change: femoral neck. . . . . . . . . . . . . . . . . . . . . . . 137


4 Bone mineral density % change: trochanter. . . . . . . . . . . . . . . . . . . . . . . . 138


5 Bone mineral density % change: Ward’s triangle. . . . . . . . . . . . . . . . . . . . . . 138


6 Bone mineral density % change: total body. . . . . . . . . . . . . . . . . . . . . . . . 139


7 Bone mineral content % change: total body. . . . . . . . . . . . . . . . . . . . . . . 139

Analysis 10.1. Comparison 10 Dynamic weight bearing exercise high force plus bisphosphonates versus bisphosphonates,

Outcome 1 Bone mineral content % change: spine. . . . . . . . . . . . . . . . . . . . . . 140


Outcome 2 Bone mineral content % change: femoral neck. . . . . . . . . . . . . . . . . . . 141


Outcome 3 Bone mineral content % change: wrist. . . . . . . . . . . . . . . . . . . . . . 142


Outcome 4 Bone mineral content % change: distal tibia. . . . . . . . . . . . . . . . . . . . 142


Outcome 5 Bone mineral content % change: tibial shaft. . . . . . . . . . . . . . . . . . . . 143

Analysis 11.1. Comparison 11 Non-weight bearing exercise high force plus antioxidants versus antioxidants, Outcome 1

Bone mineral density % change: spine. . . . . . . . . . . . . . . . . . . . . . . . . . 143

Analysis 11.2. Comparison 11 Non-weight bearing exercise high force plus antioxidants versus antioxidants, Outcome 2

Bone mineral density % change: femoral neck. . . . . . . . . . . . . . . . . . . . . . . 144

Analysis 12.1. Comparison 12 Dynamic weight bearing exercise low force plus Ca2+ versus Ca2+, Outcome 1 Bone mineral

density % change: femoral neck. . . . . . . . . . . . . . . . . . . . . . . . . . . . 144


density % change: spine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145


density % change: trochanter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145


density % change: distal tibia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

iiiExercise for preventing and treating osteoporosis in postmenopausal women (Review)



density % change: Ward’s triangle. . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

Analysis 13.1. Comparison 13 Non-weight bearing exercise low force plus calcium versus calcium, Outcome 1 Bone

mineral density % change: spine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 147


mineral density % change: total hip. . . . . . . . . . . . . . . . . . . . . . . . . . . 147


mineral density % change: femoral neck. . . . . . . . . . . . . . . . . . . . . . . . . 148


mineral density % change: trochanter. . . . . . . . . . . . . . . . . . . . . . . . . . 148


mineral density % change: total body. . . . . . . . . . . . . . . . . . . . . . . . . . 149

Analysis 14.1. Comparison 14 Non-weight bearing exercise high force plus calcium versus calcium, Outcome 1 Bone

mineral density % change: femoral neck. . . . . . . . . . . . . . . . . . . . . . . . . 149


mineral density % change: trochanter. . . . . . . . . . . . . . . . . . . . . . . . . . 150


mineral density % change: total hip. . . . . . . . . . . . . . . . . . . . . . . . . . . 150


mineral density % change: spine. . . . . . . . . . . . . . . . . . . . . . . . . . . . 151


mineral density % change: total body. . . . . . . . . . . . . . . . . . . . . . . . . . 151

Analysis 15.1. Comparison 15 Dynamic weight bearing exercise low force plus calcium/VitD versus calcium/VitD,

Outcome 1 Bone mineral density % change: spine. . . . . . . . . . . . . . . . . . . . . . 152

Analysis 15.2. Comparison 15 Dynamic weight bearing exercise low force plus calcium/VitD versus calcium/VitD,

Outcome 2 Bone mineral density % change:wrist. . . . . . . . . . . . . . . . . . . . . . 152

152APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

158WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

158HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

159CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

159DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

159SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

160INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ivExercise for preventing and treating osteoporosis in postmenopausal women (Review)


[Intervention Review]

Exercise for preventing and treating osteoporosis inpostmenopausal women

Tracey E Howe1, Beverley Shea2, Lesley J Dawson3 , Fiona Downie3 , Ann Murray4, Craig Ross5, Robin T Harbour6 , Lynn M Caldwell7, Gisela Creed8

1School of Health & Life Sciences, Glasgow Caledonian University, Glasgow, UK. 2CIET, Institute of Population Health, University

of Ottawa, Ottawa, Canada. 3Department of Physiotherapy, NHS Forth Valley, Stirling, UK. 4NHS Ayrshire and Arran, Kilmarnock,

UK. 5Physiotherapy Service for Osteoporosis, NHS Greater Glasgow & Clyde, Glasgow, UK. 6Scottish Intercollegiate Guidelines

network (SIGN), Edinburgh, UK. 7Knowledge Services Group, NHS Education for Scotland, Glasgow, UK. 8Academic Department

of Geriatric Medicine, Glasgow University, Glasgow, UK

Contact address: Tracey E Howe, School of Health & Life Sciences, Glasgow Caledonian University, Scottish Centre for Evidence

Based Care of Older People, Glasgow, Scotland, G4 0BA, UK. [email protected].

Editorial group: Cochrane Musculoskeletal Group.

Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 7, 2011.

Review content assessed as up-to-date: 2 January 2011.

Citation: Howe TE, 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 of Systematic Reviews 2011, Issue 7. Art. No.: CD000333.

DOI: 10.1002/14651858.CD000333.pub2.


A B S T R A C T

Background

Osteoporosis is a condition resulting in an increased risk of skeletal fractures due to a reduction in the density of bone tissue. Treatment

of osteoporosis typically involves the use of pharmacological agents. In general it is thought that disuse (prolonged periods of inactivity)

and unloading of the skeleton promotes reduced bone mass, whereas mechanical loading through exercise increases bone mass.

Objectives

To examine the effectiveness of exercise interventions in preventing bone loss and fractures in postmenopausal women.

Search methods

During the update of this review we updated the original search strategy by searching up to December 2010 the following electronic

databases: the Cochrane Musculoskeletal Group’s Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (TheCochrane Library, 2010 Issue 12); MEDLINE; EMBASE; HealthSTAR; Sports Discus; CINAHL; PEDro; Web of Science; Controlled

Clinical Trials; and AMED. We attempted to identify other studies by contacting experts, searching reference lists and searching trial

registers.

Selection criteria

All randomised controlled trials (RCTs) that met our predetermined inclusion criteria.

Data collection and analysis

Pairs of members of the review team extracted the data and assessed trial quality using predetermined forms. For dichotomous outcomes

(fractures), we calculated risk ratios (RRs) using a fixed-effect model. For continuous data, we calculated mean differences (MDs) of

the percentage change from baseline. Where heterogeneity existed (determined by the I2 statistic), we used a random-effects model.

1Exercise for preventing and treating osteoporosis in postmenopausal women (Review)


Main results

Forty-three RCTs (27 new in this update) with 4320 participants met the inclusion criteria. 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 (MD 1.03; 95% confidence interval (CI) 0.24 to 1.82). The most effective

intervention for BMD at the spine was combination exercise programmes (MD 3.22; 95% CI 1.80 to 4.64) compared with control

groups. Fractures and falls were reported as adverse events in some studies. There was no effect on numbers of fractures (odds ratio

(OR) 0.61; 95% CI 0.23 to 1.64). Overall, the quality of the reporting of studies in the meta-analyses was low, in particular in the

areas of sequence generation, allocation concealment, blinding and loss to follow-up.

Authors’ conclusions

Our results suggest a relatively small statistically significant, but possibly important, effect of exercise on bone density compared with

control groups. Exercise has the potential to be a safe and effective way to avert bone loss in postmenopausal women.

P L A I N L A N G U A G E S U M M A R Y

Exercise for preventing and treating osteoporosis in postmenopausal women

This summary of a Cochrane review presents what we know from research about the effect of exercise on bone mass in postmenopausal

women.

The review shows that for postmenopausal women

- Exercise will improve bone mineral density slightly.

- Exercise will reduce the chances of having a fracture slightly.

These results might have happened by chance.

What is osteoporosis and exercise

Bone is a living, growing part of your body. Throughout your lifetime, new bone cells grow and old bone cells break down to make

room for the new, stronger bone. When you have osteoporosis, the old bone breaks down faster than the new bone can replace it. As

this happens, the bones lose minerals (such as calcium). This makes bones weaker and more likely to break even after a minor injury,

like a little bump or fall.

Exercise interventions are typically those that stress or mechanically load bones (when bones support the weight of the body or when

movement is resisted for example when using weights) and include aerobics, strength training, walking and tai chi.

Best estimate of what happens to postmenopausal women who exercise

Bone mineral density at the spine

People who exercised had on average 0.85% less bone loss than those who didn’t exercise.

People who engaged in combinations of exercise types had on average 3.2% less bone loss than those who did not exercise.

Bone mineral density at the hip

People who exercised had on average 1.03% less bone loss than those who didn’t exercise.

People who exercised by strength training had on average 1.03% less bone loss.

Fractures

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S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]

Exercise for preventing and treating osteoporosis in postmenopausal women

Patient or population: preventing and treating osteoporosis in postmenopausal women

Settings:

Intervention: exercise

Outcomes Illustrative comparative risks* (95% CI) Relative effect

(95% CI)

No. of Participants

(studies)

Quality of the evidence

(GRADE)

Comments

Assumed risk Corresponding risk

Control Exercise

Total number of frac-

tures

radiographs

Study population OR 0.61

(0.23 to 1.64)

539

(4 studies)

⊕⊕⊕⊕

high

Absolute difference = 4%

Not statistically signifi-

cant.106 per 1000 67 per 1000

(27 to 163)

Bone mineral density %

change: spine

The mean bone min-

eral density % change:

spine ranged across con-

trol groups from

-4.38 to 1.05 %

The mean bone mineral

density % change: spine

in the intervention groups

was

0.85 % higher

(0.62 to 1.07 higher)

1441

(24 studies)

⊕⊕⊕⊕

high


change: femoral neck

The mean bone min-


femoral neck ranged

across control groups

from

-3.19 to 3.12 %

The mean bone min-


femoral neck in the inter-

vention groups was

0.08 % lower

(1.08 lower to 0.92

higher)

1338

(19 studies)

⊕⊕©©

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change: total hip


density % change: total

hip ranged across control

groups from

-2.18 to 2.61 %


density % change: to-

tal hip in the intervention

groups was

0.41 % higher

(0.64 lower to 1.45

higher)

863

(13 studies)

⊕⊕⊕⊕

high


change: trochanter

The mean bone min-


trochanter ranged across

control groups from

-1.62 to 2.94 %

The mean bone min-


trochanter in the interven-

tion groups was

1.03 % higher

(0.56 to 1.49 higher)

815

(10 studies)

⊕⊕⊕⊕

high

Adverse events: Falls see comment see comment not estimable 378

(3 studies)

see comment Reported as adverse

events there were 75 falls

reported in the exercise

groups and 55 in the con-

trol groups2

Other adverse events see comment see comment not estimable 907

(11 studies)

see comment Events included mus-

cle soreness, joint pain,

headache, itching

There were 60 events

reported in the exercise

groups and 5 in the con-

trol groups3

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the

assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval; OR: Odds ratio

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GRADE Working Group grades of evidence

High quality: further research is very unlikely to change our confidence in the estimate of effect

Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate

Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate

Very low quality: we are very uncertain about the estimate

1 Significant heterogeneity observed even with random effects model.2 Reported as total number of falls but individuals may have had more than one fall.3 Events reported as adverse for participants in intervention groups, generally no mention of event monitoring in control groups.

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B A C K G R O U N D

Description of the condition

Osteoporosis is a condition resulting in an increased risk of skeletal

fractures due to a reduction in the density of bone tissue (CDC

1991). The most common clinical manifestations of osteoporosis

are fractures of the hip, vertebrae or wrist. Osteoporotic-related

fractures are responsible for excess mortality, morbidity, chronic

pain, reduction in quality of life, admission to long-term care and

health and social care costs (Papaioannou 2010). For women at

the age of 50 years in developed countries, the remaining lifetime

possibility of osteoporotic fractures exceeds 40%; the remaining

lifetime probability for hip fracture alone exceeds 20% (Bessette

2008). The excess mortality associated with a hip fracture has been

estimated to be 20% (Cooper 1993). The number of osteoporotic-

related fractures is certain to increase as a result of the ageing

population (WHO 1994).

Prevention of osteoporotic-related fractures is based on the abil-

ity to estimate fracture probability by means of risk factor assess-

ment. The quality of bone, (the total characteristics of the bone

that influence the bone’s resistance to fracture), is determined by

a number of factors including bone geometry, cortical thickness

and porosity, trabecular bone morphology and intrinsic properties

of bony tissue. Low bone mass, detected by bone densitometry,

is one of the most important risk factors. Bone mineral density

(BMD) measured by dual X-ray absorptiometry (DXA) is reported

to account for 60% to 70% of the variation in bone strength

(Ammann 2003), and prospective studies have documented that

the lifetime risk of an osteoporotic-related fracture increases 1.5

to 3 times with each standard deviation (SD) decrease in bone

density (Cummings 1993). However Zebaze 2010 reported that

most bone loss is cortical, not trabecular, and occurs after the age

of 65 years; and that the resulting structural decay, including the

magnitude of intracortical remodelling and intracortical porosity,

are poorly captured by current measurement methods. Although

measurements of BMD contribute to the prediction of fracture risk

they cannot identify individuals who will have a fracture (Marshall

1996) as many fractures, particularly in older populations, are re-

sults of falls which are influenced by environmental and other

medical causes, e.g. impaired visual function, muscle strength and

balance (Gillespie 2009).

The treatment of hip fracture and the hospitalisation required fol-

lowing all types of fracture account for most of the economic costs

associated with osteoporosis (Cooper 1993). Therefore, the pre-

vention of fractures is the primary goal of intervention. See other

Cochrane systematic reviews for pharmacological interventions

for osteoporosis: alendronate (Wells 2008a); etidronate (Wells

2008b); fluoride (Haguenauer 2004); risedronate (Wells 2008c);

and strontium renalate (Cranney 2006).

Description of the intervention

Various exercise interventions, designed to stimulate bone growth

and preserve bone mass have been described and evaluated. Inter-

ventions are typically those that stress or mechanically load bones

(when bones support the weight of the body or when movement

is resisted, for example when using weights) and include aerobics,

weight bearing and resistance exercises.

How the intervention might work

In general, it is thought that disuse (not using the limbs or pro-

longed periods of inactivity) and unloading of the skeleton pro-

motes reduced bone mass (Zerwekh 1998), whereas loading pro-

motes increased bone mass. The effects of mechanical loading

have been demonstrated in athletes undertaking high-impact ex-

ercise (Taaffe 1997) and in rats (Robling 2002). Mechanical load-

ing through exercise has the potential to be a safe and effective

way to avert or delay the onset of osteoporosis in postmenopausal

women. The previous version of this review (Bonaiuti 2002) con-

cluded that exercise has beneficial effects on bone density of the

hip and spine, although long term-studies including fracture data

are rare. In addition, strength and balance exercises contribute to

fracture risk reduction through their efficacy in reducing falls risk

(Gillespie 2009).

Why it is important to do this review

The high prevalence and staggering costs (Burge 2007) of osteo-

porotic-related fractures in postmenopausal women means pre-

vention and management of this disease is important. There con-

tinues to be much interest in the effects of exercise on bone as a

nonpharmacological intervention. A systematic review is required

to identify the number of new trials in this area and summarise the

evidence for healthcare professionals, policy makers, researchers

and others with an interest in this area.

O B J E C T I V E S

To examine the effectiveness of exercise in preventing bone loss in

postmenopausal women by determining whether or not exercise

slows bone loss and has a beneficial effect on the axial (the skull,

spine and rib cage) and appendicular (the bones of the limbs and

pelvis) bone density in postmenopausal women.

M E T H O D S

Criteria for considering studies for this review



Types of studies

We considered all randomised controlled clinical trials (RCTs) of

exercise in healthy postmenopausal women.

Types of participants

We included studies where participants were healthy post-

menopausal women (including those with previous fractures) aged

between 45 and 70 years.

Types of interventions

We included all RCTs with an exercise programme (e.g. walking,

callisthenics and resisted strengthening) assumed to be adequate

to improve aerobic capacity, or both aerobic capacity and mus-

cle strength compared to standard therapy (e.g. usual activity or

placebo with or without pharmacological consumption).

Types of outcome measures

Major outcomes

• Number of incident fractures: vertebral and non-vertebral

(hip and wrist).

Secondary outcomes

• Bone mass including BMD, bone mineral content (BMC),

or calcium bone index (CaBI) immediately postintervention and

at follow-up.

BMD was measured by Single-Photon Absorptiometry (SPA),

Dual-Photon Absorptiometry (DPA), Quantitative Computerised

Tomography (QCT) or DXA at baseline, immediately postinter-

vention and at follow-up. All results were converted to the percent-

age change of BMD from baseline values. The difference between

the percentage lost in the exercise group and the percentage lost

in the control group was used as the measure of effect in pooling

the data.

• Serious adverse events including death.

• Minor adverse events including falls.

Search methods for identification of studies

Electronic searches

To identify exercise trials, we searched the following five electronic

databases: the Cochrane Musculoskeletal Group’s Trials Regis-

ter; the Cochrane Central Register of Controlled Trials (CEN-

TRAL) (The Cochrane Library); MEDLINE; EMBASE; and Cur-

rent Contents from 1966 to January 2000 with no language re-

strictions, according to the methods suggested by Dickersin 1994

and Haynes 1994 and the Cochrane Handbook for Systematic Re-views of Interventions (Higgins 2011). During this current up-

date of the review, we undertook a further search. We searched

the following electronic databases; the Cochrane Central Register

of Controlled Trials (CENTRAL) (The Cochrane Library, 2010);

MEDLINE (Appendix 1); EMBASE (Appendix 2); HealthSTAR;

Sports Discus; CINAHL (Appendix 3); PEDro (Appendix 4); Web

of Science; Controlled Clinical Trials (Appendix 5); and AMED

(Appendix 6) (all to December 2010).

Searching other resources

In addition, we searched the reference lists of included trials and

trials registers, and contacted content experts for additional studies

and data.

Data collection and analysis

Selection of studies

Following an a priori protocol, at least two review authors (BS,

TH, LD and FD) independently reviewed the eligibility criteria

for abstracts for inclusion in this review. We screened all titles

and/or abstracts generated by the searches for potentially relevant

studies based on the following criteria: the type of study; type of

participants; type of intervention; and type of outcome measure-

ments. We assessed the full-length articles of the selected titles

and/or abstracts for eligibility (for a full description see Criteria

for considering studies for this review). We resolved disagreements

by consensus or third-party adjudication.

Data extraction and management

Pairs of members of the review team used a customised data ex-

traction tool, tested prior to use, to independently extract data.

We resolved disagreements by consensus or third-party adjudica-

tion. We attempted to contact authors of studies where there was

inadequate reporting of data, to enable clarification and where

appropriate, to allow pooling. Where available and appropriate,

we presented quantitative data for the outcomes listed in the in-

clusion criteria in the analyses. Where studies reported standard

errors (SEs) of the means, we obtained SDs by multiplying SEs of

means by the square root of the sample size.

In order to assess efficacy, we extracted raw data for outcomes

of interest (means and SDs for continuous outcomes and num-

ber of events for dichotomous outcomes) where available in the

published reports. Wherever we converted or imputed reported

data, we recorded this in the notes section of the Characteristics

of included studies. All trials reported continuous outcomes as

end-point scores (i.e. mean and SD of the variable at follow-up,

assuming baseline comparability).



Assessment of risk of bias in included studies

We assessed risk of bias for each included study using the Cochrane

Collaboration’s ’Risk of bias’ tool (Higgins 2011). Pairs of mem-

bers of the review team reported the following six key domains: se-

quence generation; allocation concealment; blinding; incomplete

outcome data; selective outcome reporting; and “other bias” (com-

parability of treatment and control group at entry, and appropri-

ateness of duration of surveillance). In cases of disagreement be-

tween the review authors, we used consensus to make a decision.

The final assessments for all included studies are presented in a

’risk of bias’ table (see Characteristics of included studies).

Measures of treatment effect

For each trial, we calculated risk ratios (RRs) and 95% CIs for

dichotomous outcomes, and mean differences (MDs) and 95%

CIs for continuous outcomes (reporting mean and SD or standard

error (SE) of the mean). Where appropriate, we pooled results of

comparable groups of trials using the fixed-effect model and 95%

CIs.

Unit of analysis issues

We reported the level at which randomisation occurred in the in-

cluded studies as specified by the Cochrane Handbook for SystematicReviews of Interventions (Deeks 2011). Possible variations in study

designs include cluster randomised trials, cross-over trials, mul-

tiple observations, re-occurring events, multiple treatments and

multiple intervention groups.

Dealing with missing data

If we discovered missing data during data extraction, we attempted

to contact the original investigators of the study to request the re-

quired information. We anticipated that it may also have been nec-

essary to conduct a sensitivity analysis if assumptions were made

(Deeks 2011). We have also described the potential effect of miss-

ing data upon conclusions drawn from this review.

Assessment of heterogeneity

We tested heterogeneity between comparable trials using a stan-

dard Chi2 test and considered heterogeneity statistically significant

at P < 0.1 after due consideration of the value of the I2 statistic; a

value greater than 50% may indicate substantial heterogeneity.

Assessment of reporting biases

If there were sufficient studies, we intended to assess the possibility

of publication bias with funnel plots.

Data synthesis

We used Cochrane Review Manager software to meta-analyse the

statistics as described below (RevMan 2011). We used 95% CIs

for all outcomes.

Continuous outcomes

We calculated mean differences (MDs) using a fixed-effect model

as we measured outcomes on standard scales. We explored possible

reasons for heterogeneity in terms of prevention versus treatment

studies (primary versus secondary prevention), trial quality, dif-

fering populations and exercise programmes. We used a random-

effects model to further analyse the results which were determined

to indicate substantial heterogeneity (i.e. after due consideration

of the value of the I2 statistic, a value greater than 50%).

Dichotomous outcomes

For interpretation of the dichotomous outcome measures in this

review, we selected the RR using a random-effects model, since this

is the most appropriate statistic for the interpretation of pooled

data where the event is common and where there is statistical

heterogeneity between trials (Deeks 1998).

We performed appropriate statistical analysis using Review Man-

ager (RevMan 2011) in accordance with the Cochrane Handbookfor Systematic Reviews of Interventions (Deeks 2011).

Subgroup analysis and investigation of heterogeneity

In the presence of heterogeneity, we pooled the results of compa-

rable groups using the random-effects model and 95% CIs.

We performed separate outcome analyses to determine the effec-

tiveness of different categories of exercise interventions versus con-

trol.

Where the data allowed, we also anticipated performing separate

outcome analyses to test the following hypotheses:

1. effectiveness is not dependent on the duration and/or

intensity of the physical activity/exercise intervention;

2. effectiveness is not dependent on the setting in which the

physical activity/exercise intervention is delivered; and

3. effectiveness is not dependent on the level or type of

supervision of the physical activity/exercise intervention.

Sensitivity analysis

We anticipated that we would undertake sensitivity analyses, when

indicated, to investigate the effects of methodological quality,

for example, allocation concealment and intention-to-treat (ITT)

analysis or where cluster randomised trials are combined with each

other or with other studies in a meta-analysis.



Grading of evidence and summary of findings table

Major outcomes (including benefits and adverse events) are pre-

sented in the Summary of findings for the main comparison which

provides information on the quality of evidence and the magni-

tude of the intervention effect, as well as a summary of the main

outcome data. We have also presented an assessment of the overall

quality of evidence per outcome (high, moderate, low and very

low) using the GRADE approach as outlined in the CochraneHandbook for Systematic Reviews of Interventions (Schünemann

2011).

R E S U L T S

Description of studies

See: Characteristics of included studies; Characteristics of

excluded studies; Characteristics of studies awaiting classification;

Characteristics of ongoing studies.

Forty-three RCTs (27 new in this update) with 4320 participants

met the inclusion criteria. Although included in the original ver-

sion of this review, we excluded (Kerr 1996) from this update be-

cause participants were their own control, with one side of body

randomised to a different exercise type. Forty-one of the 43 in-

cluded studies were published in English, one in German (Von

Stengel 2009) and one in Italian (Tolomio 2009).

Exercise interventions

For details of the content of individual interventions see

Characteristics of included studies. Many factors influence the ef-

fectiveness of exercise interventions:

1. attendance;

2. adherence to the programme;

3. accuracy of the assessment system;

4. type of exercise; and

5. duration, intensity, frequency and length of exercise

programme.

The World Health Organization (WHO) defines adherence as

“the extent to which a person’s behavior such as taking medication,

following a diet, executing lifestyle changes like exercising, corre-

sponds with agreed recommendations from a health care provider”,

(WHO 2003) this is clearly different to attendance. The quality

of the reporting of these factors varied in the 43 studies included

in this review.

Compliance/adherence

Thirty-three studies reported compliance/adherence to the pro-

grammes and 10 did not (Bravo 1996; Brentano 2008; Chuin

2009; Hatori 1993; Iwamoto 2005; Lau 1992; Russo 2003; Sakai

2010; Sinaki 1989; Tolomio 2009). The attendance rate ranged

from 48% (Preisinger 1995) to 93% (Bemben 2000) and the ad-

herence rate to the exercise programmes ranged from 39% (Prince

1995) to 95% (Bocalini 2009).

Thirteen studies reported the accuracy of the assessing instrument

(i.e. the test-retest reliability) (Grove 1992; Hatori 1993; Lau

1992; Lord 1996; Martin 1993; Nelson 1994; Preisinger 1995;

Prince 1991; Prince 1995; Pruitt 1996; Revel 1993; Sinaki 1989;

Smidt 1992). Instrument accuracy ranged from 0.4% (Hatori

1993) to 3% (Grove 1992).

Setting

The studies included participants from North America (Bravo

1996; Bemben 2000; Chilibeck 2002; Chow 1987; Chubak 2006;

Chuin 2009; Going 2003; Grove 1992; Maddalozzo 2007; Martin

1993; Metcalfe 2001; Nelson 1994; Newstead 2004; Papaioannou

2003; Pruitt 1996; Rubin 2004; Russo 2003; Sinaki 1989; Smidt

1992), Australia (Kerr 2001; Lord 1996; Prince 1991; Prince

1995), Europe (Bergstrom 2008; Cheng 2002; Ebrahim 1997;

Englund 2005; Karinkanta 2007; Korpelainen 2006; Preisinger

1995; Revel 1993; Tolomio 2009; Uusi-Rasi 2003; Verschueren

2004; Von Stengel 2009), Japan (Hatori 1993; Iwamoto 2001;

Iwamoto 2005; Sakai 2010), China (Chan 2004; Lau 1992) and

Brazil (Bocalini 2009; Brentano 2008).

Length of exercise programmes

The length of the exercise programmes varied in the included stud-

ies; 10 were less than 12 months long (Bemben 2000; Bocalini

2009; Brentano 2008; Chuin 2009; Hatori 1993; Lau 1992; Russo

2003; Sakai 2010; Tolomio 2009; Verschueren 2004); 26 were 12

months long (Bergstrom 2008; Bravo 1996; Chan 2004; Chilibeck

2002; Chow 1987; Chubak 2006; Englund 2005; Going 2003;

Grove 1992; Iwamoto 2001; Iwamoto 2005; Karinkanta 2007;

Kerr 2001; Lord 1996; Maddalozzo 2007; Martin 1993; Metcalfe

2001; Nelson 1994; Newstead 2004; Papaioannou 2003; Pruitt

1996; Revel 1993; Rubin 2004; Smidt 1992; Uusi-Rasi 2003; Von

Stengel 2009); and seven were greater than 12 months (Ebrahim

1997; Kerr 2001; Korpelainen 2006; Preisinger 1995; Prince

1991; Prince 1995; Sinaki 1989).

Number of years postmenopausal

The number of years postmenopausal was reported in 15 studies

(Bemben 2000; Bravo 1996; Chan 2004; Chilibeck 2002; Chubak

2006; Going 2003; Grove 1992; Maddalozzo 2007; Nelson 1994;

Preisinger 1995; Prince 1991; Revel 1993; Russo 2003; Uusi-Rasi

2003; Verschueren 2004).

Exercise interventions

All the exercise interventions described were land based except in

one study (Tolomio 2008) which included both land and water



based exercise. We categorised the exercise interventions into the

following six categories.

• Static weight bearing (SWB); including single leg standing.

• Dynamic weight bearing exercise low force (DWBLF);

including walking and Tai chi.

• Dynamic weight bearing exercise high force (DWBHF);

including jogging, jumping, running, dancing and vibration

platform.

• Non-weight bearing exercise low force (NWBLF); e.g. low

load, high repetition strength training.

• Non-weight bearing exercise high force (NWBHF); e.g.

progressive resisted strength training.

• Combination (COMB); more than one of the above

exercise interventions.

Exercise training consisted of: DWBLF in 12 studies (Bravo

1996; Chan 2004; Chow 1987; Ebrahim 1997; Grove 1992;

Hatori 1993; Lau 1992; Lord 1996; Martin 1993; Preisinger

1995; Prince 1991; Prince 1995); DWBHF in 11 studies (Cheng

2002; Going 2003; Grove 1992; Iwamoto 2005; Karinkanta

2007; Maddalozzo 2007; Newstead 2004; Rubin 2004; Russo

2003; Uusi-Rasi 2003; Verschueren 2004); NWBLF in six studies

(Bemben 2000; Brentano 2008; Kerr 2001; Pruitt 1996; Revel

1993; Sinaki 1989); NWBHF in nine studies (Bemben 2000;

Brentano 2008; Bocalini 2009; Chilibeck 2002; Chuin 2009; Kerr

2001; Nelson 1994; Pruitt 1996; Smidt 1992); COMB in 11 stud-

ies (Bergstrom 2008; Chow 1987; Chubak 2006; Englund 2005;

Iwamoto 2001; Karinkanta 2007; Korpelainen 2006; Metcalfe

2001; Papaioannou 2003; Tolomio 2009; Von Stengel 2009); and

SWB in one study (Sakai 2010).

It should be noted that some studies included more than one

exercise intervention arm.

Frequency of the exercise intervention

The frequency of the sessions for the majority of studies was two

or three times per week. The exception being three studies where

participants had daily exercise sessions (Iwamoto 2001; Revel

1993; Sakai 2010) and seven who had four to six sessions per week

(Bergstrom 2008; Chan 2004; Cheng 2002; Lau 1992; Prince

1995; Sinaki 1989; Smidt 1992).

Content of the exercise intervention

The content of the training session was reported in five studies (Lau

1992; Lord 1996; Preisinger 1995; Prince 1991; Prince 1995) and

two studies assessed the effect of the repetition of only one exercise

(Revel 1993; Sinaki 1989). There were five studies that described

that exercise intensity was determined by maximal heart rate (

Bravo 1996; Chow 1987; Ebrahim 1997; Hatori 1993; Martin

1993), and three studies reported how the maximum strength was

measured (Nelson 1994; Pruitt 1996; Smidt 1992). One study

measured the exercise intensity in relation to body weight (Grove

1992).

Controls

In all but twelve studies the controls were invited to continue

their usual activity without any exercise prescription. One study

reported the control group performing 45 minute stretching ses-

sions once a week (Chubak 2006); one performing upper limb

exercises only (Ebrahim 1997); and one performing gentle exer-

cise and relaxation (Von Stengel 2009). In five studies controls

were divided into usual activity with drug interventions or usual

activity alone (Lau 1992; Martin 1993; Maddalozzo 2007; Prince

1991; Prince 1995). A placebo device was used in only one study

(Rubin 2004), and there were three studies which did not report

on the control group (Englund 2005; Hatori 1993; Papaioannou

2003).

Outcome measures

Fracture rate was a primary outcome measure in only one trial

(Iwamoto 2005), but was reported as an adverse event at follow-

up in three (Chan 2004; Karinkanta 2007; Korpelainen 2006).

Falls were reported as adverse events in four trials (Chan 2004;

Ebrahim 1997; Iwamoto 2005; Karinkanta 2007).

BMD was measured at the lumbar spine in 30 studies (Bemben

2000; Bergstrom 2008; Bocalini 2009; Bravo 1996; Chan 2004;

Chilibeck 2002; Chuin 2009; Ebrahim 1997; Englund 2005;

Going 2003; Grove 1992; Hatori 1993; Iwamoto 2001; Kerr

2001; Lau 1992; Lord 1996; Maddalozzo 2007; Martin 1993;

Metcalfe 2001; Nelson 1994; Newstead 2004; Papaioannou 2003;

Prince 1995; Pruitt 1996; Revel 1993; Rubin 2004; Sinaki 1989;

Smidt 1992; Uusi-Rasi 2003; Von Stengel 2009).

BMD was measured at the hip in 30 studies (Bemben 2000;

Bergstrom 2008; Bocalini 2009; Bravo 1996; Brentano 2008;

Chan 2004; Cheng 2002; Chilibeck 2002; Chuin 2009; Ebrahim

1997; Englund 2005; Going 2003; Kerr 2001; Korpelainen

2006; Lau 1992; Lord 1996; Maddalozzo 2007; Metcalfe 2001;

Nelson 1994; Newstead 2004; Papaioannou 2003; Prince 1995;

Pruitt 1996; Rubin 2004; Sakai 2010; Smidt 1992; Tolomio

2009; Uusi-Rasi 2003; Verschueren 2004; Von Stengel 2009).

These were subdivided into the following sites: femoral neck

(Bemben 2000; Bocalini 2009; Bravo 1996; Brentano 2008;

Chan 2004; Chuin 2009; Ebrahim 1997; Englund 2005; Going

2003; Kerr 2001; Korpelainen 2006; Lau 1992; Lord 1996;

Maddalozzo 2007; Nelson 1994; Newstead 2004; Papaioannou

2003; Pruitt 1996; Sakai 2010; Tolomio 2009; Uusi-Rasi

2003); intertrochanteric (Brentano 2008; Sakai 2010); trochanter

(Bemben 2000; Brentano 2008; Chan 2004; Chilibeck 2002;

Englund 2005; Going 2003; Kerr 2001; Korpelainen 2006; Lord

1996; Maddalozzo 2007; Sakai 2010; Smidt 1992; Uusi-Rasi

2003); Ward’s Triangle (Bemben 2000; Brentano 2008; Chilibeck

2002; Englund 2005; Lau 1992; Pruitt 1996; Sakai 2010; Smidt

1992); and total hip (Bemben 2000; Bergstrom 2008; Chilibeck

2002; Kerr 2001; Korpelainen 2006; Maddalozzo 2007; Newstead

2004; Pruitt 1996; Tolomio 2009; Verschueren 2004; Von Stengel



2009).

BMD was also measured at the distal radius (Korpelainen 2006;

Preisinger 1995; Rubin 2004; Uusi-Rasi 2003); forearm (Kerr

2001; Martin 1993; Prince 1991); tibia (Chan 2004; Cheng

2002); ankle (Prince 1995); and total body (Bemben 2000;

Chilibeck 2002; Chubak 2006; Englund 2005; Going 2003; Kerr

2001; Newstead 2004; Verschueren 2004).

Other outcome measures included: BMC (Englund 2005;

Karinkanta 2007; Nelson 1994; Uusi-Rasi 2003); cortical bone

density (Cheng 2002; Karinkanta 2007); trabecular bone density

(Russo 2003); CaBI (Chow 1987); body mass (Martin 1993);

muscle strength (Metcalfe 2001); and rate of falls (Von Stengel

2009).

Other adverse events were reported by 11 studies (Chow 1987;

Ebrahim 1997; Grove 1992; Karinkanta 2007; Korpelainen 2006;

Nelson 1994; Pruitt 1996; Revel 1993; Rubin 2004; Russo

2003; Uusi-Rasi 2003) and included muscle soreness, joint pain,

headache and itching.

Results of the search

From the search we found 936 references to potential studies. We

discussed and resolved disagreements by reading the full text of

the paper. We retrieved a total of 90 potential relevant trials for

further classification (see PRISMA flow chart Figure 1).



Figure 1. Study flow diagram.



Included studies

Forty-three RCTs (27 new in this update) with 4320 participants

met the inclusion criteria. On further scrutiny of the included

studies from the original version (Mayoux-Benhamou 1997) was

actually follow-up data for another included study (Revel 1993).

Forty-one of these 43 included studies were published in English,

one in German (Von Stengel 2009) and one in Italian (Tolomio

2009). Three studies are awaiting classification and one trial is

ongoing. We assessed all study designs as not affecting unit of

analysis, for example we reported no cluster randomised trials or

cross-over trials.

Excluded studies

Thirty-one studies did not meet the inclusion criteria as published

in our a priori protocol. On further scrutiny of the included stud-

ies from the original version we excluded one study (Kerr 1996)

because participants were their own control, with one side of body

randomised to a different exercise type.

Risk of bias in included studies

Pairs of review authors judged the following key domains as ’low

risk’, ‘high risk’ or ‘unclear risk of bias’:

• random sequence generation;

• allocation concealment;

• incomplete outcome data;

• selective reporting;

• blinding (participant);

• blinding (assessor); and

• “other bias” (comparability of treatment and control group

at entry, and appropriateness of duration of surveillance).

In cases of disagreement between the review authors, we made a de-

cision based on consensus. The methodological quality summary

for each included study is presented in Figure 2 and the review

authors’ judgements about each methodological quality item are

presented as percentages across all included studies in Figure 3. We

assessed the overall risk of bias as ’low’ for 13 studies (Bergstrom

2008; Bravo 1996; Cheng 2002; Chilibeck 2002; Chow 1987;

Chubak 2006; Ebrahim 1997; Karinkanta 2007; Korpelainen

2006; Lau 1992; Lord 1996; Uusi-Rasi 2003; Verschueren 2004)

and ’high risk of bias’ for four studies (Metcalfe 2001; Prince 1991;

Prince 1995; Rubin 2004).



Figure 2. Methodological quality summary: review authors’ judgements about each methodological quality

item for each included study.



Figure 3. Methodological quality graph: review authors’ judgements about each methodological quality

item presented as percentages across all included studies.

Allocation

In the original version of the review only one study had clearly

used a proper method of randomisation (Lau 1992). In this up-

date 16 studies adequately described sequence generation (’low

risk of bias’) (Bergstrom 2008; Bravo 1996; Cheng 2002; Chow

1987; Chubak 2006; Ebrahim 1997; Karinkanta 2007; Kerr 2001;

Korpelainen 2006; Lau 1992; Prince 1991; Prince 1995; Rubin

2004; Russo 2003; Sakai 2010; Verschueren 2004) and eleven

studies adequately described allocation concealment (’low risk

of bias’) (Chilibeck 2002; Chow 1987; Chubak 2006; Ebrahim

1997; Karinkanta 2007; Korpelainen 2006; Lau 1992; Lord 1996;

Prince 1991; Prince 1995; Rubin 2004). The other studies did

not clearly describe these methods (’unclear risk of bias’).

Blinding

It is difficult to ensure blinding of participants in studies of exer-

cise interventions. Only one study adequately blinded participants

for the type of exercise intervention (’low risk of bias’) (Rubin

2004), there was an ’unclear risk of bias’ in 15 studies (Bravo

1996; Brentano 2008; Cheng 2002; Chilibeck 2002; Chubak

2006; Ebrahim 1997; Going 2003; Hatori 1993; Iwamoto 2001;

Karinkanta 2007; Lau 1992; Lord 1996; Martin 1993; Nelson

1994; Uusi-Rasi 2003) and participants were not blinded in 27

studies (’high risk of bias’).

Fourteen studies adequately blinded assessors to type of ex-

ercise intervention (’low risk of bias’) (Bocalini 2009; Bravo

1996; Chilibeck 2002; Chow 1987; Chubak 2006; Hatori 1993;

Korpelainen 2006; Papaioannou 2003; Preisinger 1995; Revel

1993; Rubin 2004; Sinaki 1989; Uusi-Rasi 2003; Verschueren

2004), there was an ’unclear risk of bias’ in 28 studies and assessors

were not blinded in one study (’high risk of bias’) (Ebrahim 1997).

Incomplete outcome data

Fifteen studies were judged as appropriately addressing incom-

plete outcome data (’low risk of bias’) (Bergstrom 2008; Bravo

1996; Chow 1987; Chubak 2006; Ebrahim 1997; Going 2003;

Karinkanta 2007; Korpelainen 2006; Lord 1996; Metcalfe 2001;

Nelson 1994; Sinaki 1989; Tolomio 2009; Uusi-Rasi 2003;

Von Stengel 2009), there was an ’unclear risk of bias’ for 26

studies (Bocalini 2009; Brentano 2008; Chan 2004; Cheng

2002; Chilibeck 2002; Chuin 2009; Englund 2005; Grove

1992; Iwamoto 2001; Iwamoto 2005; Kerr 2001; Lau 1992;



Maddalozzo 2007; Martin 1993; Newstead 2004; Papaioannou

2003; Preisinger 1995; Prince 1991; Prince 1995; Pruitt 1996;

Revel 1993; Rubin 2004; Russo 2003; Sakai 2010; Smidt 1992;

Verschueren 2004) and two studies were judged as not address-

ing incomplete outcome data (’high risk of bias’) (Bemben 2000;

Hatori 1993).

Selective reporting

Insufficient information was available to permit judgement of ’low

risk’ or ‘high risk of bias’ for selective reporting for any of the 43

studies.

Other potential sources of bias

Treatment and control groups were comparable at entry in 35

studies (’low risk of bias’), it was unclear in six studies (’unclear risk

of bias’) (Bergstrom 2008; Brentano 2008; Grove 1992; Metcalfe

2001; Newstead 2004; Sinaki 1989) and significant differences

were present in two studies indicating a ’high risk of bias’ (Prince

1991; Rubin 2004). Most studies only provided data at the end

of the intervention. Only eight studies provided follow-up data

(Englund 2005; Karinkanta 2007; Korpelainen 2006; Metcalfe

2001; Preisinger 1995; Prince 1991; Revel 1993; Uusi-Rasi 2003).

Effects of interventions

See: Summary of findings for the main comparison Exercise for

preventing and treating osteoporosis in postmenopausal women

1. All exercise types versus control (Analyses 1.1 to

1.8)

Thirty-one studies examining exercise programmes versus control

reported data for the seven outcomes selected as important to

decision making:

• total number of fractures;

• percentage change in BMD at the spine;

• percentage change in BMD at the femoral neck;

• percentage change in BMD in total hip;

• percentage change in BMD at the trochanter;

• adverse events (falls); and

• other adverse events (muscle soreness, joint pain, headache

and itching).

These results are reported in Summary of findings for the main

comparison. However, the nature of the exercise programmes were

heterogeneous and thus the results should be considered with cau-

tion. Among these studies 13 were considered to have ’low risk of

bias’.

Meta-analyses revealed significant differences between the exercise

and control groups in favour of exercise for percentage change in

BMD at the spine (MD 0.85; 95% CI 0.62 to 1.07), 24 studies

and 1441 participants (Analysis 1.2); and trochanter (MD 1.03;

95% CI 0.56 to 1.49), 10 studies and 815 participants (Analysis

1.6).

The risk of fracture in exercise groups was not significantly differ-

ent than that in controls (OR 0.61; 95% CI 0.23 to 1.64), four

studies and 539 participants. There was no significant difference

between the exercise and control groups for: percentage change in

BMD at the femoral neck (MD -0.08; 95% CI -1.08 to 0.92), 19

studies and 1338 participants; or total hip (MD 0.41; 95% CI -

0.64 to 1.45), 13 studies and 863 participants. Only one study

(Uusi-Rasi 2003), 76 participants, reported percentage change in

BMC for the spine and femoral neck and no significant differences

were observed between the exercise and control groups.

Three studies (Chan 2004; Ebrahim 1997; Karinkanta 2007) (n =

378) reported falls as adverse events. There were 75 falls reported

in the exercise groups and 55 in the control groups. Other adverse

events were reported in 11 studies (Chow 1987; Ebrahim 1997;

Grove 1992; Karinkanta 2007; Korpelainen 2006; Nelson 1994;

Pruitt 1996; Revel 1993; Rubin 2004; Russo 2003; Uusi-Rasi

2003); 60 events were reported in the exercise groups and five

in the control groups, and included muscle soreness, joint pain,

headache and itching.

2. Static weight bearing (SWB) (Analysis 2.1)

Only one study Sakai 2010 involving 31 participants examined

SWB (standing on one leg for three minutes per day). A significant

difference was reported for percentage change in BMD at the hip

(Analysis 2.1).

3. Dynamic weight bearing exercise low force

(DWBLF) (Analyses 3.1 to 3.7)

Nine studies examining DWBLF exercise (including walking and

Tai chi) reported data on 705 participants. Among these stud-

ies five were considered to have ’low risk of bias’ (Bravo 1996;

Chow 1987; Ebrahim 1997; Lau 1992; Lord 1996). The compli-

ance with exercise programmes, when reported, varied from 39%

(Prince 1995) to 79.2% (Martin 1993).

The results of meta-analysis showed that there was a statistically

significant effect on percentage change in BMD of the spine (MD

0.87; 95% CI 0.26 to 1.48), seven studies and 1119 participants

(Analysis 3.1), in favour of exercise. However there was no effect

on the femoral neck (MD -1.20; 95% CI -4.45 to 2.05), five

studies and 585 participants; trochanter (MD 0.39; 95% CI -0.59

to 1.38), two studies and 241 participants; or number of fractures

(OR 0.92; 95% CI 0.21 to 3.96), two studies and 229 participants.

Results of single studies indicate a significant difference in favour

of exercise for percentage change of mean regression slope in BMD

at the wrist (MD 1.40; 95% CI 0.85 to 1.95), 103 participants

(Preisinger 1995), and in favour of the control group for percentage

change in BMD in Ward’s triangle (MD -3.60; 95% CI -5.48 to

-1.72), 23 participants (Lau 1992).



4. Dynamic weight bearing exercise high force

(DWBHF) (Analyses 4.1 to 4.16)

Ten studies examining DWBHF exercise (including jogging,

jumping, running, dancing and vibration platform) reported data

on 568 participants. Among these studies four were considered to

have ’low risk of bias’ (Cheng 2002; Karinkanta 2007; Uusi-Rasi

2003; Verschueren 2004). The compliance with exercise pro-

grammes, when reported, varied from 82.6% (Grove 1992) to

86.2% (Maddalozzo 2007).


significant effect on percentage change in BMD of the hip (MD

1.55; 95% CI 1.41 to 1.69), four studies and 179 participants

(Analysis 4.2); and trochanter (MD 1.23; 95% CI -0.01 to 2.47),

two studies and 188 participants (Analysis 4.6) in favour of exer-

cise.

There was no effect on the percentage change in BMD of the spine

(MD -1.20; 95% CI -4.45 to 2.05); mid femur (MD 0.12; 95%

CI -4.84 to 5.08); proximal tibia (MD 3.31; 95% CI -20.22 to

26.84); femoral neck (MD 1.06; 95% CI -0.32 to 2.45); or on

CaBI at the trunk and upper thighs (MD 5.30; 95% CI -7.50 to

18.10).

Results of a single study (Uusi-Rasi 2003) with 76 participants

did not indicate any effect on percentage change in BMC at the

spine (MD 1.43; 95% CI -9.18 to 12.04); femoral neck (MD

0.00; 95% CI -9.11 to 9.11); or wrist (MD -3.41; 95% CI -15.64

to 8.82).

5. Non-weight bearing exercise low force (NWBLF)

(Analyses 5.1 to 5.6)

Five of six studies examining NWBLF exercise (e.g. low load, high

repetition strength training) reported data on 231 participants.

Among these studies none were considered to have ’low risk of

bias’. The compliance with exercise programmes, when reported,

varied from 65% (Pruitt 1996) to 90% (Kerr 2001). No significant

differences were observed for any outcome.

6. Non-weight bearing exercise high force (NWBHF)

(Analayses 6.1 to 6.6)

Nine studies examining NWBHF exercise (e.g. progressive re-

sisted strengthening exercise) reported data on 292 participants.

Among these studies one was considered to have ’low risk of

bias’ (Chilibeck 2002). The compliance with exercise programmes,

when reported, varied from 65% (Pruitt 1996) to 92% (Kerr

2001).


significant effect on percentage change in BMD of the spine (MD

0.86; 95% CI 0.58 to 1.13), eight studies and 246 participants (

Analysis 6.1); and neck of femur (MD 1.03; 95% CI 0.24 to 1.82),

eight studies and 247 participants (Analysis 6.3). No significant

differences were observed for any other outcome.

7. Combination (COMB) (Analyses 7.1 to 7.9)

Ten studies examining combinations of exercise types (more than

one of the above exercise interventions) reported data on 823

participants. Among these studies five were considered to have

’low risk of bias’ (Bergstrom 2008; Chow 1987; Chubak 2006;

Karinkanta 2007; Korpelainen 2006). The compliance with exer-

cise programmes, when reported, varied from 62% (Papaioannou

2003) to 95% (Bergstrom 2008).

The results of meta-analysis showed that the risk of fractures in

exercise groups was significantly lower than that in controls (OR

0.33; 95% CI 0.13 to 0.85), two studies and 236 participants

(Analysis 7.9): in percentage change in BMD of the spine (MD

3.22; 95% CI 1.80 to 4.64), four studies and 258 participants

(Analysis 7.1); trochanter (MD 1.31; 95% CI 0.69 to 1.92), two

studies and 200 participants (Analysis 7.3); and neck of femur

(MD 0.45; 95% CI 0.08 to 0.82), three studies and 325 partici-

pants (Analysis 7.6).

However the results of meta-analysis showed that there was a statis-

tically significant effect in favour of control in percentage change

in BMD of the total hip (MD -1.07; 95% CI -1.58 to -0.56), four

studies and 468 participants (Analysis 7.2).

8. Exercise and pharmacological products versus

control and pharmacological products (Analyses 8.1

to 15.2)

Ten studies examining exercise and pharmacological products ver-

sus control and pharmacological products reported data on 598

participants. Among these studies four were considered to have

’low risk of bias’. The pharmacological products were hormone

replacement therapy (HRT) (Cheng 2002; Maddalozzo 2007;

Going 2003), bisphosphonates (Chilibeck 2002; Iwamoto 2005;

Uusi-Rasi 2003), antioxidants (Chuin 2009), calcium (Kerr 2001;

Lau 1992; Prince 1995) and calcium plus vitamin D (Martin

1993). Exercise types included DWBHF (Cheng 2002; Going

2003; Iwamoto 2005; Maddalozzo 2007; Uusi-Rasi 2003), DW-

BLF and NWBLF (Kerr 2001), and NWBHF (Chilibeck 2002;

Chuin 2009; Kerr 2001). Compliance with exercise programmes,

when reported, varied from 39% (Prince 1995) to 92% (Kerr

2001).

On the whole data for these eight comparisons comprised small

single studies. DWBHF plus HRT versus HRT demonstrated a

significant effect in favour of exercise in percentage change in

BMD at the trochanter (MD 1.86; 95% CI 0.60 to 3.13), 2 studies

and 203 participants; spine NWBHF plus bisphosphonates versus

bisphosphonates (Chilibeck 2002), 26 participants; distal tibia

and Ward’s triangle DWBLF plus calcium versus calcium (MD

0.60; 95% CI 0.46 to 0.74) (Prince 1995) and (MD 14.50; 95%

CI 10.05 to 18.95) (Lau 1992). However a significant difference

in favour of calcium was seen for DWBLF plus calcium versus

calcium (MD -1.02; 95% CI -1.36 to -0.68) (Lau 1992).



No significant differences were observed for any outcome for any

exercise type and pharmacological products versus control and

pharmacological products as listed above.

D I S C U S S I O N

Summary of main results

We have summarised the data from 43 RCTs comparing exercise

with usual activity and exercise plus pharmacological products

versus pharmacological products. We also separately examined the

effect of different categories of exercise.

Our results suggest a relatively small statistically significant, but

possibly important, effect of exercise on bone density in post-

menopausal women compared with control groups. The risk of

fracture in exercise groups was not significantly different than that

in controls (OR 0.61; 95% CI 0.23 to 1.64). Our inference is

strengthened by the consistency of significant findings in favour

of exercise for percentage change in BMD across three sites; spine

(MD 0.85; 95% CI 0.62 to 1.07); total hip (MD 0.41; 95% CI -

0.64 to 1.45); and trochanter (MD 1.03; 95% CI 0.56 to 1.49).

This inference is, however, weakened by methodological limita-

tions such as small sample sizes, loss to follow-up in most studies

and by the unexplained heterogeneity of results across studies. Few

studies provided follow-up data to determine the effect of exercise

beyond the end of the intervention. Falls were reported as adverse

events as numbers of falls rather than number of fallers; one study

reported more events than people, indicating repeat falls. Other

adverse events were reported for participants mainly in interven-

tion groups and included muscle soreness, joint pain, headache

and itching. There was generally no mention of event monitoring

in control groups.

COMB exercise programmes (comprising more than one exercise

type) had a significant effect on BMD at three sites: neck of femur;

spine; and trochanter. The risk of fracture in exercise groups was

lower than that of controls. However there was a significant dif-

ference in BMD in total hip measurement in favour of the control

group.

DWBHF exercise (jogging, jumping and vibration platforms) had

a significant effect on BMD at two sites; total hip and trochanter,

compared to the control groups, but no effect at any other site

(neck of femur, spine, mid femur, tibia, trunk and thighs, or BMC

at neck of femur and spine).

DWBLF exercise (walking or Tai chi) had a significant effect on

BMD at two sites; spine and wrist compared to the control groups.

NWBHF exercise (progressive resistance exercise) had a significant

effect on BMD at two sites; neck of femur and spine compared to

the control groups.

SWB exercise (e.g. single leg standing) had a significant effect on

BMD at the hip.

NWBLF exercise (low load high repetition strength training) had

no significant difference on any outcomes reported.

On the whole, comparisons of exercise plus pharmacological prod-

ucts versus pharmacological products were small single studies and

thus conclusions on their findings are limited.

The population included in these studies was heterogeneous but

results should be reviewed with caution due to differences in eth-

nicity. However, the lack of reporting of exercise characteristics

(type, intensity, frequency, duration and mode) of the study ex-

ercise interventions also limits the conclusions that can be drawn

from this review.

Overall completeness and applicability ofevidence

It is important for future research in this area to have standard-

ised recommendations for conducting exercise interventions and

reporting of exercise outcomes. We cannot currently determine if

the effect of the varied exercises was different in the first and in

the second period of the postmenopausal time period. The short

time of the follow-up of all the studies limits our ability to predict

the long-term effects exercise may or may not have on bone loss.

Quality of the evidence

The 43 studies (27 new studies in this update) included in this

review were predominantly in the English language and originate

mainly from North America and Europe (n = 32). Whilst this may

be seen to limit the applicability of the evidence to these healthcare

systems and social environments the evidence has potential gener-

alisability; the majority of participants were healthy community-

dwelling women.

The overall quality of the included studies was variable and should

be taken into account when interpreting the results of this review.

The risk of bias was assessed as ’low’ for only 13 studies (Bergstrom

2008; Bravo 1996; Cheng 2002; Chilibeck 2002; Chow 1987;

Chubak 2006; Ebrahim 1997; Karinkanta 2007; Korpelainen

2006; Lau 1992; Lord 1996; Uusi-Rasi 2003; Verschueren 2004).

Only one study included in this review blinded the patients (

Rubin 2004) and few blinded the assessors (Bocalini 2009; Bravo

1996; Chilibeck 2002; Chow 1987; Chubak 2006; Hatori 1993;

Korpelainen 2006; Papaioannou 2003; Preisinger 1995; Revel

1993; Rubin 2004; Sinaki 1989; Uusi-Rasi 2003; Verschueren

2004).

It is very difficult and maybe impossible to blind patients and care

providers in exercise therapy. Nevertheless, this bias is unlikely to

have influenced the BMD measurements.

Potential biases in the review process



The review was restricted to RCTs; we excluded clinical con-

trolled trials CCTs) thus limiting the potential for bias. All stud-

ies described themselves as randomised mostly without giving de-

tails of how the randomisation sequence was generated and what

precautions were taken in relation to concealment of allocation.

Only eight studies adequately deal with incomplete outcome data

(Englund 2005; Karinkanta 2007; Korpelainen 2006; Metcalfe

2001; Preisinger 1995; Prince 1991; Revel 1993; Uusi-Rasi 2003)

the remainder reporting the results for only those participants

who completed all post-treatment assessments. Fractures, falls and

other adverse events were reported as adverse events and were

mainly monitored for the exercise groups only.

Agreements and disagreements with otherstudies or reviews

Few meta-analyses have been published in this area (Berard 1997;

Hind 2007; Wolff 1999). These meta-analyses included RCTs and

CCTs, one (Wolff 1999) also included studies on premenopausal

women. All authors subdivided the studies depending on the exer-

cise characteristics and meta-analysed all exercise programmes to-

gether. While Wolff 1999 concluded that exercises prevent femoral

and lumbar bone loss, Berard 1997 concluded that weight bearing

exercises are effective mainly on the spine, but there may be some

evidence of efficacy on femoral bone and forearm bone. Weight

bearing exercise also appears to enhance bone mineral accrual in

children, particularly during early puberty (Hind 2007). The re-

sults of a meta-analysis in Nikander 2010 indicate that exercise

can significantly enhance bone strength at loaded sites in children

but not in adults.

Other reviews with limited quality evidence suggest that Tai chi

(Wayne 2007) and physical activity (Schmitt 2009) may be effec-

tive and safe methods of maintaining BMD in postmenopausal

women. Furthermore an overview of the literature (Winett 2001)

purports the benefits of resistance training on BMD. The results

of this current review suggest that high force resistance training

increases BMD whereas low force does not, indicating the impor-

tance of intensity of exercise.

This current review reported on bone mass as an outcome of ef-

fectiveness and included BMC, CaBI and BMD. Zebaze 2010 re-

ported that most bone loss is cortical, not trabecular, and occurs

after 65 years of age, and the resulting structural decay, includ-

ing the magnitude of intracortical remodelling and intracortical

porosity are poorly captured by current measurement methods.

Nikander 2010 recommends that further research is required to

quantify the effects of exercise on whole bone strength and its

structural determinants throughout life.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

Our results suggest a relatively small statistically significant, but

possibly important, effect of exercise on bone density in post-

menopausal women compared with control groups. The most ef-

fective type of exercise intervention on BMD for the neck of fe-

mur appears to be NWBHF exercise such as progressive resistance

strength training for the lower limbs. The most effective inter-

vention for BMD at the spine was COMB exercise programmes

(comprising more than one exercise type) (MD 3.22; 95% CI 1.80

to 4.64), with a change of over 3% compared with control groups.

However the risk of fracture across all exercise groups was not sig-

nificantly different than that in controls with 4 more women out

of 100 who did not exercise sustaining a fracture (absolute differ-

ence 4%).

These exercise types should be considered as preferred interven-

tions in clinical practice, however, it remains unclear as to what

constitutes an optimal exercise programme.

Implications for research

On the whole the quality of the reporting of studies in the meta-

analyses in this review was low, in particular in the areas of se-

quence generation, allocation concealment, blinding and loss to

follow-up. Future research needs to focus on standardised out-

come measures and exercise programmes, better reporting of all

the parameters of exercise programmes and, the accuracy of mea-

surements. Fracture and fall data, and adverse event reporting for

all participants regardless of group allocation should be included

for all future studies. Measuring the BMD changes for both the

hip (particularly neck of femur) and spine is important as fractures

at these sites result in high mortality and morbidity. Adequate fol-

low-up of participants is required to determine long-term effects

of exercise.

A C K N O W L E D G E M E N T S

We would like to acknowledge the following for their contribution

to the original systematic review: Donatella Bonaituti, Lovine R,

Negrini S, Welch V, Kemper HHCG, Wells GA, Tugwell P, Cran-

ney A. We would also like to thank Louise Falzon and Tamara

Rader for their assistance with the literature search. A special

thanks to Jon Godwin for his helpful advice on data queries, com-

ments and suggestions, Sarah Mitchell for assistance with data ex-

traction and to Elizabeth Ghogomu and the Cochrane Muscu-

loskeletal Group for their ongoing support and their help with the

preparation of this manuscript.



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Prince 1995 {published data only}

Prince R, Devine A, Dick I, Criddle A, Kerr D, Kent N, et

al.The effects of calcium supplementation (milk powder

or tablets) and exercise on one ensity in postmenopausal

women. Journal of Bone and Mineral Research 1995;10(7):

1068–75.

Pruitt 1996 {published data only}

Pruitt LA, Taaffe DR, Marcus R. Effects of a one-year high-

intensity versus low-intensity resistance training program

on bone mineral density in older women. Journal of Bone


Revel 1993 {published data only}

Mayoux-Benhamou MA, Bagheri F, Roux C, Auleley

GR, Rabourdin JP, Revel M. Effect of Ppsoas training on



postmenopausal lumbar bone loss: a 3-year follow-up study.

Calcified Tissue International 1997;60(4):348–53.∗ Revel M, Mayoux-Benhamou MA, Rabourdin JP, Bagheri

F, Roux C. One-year psoas training can prevent lumbar bone

loss in postmenopausal women: a randomized controlled

trial. Calcified Tissue International 1993;53(5):307–11.

Rubin 2004 {published data only}

Rubin C, Recker R, Cullen D, Ryaby J, McCabe J, McLeod

K. Prevention of postmenopausal bone loss by a low-

magnitude, high-frequency mechanical stimuli: a clinical

trial assessing compliance, efficacy, and safety. Journal of

Bone and Mineral Research 2004;19(3):343–51.

Russo 2003 {published data only}

Russo CR, Lauretani F, Bandinelli S, Bartali B, Cavazzini

C, Guralnik JM, et al.High-frequency vibration training

increases muscle power in postmenopausal women. Archives

of Physical Medicine and Rehabilitation 2003;84(12):

1854–7.

Sakai 2010 {published data only}

Sakai A, Oshige T, Zenke Y, Yamanaka Y, Nagaishi H,

Nakamura T. Unipedal standing exercise and hip bone

mineral density in postmenopausal women: a randomized

controlled trial. Journal of Bone and Mineral Metabolism

2010;28(1):42–8.

Sinaki 1989 {published data only}

Sinaki M, Wahner HW, Offord KP, Hodgson SF. Efficacy

of nonloading exercises in prevention of vertebral bone loss

in postmenopausal women: a controlled trial. Mayo Clinic

Proceedings 1989;64(7):762–9.

Smidt 1992 {published data only}

Smidt GL, Lin SY, O’Dwyer KD, Blanpied PR. The effect

of high-intensity trunk exercise on bone mineral density of

postmenopausal women. Spine 1992;17(3):280.

Tolomio 2009 {published data only}

Tolomio S, Lalli A, Travain G, Zaccaria M. Effects of a

combined weight- and non weight-bearing (water) exercise

program on bone mass and quality in postmenopausal

women with low bone mineral density. Clinica Terapeutica

2009;160(2):105–9.

Uusi-Rasi 2003 {published data only}∗ Uusi-Rasi K, Kannus P, Cheng S, Sievanen H, Pasanen

M, Heinonen A, et al.Effect of alendronate and exercise on

bone and physical performance of postmenopausal women:

A randomized controlled trial. Bone 2003;33(1):132–43.

Uusi-Rasi K, Sievanen H, Heinonen A, Kannus P, Vuori

I. Effect of discontinuation of alendronate treatment and

exercise on bone mass and physical fitness: 15-month

follow-up of a randomized, controlled trial. Bone 2004;35

(3):799–805.

Verschueren 2004 {published data only}

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Vanderschueren D, Boonen S. Effect of 6-month whole

body vibration training on hip density, muscle strength, and

postural control in postmenopausal women: a randomized

controlled pilot study. Journal of Bone and Mineral Research

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A, Kalender WA. Effect of whole body vibration exercise

on osteoporotic risk factors. Deutsche Medizinische

Wochenschrift (1946) 2009;134(30):1511–6.

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Bebenek M, Kemmler W, Von Stengel S, Engelke K,

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Notelovitz M, Martin D, Tesar R, Khan FY, Probart C,

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Pruitt 1992 {published data only}

Pruitt LA, Jackson RD, Bartels RL, Lehnhard HL.

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postmenopausal women. Journal of Bone and Mineral

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Rikli 1990 {published data only}

Rikli RE, McManis BG. Effects of exercise on bone mineral

content in postmenopausal women. Research Quarterly for

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Ruan XY, Jin FY, Liu YL, Peng ZL, Sun YG. Effects

of vibration therapy on bone mineral density in

postmenopausal women with osteoporosis. Chinese Medical

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Shen CL, Chyu MC, Yeh JK, Felton CK, Xu KT, Pence BC,

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Snow 2000 {published data only}

Snow CM, Shaw JM, Winters KM, Witzke KA. Long-

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Uusi-Rasi 2005 {published data only}

Uusi-Rasi K, Sievänen H, Heinonen A, Beck TJ, Vuori I.

Determinants of changes in bone mass and femoral neck

structure, and physical performance after menopause:

a 9-year follow-up of initially peri-menopausal women.


Villareal 2003 {published data only}

Villareal DT, Binder EF, Yarasheski KE, Williams DB,

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Xu H, Lawson D, Kras A. A study on Tai Ji exercise and

traditional Chinese medical modalities in relation to bone

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Yamazaki 2004 {published data only}

Yamazaki S, Ichimura S, Iwamoto J, Takeda T, Toyama

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References to studies awaiting assessment

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C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Bemben 2000

Methods Type of study: RCT

Participants Number of participants randomised = 35

Losses: 10 (4 high repetitions, 3 high load, 3 control)

Age: 41-60 years

Setting: USA

Inclusion:1-7 yr postmenopausal and had not performed any resistance training in the

previous 6 months

Exclusion: 1) diagnosed osteoporosis or a BMD site ≥ 2.5 SD below the mean for

the young-adult reference population; 2) a history of cardiovascular disease; 3) physical

or orthopaedic disabilities; 4) a history or current diagnosis of renal disease, chronic

digestive or eating disorders, rheumatoid arthritis, or thyroid disease; 5) a history of

prolonged bed rest; and 6) current or recent use of medications that affect bone density

(i.e. oestrogen, steroid hormones, calcitonin or corticosteroids)

Interventions Exercise group high load (HL) (NWBHF) (n = 10): 10-min warm-up, approximately

45 min of weight lifting, and ended with a 5-min cool-down. Quadriceps extension,

hamstring flexion, leg press, shoulder press, biceps curl, triceps extension, seated row and

latissimus pull. High load low reps (8 reps 80% 1RM)

Exercise group high repetition (HR) (NWBLF) (n = 7): 10-min warm-up, approximately

45 min of weight lifting, and ended with a 5-min cool-down. Quadriceps extension,

hamstring flexion, leg press, shoulder press, biceps curl, triceps extension, seated row and

latissimus pull. Low load high reps (16 reps 40% 1RM)

Control Group (n = 8): usual activity

Duration and intensity: 3 sessions per week for 6 months

Supervisor: Research assistants

Supervision: Group

Setting: Gym

Outcomes % Change BMD spine, hip (total hip, neck of femur, trochanter, Wards triangle), total

body

Notes Compliance/adherence: average attendance for the 6-month intervention was 93% for

HR and 87% for HL

Adverse events: none reported

Converted absolute data to % change

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk Subjects were matched according to the BMD of the spine after

baseline testing, then they were randomly assigned, method not

described



Bemben 2000 (Continued)

Allocation concealment (selection bias) Unclear risk Insufficient information to permit judgement of ’high risk’ or

’low risk’

Incomplete outcome data (attrition bias)

All outcomes

High risk ’As-treated’ analysis done, drop-outs mentioned but not ac-

counted for in analysis

Selective reporting (reporting bias) Unclear risk Insufficient information to permit judgement of ’high risk’ or

’low risk’

Other bias Low risk The study appears to be free of other sources of bias

Blinding (participant) High risk Not possible

Blinding (assessor) Unclear risk Not reported

Comparability of exercise and control

group at entry

Low risk No significant group differences existed in number of years post-

menopausal or in body composition variables

Appropriateness of duration of surveillance High risk Only immediately postintervention data at 6 months, no follow-

up data reported

Bergstrom 2008



Losses: 20 (Exercise: 1 failed to attend DXA, 11 did not start training or trained less

than 6 months, Control: 8 undertook other exercise)

Age: 59.6 Exercise, 58.9 control

Setting: Sweden

Inclusion: postmenopausal women 45 to 65 years with forearm fractures and T-scores

from −1.0 to −3.0 (total hip or spine)

Exclusion: T-score lower than −3 at any site, had any disease known to interfere with

bone metabolism, were on cortisone therapy or anti-resorptive medication, including

hormone replacement therapy, had a BMI lower than 19.9 or higher than 30.9, or were

already training at the level of or above that of the intervention

Interventions Exercise group (COMB) (n = 48): 3 fast 30-minute, walks and two sessions of one-

hour training per week. 5-minute warm-up, 25 minutes of strengthening exercises for

the arms, legs, back and stomach, 25 minutes of aerobic exercise, and 5 minutes of

stretching. Individuals chose own level and intensity and encouraged to increase level if

possible



Supervisor: nurses

Supervision: group

Setting: clinic



Bergstrom 2008 (Continued)

Outcomes % change BMD DEXA spine, total hip

Notes Compliance/adherence: controlled by study nurse (compliance was 95%)


80% power difference, 3% with 64 in each group


Risk of bias



bias)

Low risk Predefined random number table


’low risk’


All outcomes

Low risk Per protocol and intention-to-treat analysis


’low risk’





group at entry

Unclear risk Insufficient information to permit judgement of ’high risk’ or

’low risk’

Appropriateness of duration of surveillance High risk Only immediately postintervention data at 1 year, no follow-up

data reported

Bocalini 2009



Losses: 10 (3 exercise, 2 control, plus 5 in exercise did not achieve 90% participation)

Age: range 57-75 years

Setting: Brazil

Inclusion: women older than 55 years (and able to train 3 x per week for 24 weeks)

Exclusion: participation in a regular and structured physical activity for the last 3 months;

recent hospitalisation; motor deficiency; symptomatic cardiorespiratory disease; non con-

trolled hypertension or metabolic syndrome; severe renal or hepatic disease; cognitive



Bocalini 2009 (Continued)

impairment or debilitating conditions; marked obesity with inability to exercise; recent

bone fracture (during the past 2 years); use of any medication that may alter calcium or

bone metabolism; other medical contraindications to exercise

Interventions Exercise group strength training (NWBHF) (n = 15): Eccentric muscle action was em-

phasised for leg press, chest press, leg curl, latissimus pull down, elbow flexion, elbow

extension, leg extension, upper back row, military press, hip abductor, hip adductor and

abdominal curls. 10-minute warm-up, (running with low impact at 50% MHR), one

set 50% 1 RM, progressing to 3 sets 85% 1 RM


Duration and intensity: 1 hr sessions 3 x per week in non-consecutive days for 24 weeks

Supervisor: fitness instructor and researchers

Supervision: probably group

Setting: gym

Outcomes % change BMD DEXA lumbar spine, femoral neck

Notes Compliance/adherence: all completers required to participate in 90% of programme


Converted SE to SD

Risk of bias



bias)

Unclear risk Randomisation mentioned but insufficient information to per-

mit judgement of ’high risk’ or ’low risk’


’low risk’


All outcomes

Unclear risk ’As-treated’ analysis done, drop outs mentioned and 5 in exercise

group did not achieve 90% participation, thus were excluded


’low risk’


Blinding (participant) High risk Participants not blinded

Blinding (assessor) Low risk Investigator blind to subject condition


group at entry

Low risk No differences were identified between groups, concerning bio-

metric characteristics, muscle strength or bone densitometry pa-

rameters



Bocalini 2009 (Continued)

Appropriateness of duration of surveillance High risk Outcomes only on immediately postintervention (24 weeks), no

follow-up data reported

Bravo 1996

Methods RCT


Losses: 18 (equally divided across groups)

Age: mean 60±6 years

Setting: Canada

Inclusion: menopausal (> 12 months) community-dwelling women between the ages

of 50 and 70, with low bone mass (spine > 1g/cm2, proximal femur >0.9g/cm2), no

contradictions to undertaking physical exercise without supervision

Exclusion: not stated

Interventions Exercise group (DWBLF) (n = 61): warm up, 25 min of rapid walking: 15 min of

stepping down and up or aerobic dancing, each had to progressively reach 60-70% of her

heart rate reserve, localised exercise: 10-15 min of exercises in sitting, standing, prone

position, involving the muscles of upper limbs, abdominals and the back, cool down

period with relaxation movements, stretching, balancing and coordination exercises

Control group (n = 63): to continue their daily routine activities plus education

Duration and intensity: 1 hour long exercise classes, 3/week per 12 months

Supervisor: exercise leaders

Supervision: group

Setting: gym

Outcomes BMD spine, BMD neck of femur

Notes Compliance/adherence: not reported


Converted absolute data to % change.

Risk of bias



bias)

Low risk Random number tables, block randomisation and stratified by

age and HRT use


’low risk’


All outcomes

Low risk Missing outcome data balanced in numbers across intervention

groups, with similar reasons for missing data across groups In-

tention-to-treat analysis performed



Bravo 1996 (Continued)


’low risk’


Blinding (participant) Unclear risk Insufficient information to permit judgement of ’high risk’ or

’low risk’ but exercise is difficult to blind

Blinding (assessor) Low risk Three assessors blind to group allocation


group at entry

Low risk No significant differences between groups apart from years post-

menopause (longer in control group) and use of oestrogen (more

in exercise group)

Appropriateness of duration of surveillance High risk Only immediately postintervention data at 12 months, no fol-

low-up data reported

Brentano 2008



Losses: not stated

Age: not stated

Setting: Brazil

Inclusion: not stated

Exclusion: not stated

Interventions Exercise group Circuit training (NWBLF) (n = 9): No rest between exercises; progression

of loads. Warm-up: 5 minutes cycloergometer or treadmill, 20-10 repetitions and 45-

60% 1RM, performing 2-3 sets for each exercise, leg press, hip abduction, hip adduction,

knee extension, chest fly, reverse fly, arm curl, triceps push-down, sit-ups and back

extension

Exrcise group High intensity (NWBHF) (n = 10): 2 min rest between exercises; pro-

gression of loads. Warm-up: 5 minutes cycloergometer or treadmill. 20-6 repetitions

and 45-80% 1RM, performing 2-4 sets for each exercise, leg press, hip abduction, hip

adduction, knee extension, chest fly, reverse fly, arm curl, triceps push-down, sit-ups and

back extension


Duration and intensity: 1 hr 3 x week for 24 weeks

Supervisor: not stated

Supervision: group

Setting: gym

Outcomes BMD femoral neck, femoral trochanter, Ward’s triangle, intertrochanter



Brentano 2008 (Continued)

Notes Compliance/adherence: not stated


Data presented graphically only

Risk of bias



bias)

Unclear risk Subjects were divided into 2 subgroups: taking HRT (n = 14) and

not taking HRT (n = 14). Then, the subgroups were randomly

divided but insufficient information to permit judgement of

’high risk’ or ’low risk’


’low risk’


All outcomes


’low risk’


’low risk’


Blinding (participant) Unclear risk Not possible

Blinding (assessor) Unclear risk Insufficient information to permit judgement of ’high risk’ or

’low risk’


group at entry


’low risk’

Appropriateness of duration of surveillance High risk Only immediately postintervention data, no follow-up data re-

ported

Chan 2004



Losses: 24 (13 Exercise, 11 control)

Age: 54 (±3.5) years

Setting: Hong Kong

Inclusion: ceased menstruation between 1 and 10 years (1) no regular participation in

physical exercise (not > 0.5h/wk); (2) no hormone replacement therapy or drug treatment

known to affect bone metabolism or cause spontaneous bone loss; (3) no conditions

such as hypo- or hyperparathyroidism and hypo- or hyperthyroidism, or renal or liver

disease; (4) no history of fractures; and (5) a body mass index (BMI) above 30kg/m2



Chan 2004 (Continued)

Exclusion:

Interventions Exercise group (DWBLF) (n = 67): Yang Tau Chi Chuan style emphasises slow and

smooth movement involving major muscle groups, at a constant speed while practicing


Duration and intensity: 50 mins 5x week for 12 months

Supervisor: not reported

Supervision: group

Setting: community

Outcomes % change BMD DXA lumbar spine, neck of femur, total hip, trochanter, distal tibia

Fracture rate

Notes Compliance/adherence: Average attendance rate of the TCC exercise was 4.2±0.9 days

per week

Adverse events: Fractures occurred during the follow-up. During the 12-month study

period, a total of 4 fracture cases were documented, including 3 fracture in the control

group (1 vertebral fracture, 1 Colles’ fractures, 1 fracture at the fifth metacarpal) and 1

in the TCC group (proximal fibular fracture). All injury cases resulted from overloading

during work (the case with vertebral fracture) or falls (the other 3 cases)

Sample size of 45 for each group was estimated to achieve a statistical power of 0.8 after

excluding a dropout rate of approximately 25% during 12-month follow-up


Risk of bias



bias)




’low risk’


All outcomes

Unclear risk ’As-treated’ analysis done drop-outs mentioned


’low risk’





group at entry

Low risk No significant differences in characteristics at baseline



Chan 2004 (Continued)

Appropriateness of duration of surveillance High risk Only immediately postintervention data 12 months, no follow-

up data reported

Cheng 2002



Losses: 28 (non HRT 8 exercise, 5 control; HRT 10 exercise, 5 control)

Age: 50-57 years

Setting: Finland

Inclusion: 50 -55-year-old women, no serious cardiovascular or locomotor system prob-

lems, a body mass index of 33 kg/m2, and not currently or previously (no longer than 6

months and at least 2 years prior to screening) using medications including oestrogen,

fluoride, calcitonin, bisphosphonate’s, and steroids, last menstruation at least 0.5 years

but not more than 5 years ago

Exclusion: not reported

Interventions No HRT Exercise group (DWBHF) (n = 20): 5 circuit-training periods, each lasting 8

-10 weeks. These periods were interrupted by three high-impact aerobic dance periods,

each of 2 week duration, and a summer pause for 5 weeks. Each session commenced

with a 10 min warm-up period and concluded with stretching activities. During the

first two circuit training periods, three rotations were performed of skipping (30 sec)

, bounding over soft hurdles (13-16 cm), drop jumping (10-15 cm), and hopping (on

one leg 10 times, added during the second training period). The following three periods

comprised four rotations of bounding (19-25 cm), drop jumping (20-25 cm), hopping

(10 times per leg) and leaping (10 times). In addition, all circuit training sessions included

3 or 4 of the following resistance exercises for the upper body: chest fly, latissimus pull

down, military press, seated row and biceps curl. The home exercise programme was

also designed as a circuit training routine comprising three rotations of skipping (30

sec), hopping (10 times per leg) and drop jumping (15 cm). In addition, exercises to

strengthen the abdominal and lower back region were included. Average GRF was 4.3

times body weight (BW) for drop-landing from a 10 cm height, and 5.2 times BW from

20 and 25 cm heights; bounding over the hurdles 4.9-5.1 BW, skipping, hopping, and

leaping 3.8, 3.4, and 4.8 BW, respectively

No HRT Control Group (n = 20): usual activity

HRT Exercise group (DWBHF) (n = 20): as exercise group above

HRT Control Group (n = 20): usual activity

Duration and intensity: 2 x supervised and 4 non supervised sessions per week 12 months


Supervision: group/individual

Setting: gym/home

Outcomes BMD DXA proximal femur, tibial shaft

Cortical tibia



Cheng 2002 (Continued)

Notes Compliance/adherence: average attendance 1 x per week



Risk of bias



bias)

Low risk Randomisation by drawing lots


’low risk’


All outcomes

Unclear risk ’As-treated’ analysis done drop-outs mentioned but not con-

trolled for


’low risk’


Blinding (participant) Unclear risk Stated double-blind (may be related to the HRT component)

but insufficient information to permit judgement of ’high risk’

or ’low risk’

Blinding (assessor) Unclear risk Stated double-blind (may be related to the HRT component)

but insufficient information to permit judgement of ’high risk’

or ’low risk’


group at entry

Low risk No significant differences in physical characteristics at baseline



Chilibeck 2002



Losses: 9 (4 non bisphosphonate exercise, 3 bisphosphonate exercise, 2 non bisphospho-

nate control)

Age: mean age of groups ranged from 55.9 to 58.8 years

Setting: Canada

Inclusion: postmenopausal status (cessation of bleeding status for one year)

Exclusion: skeletal; disorders, kidney disease or bone related disorders, chronic disease or

chronic medication likely to affect metabolism or calcium imbalance. BMD z-score < -2.



Chilibeck 2002 (Continued)

0, HRT, bisphosphonate therapy in last year, recent participation in exercise programmes,

history of cardiac disease or high blood pressure

Interventions All received 10 µg vitamin D/d and those in non bisphosphonate received 500 mg

calcium carbonate/d

Non bisphosphonate exercise group (NWBHF) (n = 10): warm up cycling and stretching,

2 sets 8-10 reps of; bench press, latissimus dorsi pull down, shoulder press, biceps curl,

back extension, hip extension, flexion, adduction and abduction, knee flexion, knee

extension and leg press. initially 70% 1RM then progressed

Non bisphosphonate control Group (n = 12): usual activity

Bisphosphonate exercise group (NWBHF) (n = 12): as above

Bisphosphonate control group (n = 14): usual activity

Duration and intensity: 3 days per week for 12 months


Supervision: individual

Setting: gym

Outcomes % change BMD spine, total hip, femoral neck, trochanter, Ward’s triangle, whole body

% change whole body BMC

Notes Compliance/adherence: Non bisphosphonate exercise group 77.6%, bisphosphonate

exercise group 74.8% of training sessions


9 subjects per group would demonstrate change α of 0.05 with 80% power

Converted SE to SD

Risk of bias



bias)



Allocation concealment (selection bias) Low risk Insufficient information although mentions double-blind


All outcomes

Unclear risk ’As-treated’ analysis done drop-outs mentioned but not con-

trolled for


’low risk’


Blinding (participant) Unclear risk Mentions double-blind but probably relates to medication status

Blinding (assessor) Low risk States double-blind



Chilibeck 2002 (Continued)


group at entry

Low risk No significant differences in characteristics at baseline



Chow 1987

Methods RCT


Losses: 4 controls, 2 (DWBLF), 4 (COMB)

Age: mean age 56 years

Setting: Canada

Inclusion: no history of: fractures, metabolic bone disease, renal, liver or thyroid disor-

ders, gastrectomy, alcoholism, oestrogen or other drugs affecting bone metabolism


Interventions Exercise group (DWBHF) (n = 19): 5-10 min of stretching and calisthenic warm up,

exercise followed by 30 min of aerobic activities at 80% MaxHR (walking, jogging,

dance)

Exercise group (COMB) (n = 20) 5-10 min of stretching and calisthenic warm up,

exercise followed by 30 min of aerobic activities at 80% MaxHR (walking, jogging,

dance) plus 10-15 min session of low intensity strength training (isometric and isotonic

contractions of limbs and trunk muscles. 10 repetitions for each muscle group

Control Group (n = 19): continue daily routine activities, refrain from any regular fitness

exercises (telephoned 4 x per year)

Duration and intensity: 3 sessions per week for 1 year

Supervisor: certified fitness instructor

Supervision: group

Setting: hospital gym

Outcomes CaBI.

Notes Compliance/adherence: overall attendance at exercise class was 70%

Adverse events: 1 (DWBLF) knee pain; 2 (COMB) knee pain; 1 (COMB) back pain

Power calculation done 15 per group, and all groups of appropriate size


Risk of bias



bias)

Low risk Random number generator

Allocation concealment (selection bias) Low risk Sequential sealed envelopes



Chow 1987 (Continued)


All outcomes

Low risk Details supplied. Discussion of reasons for dropout. Comparison

with dropout and excluded groups


’low risk’


Blinding (participant) High risk Not practical for exercise programme

Blinding (assessor) Low risk Assessors blind


group at entry

Low risk Initial mean values of bone mass and aerobic capacity were

within normal ranges for all groups



Chubak 2006



Losses: 3 exercise group

Age:50-75 years, mean 61 years

Setting: USA

Inclusion: overweight/obese, postmenopausal women sedentary (< 60 min/wk of mod-

erate-to vigorous-intensity exercise), overweight (BMI 25.0 to 30.0 kg/m2, or BMI be-

tween 24.0 and < 25.0 kg/m2 and percent body fat > 33%) or obese (BMI > 30.0 kg/

m2), no menstrual periods for the previous 12 months

Exclusion: using hormone therapy in the past 6 months, being too physically active, hav-

ing medical conditions contraindicating moderate to vigorous-intensity exercise, having

a clinical diagnosis of

diabetes, and currently using tobacco

Interventions Exercise group (COMB) (n = 87): moderate-intensity aerobic exercise (60-75% of maxi-

mal heart rate), 40% of observed maximal heart rate for 16 min per session and gradually

increased to 60-75% of maximal heart rate for 45 min per session by week 8. Treadmill

walking and stationary bicycling. Strength training, consisting of two sets of 10 repeti-

tions of leg extension, leg curls, leg press, chest press, and seated dumbbell row

Control Group (n = 86): 45-min stretching sessions once a week

Duration and intensity: 45 mins, 5 days per week for 12 months (3 supervised sessions

per week months 1-3 and to exercise 2 d/wk at home; months 4-12 at least one of the

three supervised sessions weekly and to exercise 4 d/wk either at home or elsewhere


Supervision: group and individual

Setting: gym and home



Chubak 2006 (Continued)

Outcomes BMD Total body

Notes Compliance/adherence: exercisers averaged 172 min/wk (SD = 89) of exercise



Risk of bias



bias)

Low risk Stratifying on body mass index (BMI) (above and below 27.5

kg/m) randomly assigned women to either the exercise or the

stretching arm of the trial. Randomisation was performed

by random number generation

Allocation concealment (selection bias) Low risk Group assignment was placed in a sealed envelope, which was

opened by the study coordinator at the time of randomisation


All outcomes

Low risk Intention-to-treat analysis performed


’low risk’



Blinding (assessor) Low risk Technicians blinded to group allocation


group at entry

Low risk Groups similar with respect to demographic characteristics and

known predictors of bone mineral density and other subject

characteristics



Chuin 2009



Losses: not reported

Age: 61-73 years, 66.1 years

Setting: Canada

Inclusion: healthy, Caucasian, without major incapacity, no medication influencing

metabolism, non-smoker, moderate drinker, NBMI 18-30 kg/m2, no consumption of



Chuin 2009 (Continued)

antioxidant supplements during last month, postmenopausal, no HRT


Interventions Antioxidants (600 mg/day vitamin E and 1,000 mg/day vitamin C)

Placebo and Exercise group (NWBHF) (n = 8): 15 min warm up, treadmill, cycle and

stretching; 45 mins resistance training leg press, bench press, leg extension, shoulder

press, sit up, seated row, triceps extensions, biceps curl. 3 sets 8 reps per set at 80% 1RM

Placebo Control Group (n = 7): usual activity

Antioxidant exercise group (NWBHF) (n = 8): as exercise above

Antioxidant control group (n = 8): usual activity

Duration and intensity: 60 mins sessions 3 x week for 6 months


Supervision: groups

Setting: gym

Outcomes BMD spine, femoral neck

Notes Compliance/adherence: not stated but one missed session per month accepted for com-

pliance purposes



Risk of bias



bias)




’low risk’


All outcomes

Unclear risk Completer analysis. Loss not accounted for


’low risk’




’low risk’


group at entry

Low risk Groups were similar for baseline characteristics, body composi-

tion, strength



Chuin 2009 (Continued)


up data reported

Ebrahim 1997

Methods RCT


Losses: 32 exercise group, 36 control

Age: mean ages (66-70) years

Setting: UK

Inclusion: women who had sustained an upper arm fracture in the past 2 years

Exclusion: not recorded

Interventions Exercise group (DWBLF) (n = 49): self paced brisk walking

Control Group (n = 48): upper limb exercises for fracture

Duration and intensity: 40 mins 3 x week for 2 years

Supervisor: nurse

Supervision: seen every 3 months and phone calls monthly

Setting: home

Outcomes BMD lumbar spine, femoral neck

Notes Compliance/adherence: All women completing trial reported carrying out regular brisk

walking at least 40 mins three times per week

Adverse events: 1 exercise related trauma reported. By the end of the trial the brisk

walking group had sustained a significant excess of 15.2 falls per 100 person years

No power calculation. Very small study (15 total, 5 per exercise group)

Risk of bias



bias)

Low risk Computer generated randomised allocation

Allocation concealment (selection bias) Low risk Sequentially numbered envelopes


All outcomes

Low risk Missing outcome data balanced in numbers across intervention

groups, with similar reasons for missing data across groups. Data

for all participants, including one dropout at 11 months


’low risk’




Ebrahim 1997 (Continued)



Blinding (assessor) High risk Same nurse saw both groups


group at entry

Low risk No significant differences between groups apart from slightly

younger women in the exercise group

Appropriateness of duration of surveillance High risk Only immediately postintervention data at 2 years, no follow-

up data reported

Englund 2005



Losses: 3 exercise, 5 control

Age: 66-87 years

Setting: Sweden

Inclusion: not reported

Exclusion:dementia, current smoking, current hormone replacement therapy (HRT),

and use of a walking aid, cardiovascular disease, or functional disability, of a degree that

would contraindicate physical exercise

Interventions Exercise group (COMB) (n = 24): 10 min of warming-up, followed by a mix of aerobic

(walking and jogging), strengthening (legs, abdominal, and back muscles were trained

by means of body resistance only) , balance and coordination exercises for 27 min.

The programme then ended with 11 min of cooling down, stretching and relaxation. If

participants missed out on a training session they were advised to perform a home exercise

programme instead. This programme included brisk walking for 30 min, squats with

3·10 repetitions, and training of hand grip with a piece of T-foam for 3·15 repetitions

Control Group (n = 24):

Duration and intensity: 50 mins twice a week for 12 months, with a 5-week break during

the summer vacation

Supervisor: physiotherapist

Supervision:not reported

Setting:not reported

Outcomes BMD spine, femoral neck, trochanter, Ward’s triangle, arms, total body (g/cm2)

BMC total body (g)

Notes Compliance/adherence: mean percentage of scheduled sessions attended for the exercise

group was 67%

Adverse events: not recorded

A sample size of 24 in each group, a-level of 0.05 and standard deviation of 10% gave

30% power to detect a 5% difference in change between the two groups




Englund 2005 (Continued)

Risk of bias



bias)

Unclear risk Pair-wise age matched, randomised mentioned but insufficient

information to permit judgement of ’high risk’ or ’low risk’


’low risk’


All outcomes

Unclear risk ’As-treated’ analysis done drop-outs mentioned but not ac-

counted for in analysis


’low risk’



Blinding (assessor) Unclear risk Unclear but the same investigator carried out all analyses


group at entry

Low risk There was no significant difference in total BMD between the

groups at the beginning of the

study but mean age for menopause was significantly higher in

the control group

Appropriateness of duration of surveillance Low risk Immediately postintervention data 12 months and 5 year follow-

up data reported

Going 2003


Participants Number of participants randomised = 320 (HRT, n = 159; NHRT, n = 161)

Losses: Retention rates were 82%, 89%, 78% and 84% for EX/NHRT, NEX/

HRT, EX/NHRT and NEX/NHRT, respectively. The dropout rate for EX (20%) and

NEX (13%), NonHRT (19%), HRT (14%)

Age: 40-65 years

Setting: USA

Inclusion: women who were undergoing hormone replacement therapy for at least 1 year

and not more than 5.9 years AND women who had not used HRT during the preceding

year. Surgical or natural menopause (3-10.9 years). BMI < 33, non smoker, no history of

osteoporotic fractures, initial lumbar spine and hip BMD > Z -3.0. Cancer and cancer

treatment free for the last 5 years, excluding skin cancer, no medication affecting BMD,

no beta blockers or steroids. Ca intake > 200 mg per day. Less than 120 min physical

activity per week. No weightlifting or similar activity.



Going 2003 (Continued)


Interventions Divided into HRT and non HRT groups. All groups taking Ca supplements as prescribed

HRT Exercise group (DWBHF) (n = 86): supervised aerobic, weight-bearing and weight-

lifting exercise. Leg press, hack squats or Smith squats, lat pull downs, lateral rows, back

extensions, right and left arm dumbbell presses, and rotary torso. Two sets of 6 to 8

repetitions 70% - 80% 1-RM. Weight bearing circuit comprising walk/jog, skipping,

hopping, stair climbing/boxstep. Progressive impact regime

HRT Control Group (n = 73): usual activity

NonHRT Exercise group (DWBHF) (n = 91): supervised aerobic, weight-bearing and

weight-lifting exercise as above

Non HRT control Group (n = 70): usual activity

Duration and intensity: 3x per week for 12 months

Supervisor: trainer

Supervision: group

Setting: community

Outcomes BMD DEXA total body, AP lumbar spine, neck of femur, trochanter

Notes Compliance/adherence: Attendance at exercise sessions averaged 71.8±19.9%


Converted data from average change over one year to change at end of study

Risk of bias



bias)




’low risk’


All outcomes

Low risk Intention-to-treat analysis undertaken


’low risk’





group at entry

Low risk Groups similar at baseline for age, oestrogen levels, BMD and

physical characteristics. Women not using HRT 1.6 years older



Going 2003 (Continued)


up data reported

Grove 1992

Methods Type of study:RCT


Losses:1 subject in DWBHF group injured at 11 months, all post-test data from subject

collected at this time point

Age:46-64 yrs

Setting: USA

Inclusion: postmenopausal sedentary Caucasian women

Exclusion: women who were active during last year; < 1 year or > 8 years postmenopausal;

any renal, thyroid or liver disease; unwillingness to complete study; on medications that

would affect calcium metabolism and absorption (except oestrogen)

Interventions Exercise group (DWBLF) (n = 5): 15 mins warm up (stretching), 20 min exercise(low

impact), 20 mins cool down (abdominal exercises). GRF for exercises, slow walk = 1.19

BW, fast walk = 1.49 BW, heel jack no jump = 1.34 BW, Charleston = 1.32 BW

Exercise group (DWBHF) (n = 5): 15 mins warm up (stretching), 20 min exercise (high

impact), 20 mins cool down (abdominal exercises). GRF for exercises, jumping jack =

3.29 BW, running-in-place = 2.47 BW, knee-elbow with jump = 2.79 BW


Duration and intensity: 1 hr 3x week for 12 months


Supervision: group

Setting: gym

Outcomes Lumbar BMD at baseline, 6 and 12 months

Notes Compliance/adherence: DWBLF = 80.0±6.6%, DWBHF = 82.6±4.1%

Adverse events: 1 subject in DWBHF group injured at 11 months

Risk of bias



bias)

Unclear risk Matched by BMD and weight and randomly assigned to groups,

method not stated


’low risk’


All outcomes

Unclear risk Small numbers in each group and only one loss



Grove 1992 (Continued)


’low risk’




’low risk’


group at entry


’low risk’



Hatori 1993



Losses: 2 from exercise group (lack of time)

Age: 46-67 years

Setting: Japan

Inclusion: health postmenopausal women no history of oophrectomy


Interventions Exercise group:

DWBLF (n = 9): stretching of the legs, torso and arms, followed by 30 min of walking

on flat grass-covered ground moderate intensity: 90% of the heart rate

DWBLF (n = 12): stretching of the legs, torso and arms, followed by 30 min of walking

on flat grass-covered ground high intensity: 110% of the heart rate

Control Group (n = 12): not reported

Duration and intensity: 3 times/week during 7 months


Supervision: not clear

Setting: not stated

Outcomes % change in BMD

Lumbar Spine (DEXA)



Data for the group working at 110% HR was used in analysis

Risk of bias



Hatori 1993 (Continued)



bias)

Unclear risk Randomisation reported but insufficient information about the

sequence generation process to permit judgement of ’high risk’

or ’low risk’


’low risk’


All outcomes

High risk ’As-treated’ analysis done, drop-outs mentioned but unclear as

to which groups


’low risk’




Blinding (assessor) Low risk Assessor had no knowledge of group allocation


group at entry

Low risk No significant difference between the groups at entry

Appropriateness of duration of surveillance High risk Assessment at 7 months during the exercise programme of 7

month duration

Iwamoto 2001




Age: 53-77 years

Setting: Japan

Inclusion: postmenopausal women with diagnosis of osteoporosis


Interventions Concurrent calcium lactate 2.0 g and hydroxy vitamin D3 1 µg

Exercise group (COMB) (n = 15): brisk walking and two sets a day of gymnastic training,

consisting of 15 repetitions of straight leg raising, squatting, and abdominal

and back muscle strengthening exercises


Duration and intensity: daily for 12 months



Setting: home



Iwamoto 2001 (Continued)

Outcomes % change BMD lumbar

Notes Compliance/adherence: 100% at least five days per week


Risk of bias



bias)




’low risk’


All outcomes


’low risk’


’low risk’



Blinding (assessor) Unclear risk Not reported. Insufficient information to permit judgement of

’high risk’ or ’low risk’


group at entry

Low risk No significant differences in initial lumbar BMD

Appropriateness of duration of surveillance High risk Immediately postintervention data at 12 months, and follow-

up after further year

Iwamoto 2005



Losses: none reported

Age: 70.6±8.7 control, 71.9±8.1 exercise

Setting: Japan

Inclusion:55-88 years, BMD score < 70 or 70-80%, history of osteoporotic fractures

and chronic back pain

Exclusion: musculoskeletal diseases considered to cause back pain



Iwamoto 2005 (Continued)

Interventions All participants received 5 mg alendronate

Exercise group (DWBHF) (n = 25): whole body vibration plate at 20 Hz


Duration and intensity: 4 mins, 1 x week for 12 months



Setting: clinic

Outcomes BMD

vertebral fractures (radiographs)

Notes Compliance/adherence: not stated

Adverse events: 2 patients in control group and one in exercise group had falls

Risk of bias



bias)




’low risk’


All outcomes

Unclear risk ’As-treated’ analysis done no drop outs mentioned


’low risk’





group at entry

Low risk

Appropriateness of duration of surveillance Low risk



Karinkanta 2007


Participants Number of participants randomised: 149

Losses: Total = 5 (4 from the training groups and 1 from control). (Drop out rate 3.4%)

Age: 70-79 years: RES = 72.7 (2.5); BAL = 72.9 (2.3); COMB = 72.9 (2.2); CON = 72

(2.1)

Sex: female

Health status defined by authors: healthy older (> 70) females

Setting: Finland

Inclusion: willing to participate; age between 70-79 years; full understanding of study

procedures; no history of illness contraindicating exercise or limiting participation in

exercise programmes, no history of illness affecting balance or bones; no uncorrected

vision problems; no medications known to affect balance or bone metabolism (12 months

before enrolment)

Exclusion: Involved in intense exercise more than 2x week or t-score for femoral neck

bone mineral density (BMD) lower than -2.5

Interventions Exercise group (DWBHF) = resistance training (n = 37). Progressing towards 75-80%

1RM 3 sets of 8-10. Large muscle group ex = sit-stand with weighted vest, squats, leg

press, hip abduct, hip extension, calf raise, rowing with resistance machines. Different

combinations of above were used in 10 week cycle to prevent monotony

Exercise group (DWBHF) = balance jumping training (n = 37). Balance agility and

impact exercise - 4 different aerobics and step aerobic programmes which were repeated.

Progressive difficulty of steps, impact and jumps

Exercise group (COMB) = resistance and balance jumping training (n = 38). Reistance

and balance training on alternate weeks as above

Control group = no training (n = 37)

Duration and intensity: 3x weekly for 12 months, 50 mins. Warm up 7-10 mins; 25-30

mins exercise; 8-10 min cool down

Supervisor: exercise leaders of UKK institute

Supervision: groups but uncertain of number in each as not recorded

Setting: not recorded

Outcomes BMD DEXA

• Bone mineral content BMC (g)

• Cortical density (CoD) mg/cm

Notes Compliance/adherence: mean training compliance = attendance 67% (RES = 74%;

COMB = 67%; BAL = 59%)

Adverse events: 14 due to musculoskeletal injuries or symptoms - 2 falls but they

returned to classes. No difference in monthly reported health problems with exercisers

and controls

Fractures reported during 1 year follow-up period:

Resistance group 1 hip 1 rib; Balance group 1 shoulder; Combined 1 hip; Control 1

patella

Initial study data converted absolute data to % change. Follow-up study data was not

presented in a useable form

Risk of bias



Karinkanta 2007 (Continued)



bias)

Low risk Computer generated randomisation list drawn up by statistician,

blinded to study participants and their characteristics, randomly

allocated participants into 4 groups

Allocation concealment (selection bias) Low risk Statistician, blinded to study participants and their characteris-

tics, randomly allocated participants into 4 groups


All outcomes

Low risk Intention-to-treat and per protocol analysis

Selective reporting (reporting bias) Unclear risk Insufficient information to permit judgement of ’yes’ or ’no’ all

main outcome measures reported on



Blinding (assessor) Unclear risk Insufficient information to permit judgement of ’yes’ or ’no’


group at entry

Low risk Statistics reported groups equivalent at baseline

Appropriateness of duration of surveillance Low risk Immediately postintervention data at 12 months, and one year

postcessation of intervention

Kerr 2001



Losses: Retention at 2 years was 71% (59% in the S group, 69% in the F group, and

83% in the C group),

Age: mean 60 (6.5) years

Setting: Australia

Inclusion: more than 4 years past menopause and physically capable of entering exercise

groups but who were not already exercising at a moderate intensity more than 2 h/week

Exclusion: hormone replacement or other medications or who had diseases known to

affect bone density and those who had cardiovascular, physical, or orthopedic disabilities

Interventions All subjects given 600 mg calcium per day

Exercise group (NWBHF) (n = 24): warm-up consisting of brisk walking and stretching.

This was followed by 30 minutes of resistance weight training exercises and progressively

increased the loading, wrist curl, reverse curl, biceps curl, triceps pushdown, hip flexion,

hip extension, latissimus dorsi pull down, and calf raise

Exercise Group (NWBLF) (n = 30): as above but additional stationary bicycle riding



Kerr 2001 (Continued)

with minimal increase in loading


Duration and intensity: 1 hr sessions 3 x per week 2 years

Supervisor: exercise physiologists

Supervision: group

Setting: gym

Outcomes BMD hip (total hip, femoral neck, trochanter, Wards triangle) , lumbar spine, and radial

forearm

Notes Compliance/adherence: Exercise compliance was very high in the first 6 months for both

groups (S group, 90±12%; F group, 92± 8%) but declined from this point on. In the

last 6 months of compliance was 61±23% for the S group and 67±20% for the F group.

The average exercise compliance over 2 years was 74±13% in the S group and 77±14%

in the F group


Risk of bias



bias)

Low risk Block randomisation to one of three groups


’low risk’


All outcomes

Unclear risk ’As-treated’ analysis done drop-outs mentioned but unclear as

to which groups


’low risk’





group at entry

Low risk No difference between the groups at baseline

Appropriateness of duration of surveillance High risk Only immediately postintervention data 2 years, no follow-up

data reported



Korpelainen 2006



Losses: 68 women (81.0%) in the exercise group and 65 (85.5%) women in the control

group completed the study

Age: mean age 73 years

Setting: Finland

Inclusion: hip BMD value of more than 2 SD below the reference value

Exclusion: use of a walking aid device other than a stick, bilateral hip joint replacement,

unstable chronic illness, malignancy, medication known to affect bone density, severe

cognitive impairment and involvement in other interventions

Interventions Exercise group (COMB) (n = 84): jumping and balance exercises, including walking,

knee bends, leg lifts, heel rises and drops, dancing, stamping, stair climbing and stepping

up and down from benches


Duration and intensity: 1hr sessions, 30 months

Supervisor: physiotherapist

Supervision:group and individual

Setting: clinic and home

Outcomes BMD Radius and hip (total hip, neck of femur, trochanter)

During the 30-month follow-up, there were 88 falls in the exercise group and 101 falls

in the control group

(P = 0.10). The incidence of fall-related fractures was higher in the control group (n =

16) than in the exercise group (n = 6; P = 0.019). One woman in the control group had

two fractures, and all other 20 women had one fracture

Notes Compliance/adherence: Attendance at the exercise sessions averaged 78% during the first

supervised 6-month period, 74% during the second supervised period and 73% during

the last supervised 6 months. The average frequency of performing the home exercise

programme was three times per week

Adverse events: Three women in the exercise group experienced musculoskeletal prob-

lems that required minor modifications in the training regimen

5% level would require 64 women in each group to give an 80% power to detect a 0.02

g/cm2 difference in the primary outcome (femoral neck, trochanter and total hip BMD

with an SD of

0.04 g/cm2) between the groups

Risk of bias



bias)

Low risk Computer-generated random numbers

Allocation concealment (selection bias) Low risk Randomisation provided by a technical assistant not involved in

the conduction of the trial



Korpelainen 2006 (Continued)


All outcomes

Low risk Data were analysed on an intention-to-treat basis, and any miss-

ing follow-up data

was replaced with the last known value even if this was the

baseline value


’low risk’



Blinding (assessor) Low risk Operators were unaware of the women’s trial status


group at entry

Low risk No significant difference between the groups at baseline

Appropriateness of duration of surveillance Low risk Immediately postintervention data 30 months, with follow-up

data reported mean 7.1 years

Lau 1992

Methods RCT


Losses:10

Age: 62-92 years

Setting: China (Hong Kong)

Inclusion: Female residents in hostel for elderly with mental function ≥ 6 on Hodkinson

Scale

Exclusion: metabolic bone disease; diabetes mellitus; previous hip fracture; blood crea-

tinine level > 125 mUmol/l

Interventions Calcium supplementation group (n = 12) received 800 mg calcium daily

Exercise group and placebo (DWBLF) (n = 11): participants stepped up and down 23

cm high block 100 times then exercised upper trunk while standing for 15 minutes

Exercise group and calcium supplementation (DWBLF) (n = 15): participants exercised

as above and received 800 mg calcium per day

Control Group (n = 12): received placebo tablet daily

Duration and intensity: 4 times per week for 10 months. Submaximal exertion effort

Supervisor: research nurse

Supervision: throughout study


Outcomes % change in BMD hip (neck of femur, Wards triangle) and lumbar spine



Lau 1992 (Continued)

Notes Compliance/adherence: not recorded

Adverse events:epigastric discomfort (n = 1), and diarrhoea (n = 1) from calcium sup-

plement

Risk of bias



bias)

Low risk Random permuted blocks

Allocation concealment (selection bias) Low risk List prepared in advance and independent of sequence of entry


All outcomes


to which groups


’low risk’




Blinding (assessor) Unclear risk Serial BMD measures were computerised and largely automatic

however the operator referred to copies of the first image in

subsequent measurements


group at entry

Low risk No significant differences observed in baseline characteristics


low-up data recorded

Lord 1996

Methods RCT


Losses: 32 from exercise group, 19 from control group

Age: 60-85 yrs (mean 71.6; SD 5.3)

Setting: Australia

Inclusion: women who had participated in a previous falls and fractures study, living

independently in the community

Exclusion: illness or immobility; hospitalisation; medial conditions of neuromuscular,

skeletal or cardiovascular system that precluded participation in exercise programme;

non English speaking; participating in exercise classes of equivalent intensity to study

intervention



Lord 1996 (Continued)

Interventions Exercise group (DWBLF) (n = 90): exercise: 5 warm up period: 35 min conditioning

period (aerobic exercise, activities for balance, hand-eye and foot-eye coordination and

stretching exercises); stretching period 15 min; relaxation 15 minutes

Control Group (n = 89 ): no organised activity

Duration and intensity:1 hour exercise classes twice weekly for four 10-12 week sessions

for 12 months

Supervisor: 3 trained instructors

Supervision: at each class

Setting: community exercise class

Outcomes BMD, Lumbar spine, femoral neck, trochanter

Notes Compliance/adherence: 59.8 (72.9%) 53 participants attended 50 or more classes

Adverse events: none

Risk of bias



bias)

Unclear risk Complex randomisation procedure, but unclear how randomi-

sation carried out

Allocation concealment (selection bias) Low risk Randomisation conducted prior to recruitment


All outcomes

Low risk All initial participants accounted for


’low risk’




Blinding (assessor) Unclear risk Not recorded


group at entry

Low risk No significant differences between groups at entry





Maddalozzo 2007



Losses: retention rates 83% NHRT plus exercise, 89% HRT plus exercise; 91% HRT

no exercise; and 82% control group

Age: 52.1± 3.0 years

Setting: USA

Inclusion: women who had experienced the menopause within the previous 0-36 months

from the time of baseline testing as determined retrospectively from questionnaire reports;

(2) no menstrual cycles within the previous 12 months without being pregnant, but not

longer than 36 months (based on questionnaire recall phone screening interview); (3)

follicle-stimulating hormone levels ≥ 40 mIU/mL (obtained from the subjects physician)

; (4) body mass index (19-30 kg m−2), (5) 36 months or less of being diagnosed as

being postmenopausal by their general physician; and (6) either taking HRT 0.625 mg

conjugated equine oestrogen, (Premarin®) or non HRT use

Exclusion: non-HRT users who had taken HRT for 12 consecutive months prior to

applying to the study; (2) hypertension; (3) metabolic disease that may affect bone or

muscle metabolism (including diabetes and thyroid disease); (4) statin medications for

hypercholesterolaemia), multiple sclerosis; and (4) osteoarthritis or other musculoskeletal

disorders that prevented participation

Interventions Non HRT Exercise group (DWBHF) (n = 35): free weight back squat and free weight

dead lift exercises repetitions at a speed of 1-2 sets for the concentric (lifting) and 2-3

sets for the eccentric (lowering) phases. Two warm-up sets of 10-12 repetitions at 50%

of 1RM then 3 working sets at 60-75% of 1 RM (set 1 = 8 reps; set 2 = 10 reps; and set

3 = 12 reps)

Non HRT Control Group (n = 34)

HRT exercise group (DWBHF) (n = 37): as Non HRT Exercise group

HRT Control Group (n = 35)

Duration and intensity: 50 mins 2 x week for 52 weeks

Supervisor: personal trainer


Setting: gym

Outcomes BMD DXA lumbar spine (L1-L4), proximal femur (total hip, femoral neck, and greater

trochanter) and whole body composition

Notes Compliance/adherence: non-HRT plus exercise (84.7±12.8%) and HRT plus exercise

group (86.2±11.4%)


Desired power ≥ 0.8, alpha = 0.05, and an expected difference between groups of 4%

increase in muscle mass and a 1% increase in spine BMD, 25 subjects per group were

needed

Risk of bias




Maddalozzo 2007 (Continued)


bias)

Unclear risk Self selected as either HRT or non-HRT replaced then ran-

domised. Randomisation mentioned but insufficient informa-

tion to permit judgement of ’high risk’ or ’low risk’


’low risk’


All outcomes


to which groups


’low risk’





group at entry

Low risk No significant differences were observed at baseline on any vari-

able except for spine BMD between HRT and non-HRT groups

Appropriateness of duration of surveillance High risk Only immediately postintervention data at 52 weeks, no follow-

up data reported

Martin 1993

Methods RCT


Losses: 21, control n = 5, 30 min group n = 7, 45 min group n = 9

Age:49 - 66 years

Setting: Florida USA

Inclusion: women at least 12 months postmenopause; non-smoking; white (mainly

European descent); no medical or orthopaedic contraindications to exercise; no use

of medication known to interfere with calcium metabolism in preceding 12 months;

no actively participation in aerobic or strength training programmes in preceding 12

months; no history of intolerance to dairy products; willing to take calcium and vitamin

D supplementation; no bony vertebral abnormalities of lumbar or thoracic spine on x-

ray; willing to accept randomisation


Interventions All groups received calcium and vitamin D supplementation

Exercise group 1 (DWBLF) (n = 27): 30 minute group. Start and end with 3-5 min of

warm up to 60% of max heart rate. Then treadmill to 7% grade (inclination) and to

70% max heart rate in the first 2-4 weeks, and after to 85% (gradually) for 30 minutes

in total

Exercise group 2 (DWBLF) (n = 25): start and end with 3-5 min of warm up to 60%



Martin 1993 (Continued)

of max heart rate. Then treadmill to 7% grade (inclination) and to 70% max heart rate

in the first 2-4 weeks, and after to 85% (gradually) for 45 minutes in total

Control Group (n = 19): calcium and vit D, no exercise

Duration and intensity: 3 times a week for 1 year

Supervisor: not recorded

Supervision: not recorded


Outcomes BMD Lumbar, Proximal forearm, Distal forearm, Body Mass

Notes Compliance/adherence: Group 1: 77.5 - 79.2 %, Group 2: 85.2 - 82.4% at 0 -6 and 6

- 12 months


Risk of bias



bias)



or ’low risk’


’low risk’


All outcomes

Unclear risk ’As-treated’ analysis done, drop-outs mentioned but different

across the groups


’low risk’





’low risk’


group at entry


Appropriateness of duration of surveillance High risk Only immediately postintervention data at 12 months no fol-




Metcalfe 2001


Participants Number of participants randomised = 301 (266 completed)

Losses: 35

Age: 40-66 average 55.6 years

Setting: USA

Inclusion: postmenopausal women, sedentary, non smoking, no history of fracture or

osteoporosis


Interventions Calcium tablets administered to both groups (800 mg per day)

Non HRT Exercise group (COMB) (n = 177) warm up (5/10 min), progressive weight

bearing (25 min) skipping, jogging, jumping, stair climbing with weighted vests. Re-

sistance exercises with large muscle groups (20 min) 70-80% 1RM Resistance exercises

with small muscle groups (10 min), Abdominal strengthening (5 min), Stretching and

balance (5 min)

Non HRT Control Group (n = 124): usual activity

HRT Exercise group (COMB) (n =) : as exercise above

HRT control group (n =): usual activity

Duration and intensity: 60-75 minute session 3 non consecutive days per week for 12

months

Supervisor: trainer with BSc MSc in exercise science or related field, certification by

nationally recognised fitness and strength training organisation, and specifically trained

in BEST programme by physical therapist

Supervision: ratio of trainers to participants was 1:5

Setting: community fitness facility

Outcomes BMD spine and hip using dual energy -ray absorptiometry

Muscle strength

Notes Compliance/adherence: 35 of exercise group dropped out. Retention rate 80.2% adher-

ence to programme > 70.4%


Risk of bias



bias)




’low risk’


All outcomes

Low risk Losses accounted for in exercise group


’low risk’



Metcalfe 2001 (Continued)

Other bias High risk Exercise group appeared to have more support with incentive

programmes, social interaction and mentoring from trainers



’low risk’


group at entry

Unclear risk No data provided to compare group demographics

Appropriateness of duration of surveillance Low risk Immediately postintervention data at 12 months, 4 year follow-

up data reported

Nelson 1994

Methods RCT


Losses: 1 participant from exercise group (suffered MI on holiday during first month of

study)

Age: 50-70 yrs

Setting: USA

Inclusion: at least 5 years postmenopausal; < 70 years of age; not participating in regular

exercise programme (no strength training and < 20 mins of aerobic exercise twice per

week); weighing less than 130% of ideal body weight; non-smoking; no more than 1

crush fracture of spine; no history of other osteoporotic fractures; and had not taken

oestrogen or other medications known to affect bone for at least 12 months.


Interventions Exercise group (NWBHF)(n = 21): 45 min sessions, 3 sets of eight repetition: high

intensity strength training (concentric and eccentric contractions: hip extension, knee

extension, lateral pull down, back extension, abdominal flexion using pneumatic resis-

tance machine)

Control Group (n = 19): they were asked to maintain their current level of physical

activity during the year

Duration and intensity: 52 weeks (2 weeks off for vacation), 2 times per week, with at

least 1 day of rest between sessions

Supervisor: exercise trainer

Supervision: no more than two participant to each trainer


Outcomes BMD (lumbar spine), femoral neck, Total Body (BMC)

Notes Compliance/adherence: attendance averaged 87.5% +/- 1.8%

Adverse events: 7 participants suffered transient musculoskeletal pain requiring minor

modification of training regimen, but completed programme



Nelson 1994 (Continued)

Risk of bias



bias)



or ’low risk’


’low risk’


All outcomes

Low risk ’As-treated’ analysis done drop-outs mentioned but unclear as

to which groups


’low risk’

Other bias Low risk


group at entry

Low risk

Appropriateness of duration of surveillance High risk

Newstead 2004



Losses: 7 ( 2 exercise, 5 control)

Age: 50-65 years

Setting: USA

Inclusion: no co-morbidity e.g. diabetes, CHD, PVD, pulmonary or orthopaedic dys-

functions; not taking alendronate medication etc.; no current exercise programme; no

history of osteoporotic fractures; BMI 21-31; on HRT if postmenopausal for >5 years.

BMD T-score > -1.5 SD at hip and lumbar spine


Interventions Exercise group jumping (DWBHF)(n = 25): progressive multidirectional jumping, in-

creasing jump heights and repetitions (max 200)



Supervisor: physical therapist

Supervision: group 2x week, individual 1 x week

Setting: gym

Outcomes BMD femoral neck, total hip, lumbar spine



Newstead 2004 (Continued)

Notes Compliance/adherence: average 82% at month 6 and 75% month 12


Risk of bias



bias)




’low risk’


All outcomes


to which groups


’low risk’





group at entry


’low risk’


up data reported

Papaioannou 2003



Losses: 14 lost at 6/12 (n = 60), 3 lost at 12/12 (n = 57)

Age: mean age 71.6 (SD = 7.33) exercise group, 72.2 (SD = 7.98) in control. No

significant differences in drop outs between groups

Setting: Canada

Inclusion: postmenopausal women 60yr + with osteoporosis (lumbar BMD >= 2.5 SD

below young adult mean) and at least one vertebral fracture

Exclusion: vertebral fracture within last 3 months; secondary causes of bone loss; other

diagnosis for back pain; resting heart rate > 100 beats per min and uncontrolled hyper-

tension; unable to stand independently for 3 min



Papaioannou 2003 (Continued)

Interventions Exercise group (COMB) (n = 37): exercise programme detailed in manual with diagrams,

comprised stretching, strength training upper and lower limbs and aerobics

Control Group (n = 37):

Duration and intensity: 60 minutes of exercise over the course of the day, 3 days per

week, with 1 rest day between for 12 months

Supervisor: exercise Therapist. No further details

Supervision:exercise group - monthly visits for first 6/12 with programme review. Follow-

up call every 2 weeks to 12 months. Control - telephone contact by exercise therapist

every month for 12 months

Setting: home

Outcomes DXA BMD lumbar spine (L2-4) femoral neck at baseline and 12 months

Notes Compliance/adherence: defined as completing 3 sessions per week at least 80% of weeks.

62% participant’s adherent

Adverse events: not reported

No data reported

Risk of bias



bias)


mit judgement of ’Yes’ or ’No’


’low risk’


All outcomes

Unclear risk No data presented for BMD other than no differences over 12

months between the groups


’low risk’



Blinding (assessor) Low risk Research assistant and BMD investigator blinded


group at entry

Low risk Baseline variables not significantly different between groups





Preisinger 1995

Methods RCT



Age: 45-75 yrs

Setting: Australia

Inclusion: caucasian; 45-75 yrs of age; postmenopausal at least 1 year; did not suffer

from malabsorption or other chronic diseases; non smoking; not taking oestrogen, other

steroid hormones, anticonvulsants or thiazide diuretics; sedentary lifestyle; and normal

blood results from described list.

Exclusion: retrospective exclusion of women not attending tests or who commenced

drug treatment for osteoporosis during follow-up period

Interventions Exercise group (DWBLF) (n = 82):

1a (n = 39): warm up of brisk walking, modest jogging, arm swings and moderate skill

exercises, stretching exercises hip and leg muscles, and complex resisted exercises to train

movement patterns (diagonal or diagonal spiral movements) using elastic bands and

gymnastic balls

1b (n = 43): stopped exercise treatment, performed it irregularly or less than 1 h per

week

Control Group (n = 64): no therapy

Duration and intensity: at 3 times per week for 20 mins. Resisted exercises described as

using considerable energy

Supervisor: qualified therapist

Supervision: 20 times over initial 10 week period, then 5 times every subsequent six

months


Outcomes BMD, SPA, Radium, Proximal

Notes Compliance/adherence: 48% performed exercises regularly for the prescribed time

Exercise group split retrospectively based on interviews and review of records at follow-

up visit to 1a, 1b


No baseline data for lumbar spine and femoral neck presented to enable % change to be

calculated

Risk of bias



bias)



Allocation concealment (selection bias) Unclear risk Insufficient information to permit judgement of ’Yes’ or ’No’


All outcomes

Unclear risk Insufficient reporting of drop-outs from beginning of the study



Preisinger 1995 (Continued)

Selective reporting (reporting bias) Unclear risk Insufficient information to permit judgement of ’Yes’ or ’No’

Other bias Unclear risk Poorly reported study - difficult to assess potential biases


Blinding (assessor) Low risk Assessments were made by same investigator who was unaware

of BMD measurements


group at entry


Appropriateness of duration of surveillance Low risk Immediately postintervention and six monthly follow-up over

ten year period

Prince 1991

Methods RCT


Losses: 17, exercise group n = 6, exercise calcium group n = 3, exercise oestrogen group

n = 8

Age: mean 56±4 yrs

Setting: Australia

Inclusion: women with low forearm bone density; > 43 years of age; postmenopausal

for 1-10 years; without hypertension or chronic diseases; not taking oestrogen, steroid

hormones, anticonvulsants or thiazide diuretic drugs

Exclusion: women with bone density not more than 1SD below mean for premenopausal

women. Control group was randomly assigned from this group

Interventions Exercise + placebo group (DWBLF) (n = 41): weekly class consisting of 1 hour low

impact aerobics of which 30% of time devoted to arm exercises. Twice weekly 30 min

brisk walk

Exercise + calcium supplementation (n = 39): a/a

Exercise + oestrogen supplementation (n = 40); a/a

Control Group (n = 40): no exercise or placebo

Duration and intensity: 1 hour class x 1 per week, 30 mins brisk walking x 2 per week

for 2 years

Supervisor: trained physiotherapist

Supervision: during exercise class only


Outcomes BMD forearm measured every 3 months

Notes Compliance/adherence: 56% exercise only group; 24% exercise + calcium group; 44%

exercise = oestrogen group attended a minimum of 10 classes in any 12 week period

Adverse events: flushing, breast tenderness, sleeplessness etc



Prince 1991 (Continued)

Risk of bias



bias)

Low risk Shuffling of sealed envelopes

Allocation concealment (selection bias) Low risk Only pharmacist knew assignments


All outcomes

Unclear risk Unclear why so many of the exercise groups dropped out or did

not complete sufficient exercise classes


Other bias High risk Drug company Upjohn Australia supplied medication and sup-

ported research


Blinding (assessor) Unclear risk Insufficient information to permit judgement of ’Yes’ or ’No’


group at entry

High risk Control group had normal BMD, and had been postmenopausal

for less time (5.8±2.6 v 4.5±2.1)

Appropriateness of duration of surveillance Low risk Only immediately postintervention data at 2 years, no follow-

up data recorded

Prince 1995

Methods RCT


Losses: not recorded

Age: 50-70 yrs

Setting: Australia

Inclusion: 50-70 yrs of age, > 10 yrs postmenopausal

Exclusion: significant chronic diseases, had received oestrogen, other steroid hormones,

anticonvulsants, thiazide diuretic drugs or medications that could influence calcium

metabolism

Interventions Exercise group + calcium (DWBLF) (n = 42): 2 x 1 hour supervised classes comprising

weight bearing exercise (not specified)

Calcium group (n = 42): no exercise

Milk powder group (n = 42): no exercise

Control Group (n = 42): placebo medication only

Duration and intensity: 4 hours per week, at 60% of peak maximal heart rate for age for

2 years



Prince 1995 (Continued)


Supervision: supervision during exercise class

Setting: not stated

Outcomes BMD lumbar spine, hip, distal tibia/fibula at baseline, 6, 12 18 and 24 months

Notes Compliance/adherence: 39% of exercise group exercised for 3 hours per week at 60%

peak heart rate

Adverse events: not reported

Risk of bias



bias)

Low risk Block randomisation with sealed envelopes prior to study com-

mencing

Allocation concealment (selection bias) Low risk Sealed envelopes


All outcomes

Unclear risk ’As-treated’ analysis done no drop-outs mentioned and no indi-

cation of numbers in each group


’low risk’

Other bias High risk Drug company supplied placebo and calcium tablets



group at entry

Low risk


Pruitt 1996

Methods RCT


Losses: 14

Age: 65-82 years

Setting: America

Inclusion: Healthy caucasian women not currently taking HRT, or those on HRT for 1

year or more

Exclusion: evidence of acute or uncontrolled chronic illness or conditions that would

prevent participation in exercise class, vertebral compression fractures, disorders affecting

bone metabolism



Pruitt 1996 (Continued)

Interventions Exercise group 1 (NWBHF) (n = 15): supervised exercise session comprising bench press,

lateral pull down, military press, biceps curl, knee extension, knee flexion, hip abduction

and adduction, leg press, back extension. 1 set 14 reps at 40% 1RM, 2 sets 7 reps at 80%

1RM

Exercise group 2 (NWBLF) (n = 13): a/a 3 sets 12 reps at 40% 1RM

Control Group (n = 12): no exercises

Duration and intensity: 3 times per week for 12 months, lifting time 50 -55mins. 1RM

tests administered every 2 weeks for first 3 months then every 3 weeks to adjust workload


Supervision: every session

Setting: Gym

Outcomes BMD lumbar spine, hip (total hip, neck of femur, Wards triangle) at baseline and 12

months

Notes Compliance/adherence: 65%

Adverse events: aggravation of pre-existing back or knee condition (n = 2)

Risk of bias



bias)



or ’low risk’


’low risk’


All outcomes

Unclear risk ’As-treated’ analysis done drop-outs mentioned but different

across the groups


’low risk’. One outlier whose spinal BMD was more than 4SD

from group mean was not included in analysis




’low risk’


group at entry






Revel 1993

Methods RCT


Losses: 11 withdrew but were not lost to follow-up (treatment group n = 6, control group

n = 5)

Age: 54±3 yrs

Setting: France

Inclusion: recruited from pension fund membership. Healthy postmenopausal caucasian

women, postmenopausal for between 1 - 12 years (mean = 6±3). Not on oestrogen or

oestrogen like compounds, corticosteroids, fluoride salts, diphosphonate’s or calcitonin


Interventions Exercise group (NWBLF) (n = 39): performed 60 repetitions of active hip flexion in

sitting with 5 kg sandbag on knee. Hip flexion limited to 30 degrees. Could be performed

over 2 or 3 sessions

Control Group (n = 39): deltoid training, no further details

Duration and intensity: 1 year, 60 repetitions daily


Supervision: exercises taught initially no further supervision recorded


Outcomes TBMD L1/L4

Notes Compliance/adherence: 55% fully completed the training programme. 5 participants

withdrew as they found the study too constraining (treatment group n = 4, control n =

1)

Adverse events: treatment group hip pain (n = 1), control group shoulder pain (n = 3,

back pain (n = 1)

Follow-up data not reported by group

Risk of bias



bias)





All outcomes

Unclear risk Outcome reported for all that completed the trial. Authors say

they did an ITT analysis on all but 5 of the participants, but

none of the tables have figures that match this number



Blinding (participant) High risk Not feasible for exercise programmes



Revel 1993 (Continued)

Blinding (assessor) Low risk Radiologist who performed scans was blinded to randomisation

result


group at entry


Appropriateness of duration of surveillance Low risk Only immediately postintervention data at 12 months, follow-

up data at 2 years postintervention reported

Rubin 2004

Methods RCT


Losses: 6 (1 active, five placebo) withdrew within first 3/12 and were replaced by new

subject in same treatment type

Age: 47-64 years

Setting: USA

Inclusion: 3-8 years postmenopausal women, normal nutritional status, stable weight,

estimated daily Ca intake ≥ 500 mg daily, capable of following protocol, body mass 45

kg-84 kg

Exclusion: any pharmacological intervention for osteopenia within last 6 months, steroid

use, current smoking status, consumption of excessive alcohol, evidence of osteomalacia,

osteogenesis imperfect, GI disease, history of malignancy, and/or prolonged immobili-

sation of axial or appendicular skeleton within last 3 years, spondyloarthrosis, thyrotoxi-

cosis, psychomotor disturbances, hyperparathyroidism, renal or hepatic disease, chronic

diseases known to affect muscular system, and/or engaged in high impact activities at

least 3 x per week

Interventions Exercise group (DWBHF) (n = 33): vibration plate that vibrated at 30 Hz, 0.2 g peak

to peak

Control Group (n = 37): placebo device, protocol a/a

Duration and intensity: 2 x 10 mins treatments per day separated by a minimum of

hrs, 7 days per week for 1 year

Supervisor: none

Supervision: none

Setting: home

Outcomes BMD by DXA R & L femur, lumbar spine, distal 1/3 radius at baseline, 3, 6 and 12

months

Notes Compliance/adherence: 37% completing study were at least 80% compliant (10 active,

7 placebo), 72% at least 60% compliant (19 active, 14 placebo)

Adverse events: 1 person (placebo group) reported headache

Data presented as % change but as a function of compliance > 80% with exercise and

only mean values presented

Risk of bias



Rubin 2004 (Continued)



bias)

Low risk Confidential randomised number sequence

Allocation concealment (selection bias) Low risk Generated by individual statistical consultant


All outcomes

Unclear risk Losses accounted for and analysis based on the 56 subjects who

completed the study and were scanned at end of study


Other bias High risk Research funded by inventors of device

Blinding (participant) Low risk Each device emitted same low frequency sound, all participants

insulated from each other at home

Blinding (assessor) Low risk Randomised code broken on completion of study


group at entry

High risk Significant differences in body weight and BMI with placebo 5

kg heavier than exercise group (P = 0.03)



Russo 2003



Losses: 6 at randomisation, 3 at follow-up (1 control, 3 exercise)

Age: mean (SE) exercise 60.7 (6.1) and control 61.4 (7.3) years

Setting: USA

Inclusion:1 year postmenopausal

Exclusion: metabolic bone disorders, conditions contraindicating vibration training

Interventions Exercise group (DWBHF) (n = 17): vibrating plates lateral oscillations 0.1-10 g. Pro-

gressive frequency up to 28 Hz up to 2 mins duration


Duration and intensity: 2 x week for 6 months



Setting: gym

Outcomes BMD

Trabecular volumetric bone density (mg/cm3)

Cortical volumetric bone density (mg/cm3)



Russo 2003 (Continued)


Adverse events: transient, slight lower leg itching and erythema, was also observed in

6 of 17 treated participants in this study. In no case, however, did this problem persist

after the first 3 training sessions or cause interruption of the intervention. Knee pain

of moderate intensity, without objective clinical signs, was observed in 2 overweight

participants with pre-existing knee osteoarthritis. The pain subsided in both participants

after a few days of rest

Risk of bias



bias)

Low risk Randomisation by random number table


’low risk’


All outcomes

Unclear risk ’As-treated’ analysis done drop-outs mentioned


’low risk’

Other bias Low risk

Blinding (participant) High risk


group at entry

Low risk


Sakai 2010



Losses: 16 (3 exercise, 13 control)

Age: mean age 68.3 years (61-85)

Setting: Japan

Inclusion: not stated


Interventions Exercise group (SWB) (n = 49): single leg standing


Duration and intensity: 1 min per leg, 3 x per day for 6 months




Sakai 2010 (Continued)

Supervision: home exercise

Setting: home

Outcomes BMD DEXA neck, trochanter, intertrochanter, Ward’s triangle



Risk of bias



bias)

Low risk Randomisation by envelopes


’low risk’


All outcomes

Unclear risk ’As-treated’ analysis done drop-outs mentioned but different

across the groups


’low risk’





group at entry

Low risk There were no significant differences in age, body height, body

weight, body mass index and hip BMD between the 2 groups

at baseline


up data reported

Sinaki 1989

Methods RCT


Losses: 3 from control group

Age: 49-65 yrs

Setting: America

Inclusion: postmenopausal, 49-65 yrs of age, normal diet, without calcium, vitamin D

or oestrogen supplementation. With normal ECG, blood results and urine analysis

Exclusion: baseline BMD below 5th percentile of normal range



Sinaki 1989 (Continued)

Interventions Exercise group (NWBLF) (n = 34): back extension exercises performed in prone against

resistance using backpack weighted to the equivalent of 30% of maximum isometric

strength up to a maximum of 50 lb (22.7 kg)

Control Group (n = 34): no active exercise

Duration and intensity: 10 repetitions once a day, five days per week for 2 years


Supervision: at outset only

Setting: home

Outcomes BMD lumbar spine at baseline, 6, 12, 18 and 24 months


Adverse events: none recorded

Risk of bias



bias)



or ’low risk’


’low risk’


All outcomes

Low risk ’As-treated’ analysis done, all 3 drop-outs were in control group


’low risk’



Blinding (assessor) Low risk Assessor had no knowledge of group allocation


group at entry

Unclear risk No significant differences observed in baseline characteristics

apart from total serum calcium and total thyroxine

Appropriateness of duration of surveillance High risk Only immediately postintervention data at 2 years, no follow-

up data reported



Smidt 1992

Methods RCT


Losses: 6; not clear which groups these came from

Age: control group = 55.4±8, exercise group 56.6±6.6

Setting: America

Inclusion: physician consent, no current medical history (within last 12 months) of low

back pain, kidney, cardiac, neuromuscular or musculoskeletal dysfunction. No current

involvement in weight training programme for abdominals or back extensors, no obesity

that preclude ability to use trunk testing equipment, at least one year postmenopause


Interventions Exercise group (NWBHF) (n = 22): 3 sets of 10 repetitions of sit ups, prone trunk

extension and double leg flexion (i.e. 90 reps in total) at 70% of maximal strength test,

increasing by 2-5% monthly depending on ability

Control Group (n = 27): maintain current lifestyle

Duration and intensity: 3 to 3 times per week for 12 months


Supervision: at outset and once per month

Setting: home

Outcomes BMD lumbar spine L2-4, hip (neck of femur, trochanter) at baseline, 6 and 12 months

Notes Compliance/adherence: 11 participants performed exercises 3 times per week, 9 exercised

2-3 times


Bad luck with randomisation: control group turned out to be very physically active

Risk of bias



bias)





All outcomes

Unclear risk Insufficient information to permit judgement of ’Yes’ or ’No’


Other bias Low risk The study appears to be free of other source of bias

Blinding (participant) High risk Not practical for exercise classes




Smidt 1992 (Continued)


group at entry

Low risk No significant difference between groups at entry



Tolomio 2009



Losses: 17. 16 failed to attend first session, 1 did not return following first session, 6 did

not attend BMD scanning. 23 lost in exercise group, 12 in control group

Age: postmenopausal (no other information recorded)

Setting: Italy

Inclusion: Postmenopausal women with osteoporosis or osteopenia

Exclusion: orthopaedic operations

Interventions Exercise group (n = 81) (COMB): 15 minutes warm up: walking at reasonable pace,

joint movement, balance exercises, stretches. 30 minutes diverse exercises depending on

objective i.e. strength, balance or flexibility using weights, balls, theraband and steps. 15

minutes cool down as warm up but lighter

Control Group (n = 79): no exercises

Duration and intensity: 44 weeks - 60 minutes 3 x per week at gym for 11 weeks; 1x per

week at gym; and 2x per week in thermal water (spa) for 17 weeks; then 3x per week

home exercises

Supervisor: unclear

Supervision: not clear for first two stages of trial. Telephone checks with advice for home

exercise programme

Setting: gym; gym/spa; home

Outcomes BMD femoral neck and total hip



Data converted to % change

Risk of bias



bias)






Tolomio 2009 (Continued)


All outcomes

Low risk All participants accounted for including drop-outs


Other bias Unclear risk Insufficient information to permit judgement of ’Yes’ or ’No’


Blinding (assessor) Unclear risk Insufficient information to permit judgement of ’Yes’ or ’No’


group at entry

Low risk No significant difference between groups at entry



Uusi-Rasi 2003



Losses: 7 (5 exercise and 2 control)

Age: exercise mean 53.3 (2.2), control 53.2 (2.1) years

Setting: Finland

Inclusion: 1-5 years postmenopause; no previous bone fractures; neither current nor

previous use of oestrogen, corticosteroids, bisphosphonates, nor other drugs, nor illness

affecting bone metabolism; no contraindication to exercise or alendronate;

previous regular exercise less than two times a week; femoral neck BMD 0.650 g/cm2

and an FSH level greater than 30 IU/L

Exclusion: less than 1 year or more than 5 years postmenopause; history of chronic

illness; evidence of metabolic bone disease or use of bone-specific medications; concurrent

serious medical conditions including sepsis or disseminated cancer; abnormalities of the

oesophagus; inability to stand or sit upright for at least 30 min; hypersensitivity to any

component of the study drug; and hypocalcaemia

Interventions Non alendronate Exercise group (DWBHF) (n = 41): placebo plus warm-up, 20 min of

multidirectional jumping exercises, 15 min of callisthenics (stretching and non impact

exercises), and 10 min cool down. The programme was progressive peak forces varied

between 2.1 and 5.6 times body weight

Non alendronate Control Group (n = 41): placebo usual activity

Alendronate exercise group (DWBHF) (n = 41): as exercise above

Alendronate control group (n = 41): usual activity

Duration and intensity: 1 hr 3 x week for 1 year

Supervisor: experienced exercise leaders of the UKK Institute

Supervision: group

Setting: gym



Uusi-Rasi 2003 (Continued)

Outcomes The bone mineral content (BMC, g) and areal bone mineral density (BMD, g/cm2) of

the lumbar spine, right proximal femur (femoral neck and trochanter area of the femur)

, and nondominant distal radius

Notes Compliance/adherence: Mean (SD) compliance in the exercise group, defined as

attendance in the training sessions, was 1.6 0.9 times per week

Adverse events: 19 subjects from the exercise group consulted the attending physician

(P.K.) due to musculoskeletal injuries or symptoms; 1 subject had an acute severe ankle

sprain requiring surgical treatment. The rest were mild overuse symptoms; 1 subject

with a mild knee distortion injury; 5 subjects with an overuse problem at the knee joint

(3 with chondromalacia patellae and 2 with unspecific knee pain); 4 with an overuse

problem at the foot (2 with an insertional tendinopathy of the Achilles tendon and 2

with unspecific foot pain); 2 with low back pain (1 sciatica, 1 unspecific); 2 with hip

pain (1 trochanteric bursitis, 1 unspecific); 2 with shoulder pain (both supraspinatus

tendinitis); and 2 with unspecific fibromyalgia (tension neck symptoms)

Risk of bias



bias)




’low risk’


All outcomes

Low risk Intention-to-treat analysis


’low risk’



’low risk’ but states double-blind

Blinding (assessor) Low risk Outcomes assessors blinded to treatment group allocation


group at entry

Low risk There were no clinically relevant differences between groups

Appropriateness of duration of surveillance Low risk Immediately postintervention data 12 months and follow-up

data at 15 months postintervention reported



Verschueren 2004




Age: 58-74 years

Setting: Belgium

Inclusion: 60 and 70 years of age, non-institutionalised, and free from diseases or med-

ications known to affect bone metabolism or muscle strength

Exclusion: total body BMD T-score of less than -2.5

Interventions Exercise group vibrating platform (DWBHF)(n = 25): static and dynamic knee-extensor

exercises on the vibration platform, progressive exercise

Exercise group resistance training (NWBHF)(n = 22): warm-up, resistance training

programme for knee extensors on a leg extension and a leg press machine. Training

programme was designed (ASCM) for individuals older than 60 years of age. Progressive

resistance


Duration and intensity: 72 training sessions within a 24-week period. Training frequency

was three times a week


Supervision: individual and group for resistance training

Setting: gym

Outcomes BMD DEXA total hip, total body



Risk of bias



bias)

Low risk Randomisation by computer-generated random numbers age-

matched women


’low risk’


All outcomes

Unclear risk ’As-treated’ analysis done, insufficient information to permit

judgement of ’high risk’ or ’low risk’


’low risk’



Blinding (assessor) Low risk Technician unaware of intervention type



Verschueren 2004 (Continued)


group at entry

Low risk No significant differences were observed at baseline between the

experimental and the control groups in terms of age, weight,

body mass, years since menopause, BMD, serum levels of os-

teocalcin and CTX, isometric and dynamic muscle strength, fat

mass or lean body mass

Appropriateness of duration of surveillance High risk Only immediately postintervention data, no follow-up data re-

ported

Von Stengel 2009



Losses: 16, group 1 n = 5, group 2 n = 7, control n = 4. All invited for final measurements,

11 did not attend; group 1 n = 1, group 2 n = 6, control n = 4

Age: 65-72 years

Setting: Germany

Inclusion: Over 65, postmenopausal

Exclusion: relevant co-morbidity or drug treatment which could influence bone

metabolism

Interventions Exercise group (COMB) (n = 50): Low impact aerobics, strengthening exercises and

balance

Exercise group (COMB) (n = 50): Low impact aerobics, strengthening and balance

exercise as above and vibration plate. Vibration between 25-35 Hz, intensity increased

at 3 and 6 months

Control Group (n = 51): gentle exercise and relaxation class x 1 per week

Duration and intensity: 60 minutes 2x per week for 12 months


Supervision: not reported

Setting: hospital

Outcomes BMD total hip and spine, rate of falls



Selected exercise group with vibration plate for analysis. Data converted to % change

Risk of bias



bias)






Von Stengel 2009 (Continued)


All outcomes

Low risk Losses explained and data analysed on intention-to-treat

Selective reporting (reporting bias) Low risk Reporting as per protocol

Other bias Low risk The study appears to free of other sources of bias




group at entry




Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Ay 2005 No BMD DEXA, only US measures

Bebenek 2010 Control group underwent low intensity exercise

Bemben 2010 Subjects were assigned to a group based on their availability to attend the scheduled training sessions

Cao 2009 No BMD DEXA, only US measures

De Matos 2009 Not RCT subjects, selected group

Engelke 2006 Not RCT subjects, selected group

Hans 2002 Not an RCT

Hawkins 2002 Participants allocated to groups based on proximity to laboratory

Heinonen 1996 Pre-menopausal participants

Kemmler 2003 Not an RCT

Kerr 1996 Participants were their own control, one side of body randomised to a different exercise type

Kerschan-Schindl 2000 Randomisation not mentioned, described as observational study



(Continued)

Kohrt 1995 Controlled trial, not an RCT

Kontulainen 2004 Pre-menopausal participants

Kriska 1986 No BMD outcomes

Leichter 1989 Not an RCT or CCT (before/after study)

Lohman 1995 Pre-menopausal participants

Mayoux-Benhamou 1995 Duplicate publication, French version

Nelson 1991 No control group

Notelovitz 1991 Surgical menopause, no control group

Pruitt 1992 Not an RCT

Rikli 1990 Controlled trial, not an RCT

Ruan 2008 Not RCT

Shen 2009 No outcome measures for BMD, only bone formation biomarkers

Snow 2000 Original study not an RCT

Song 2010 Participants had osteoarthritis

Tolomio 2008 No BMD DEXA, only US measures

Uusi-Rasi 2005 Follow-up of peri-menopausal women

Villareal 2003 Not an RCT

White 1984 Not an RCT

Xu 2004 Not RCT

Yamazaki 2004 Not RCT. Group assignment according to the wish of the participants



Characteristics of studies awaiting assessment [ordered by study ID]

Ilona 2010



Losses: not recorded

Age: 43-65 years

Setting: Romania

Inclusion: postmenopausal women diagnosed with osteoporosis or osteopenia

Exclusion: concurrent orthopaedic or neurological disorders

Interventions Exercise group (NWBLF) (n = 23): exercise, diet (diary products and veg), medication (Fosamax, Ca supplements,

Vit D)

Control Group (n = 23 ): diet (dairy products and veg), medication (Fosamax, Ca supplements, Vit D)

Exercise group and controls well matched

Duration and intensity: twice per week, 1 hour for 12 months. 8 - 10 repetitions with 1 minute between sets initially,

rising to 12-15 times higher by end of intervention period

• Warm up 10 min, static stretches, walking, deep breathing, easy running

• Strength exercise 40 min low load, high repetition exercise for upper limbs performed in sitting, and

callisthenic in supine and standing

• Cool down, 10 min (not reported)

Supervisor: physiotherapist, experience not recorded

Supervision: close physiotherapist surveillance


** paper classifies study as measuring the effect of high impact exercise but impact appears to occur only in warm up

phase, clarification on the researchers definition of callisthenic exercise would be helpful

Outcomes BMD , T score lumbar spine DEXA (L1 -4) baseline and 12 months


Adverse events: not recorded

Karaarslan 2010

Methods Type of study:

Participants Number of participants randomised =

Losses:

Age:

Setting:

Inclusion:

Exclusion:

Interventions Exercise group (n =):

Control Group (n = ):

Duration and intensity:

Supervisor:

Supervision:

Setting:



Karaarslan 2010 (Continued)

Outcomes

Notes Compliance/adherence:

Adverse events:

awaiting full paper

Kemmler 2004a

Methods Type of study:

Participants Number of participants randomised =

Losses:

Age:

Setting:

Inclusion:

Exclusion:

Interventions Exercise group (n =):


Duration and intensity:

Supervisor:

Supervision:

Setting:

Outcomes

Notes Compliance/adherence:

Adverse events:

awaiting full paper

Characteristics of ongoing studies [ordered by study ID]

Wayne 2010

Trial name or title not known

Methods Type of study: Pragmatic RCT


Losses:

Age: 45-70

Setting: America

Inclusion: women aged 45-70; postmenopausal > 12 months; BMD T scores of hip and/or spine between -

1.0 and 2.5; does not exercise more than 5 days a week on average for more than 60 minutes per day

Exclusion: osteoporotic (T-score < - 2.5) at any site or a fracture in last 2 years not caused by road traffic

collision; prior or current use of: oestrogen or calcitonin (within last year); medication that increases risks of



Wayne 2010 (Continued)

fracture (e.g. steroids, anti-convulsants, anticoagulants, lithium); medications that modify bone metabolism;

use of calcium supplements above 1200-1500 mg; malignancies other than skin cancer; diagnosis of anorexia

along with BMI < 17.5; conditions causing secondary osteoporosis; tobacco use in past year; physical or

mental disabilities that preclude informed consent in participation; geographical or scheduling limitations

that preclude weekly participation in exercise class and study; current regular practice of Tai Chi

Interventions Exercise group (DWBLF) (n =):


Duration and intensity: 9 months. Minimum 2 classes (60 min each session) and 2 additional practice sessions

(min 30 min) per week in first month, then a minimum of 1 per week and 3 practice sessions for remaining

8 months

Supervisor: classes led by junior instructor supervised by senior instructor

Supervision: at class

Setting: Tia Chi, school and home

Outcomes BMD lumbar spine and proximal femur assessed by DEXA

Compliance/adherence:

Adverse events:

Starting date Not recorded

Contact information peter [email protected]

Notes Registered with Clinical Trials.gov, ID number NCT01039012



D A T A A N D A N A L Y S E S

Comparison 1. Any exercise versus control

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Total number of fractures 4 539 Odds Ratio (M-H, Random, 95% CI) 0.61 [0.23, 1.64]

2 Bone mineral density % change:

spine

24 1441 Mean Difference (IV, Fixed, 95% CI) 0.85 [0.62, 1.07]


femoral neck

19 1338 Mean Difference (IV, Random, 95% CI) -0.08 [-1.08, 0.92]


Ward’s triangle

6 185 Mean Difference (IV, Fixed, 95% CI) -2.67 [-4.06, -1.28]


hip

13 863 Mean Difference (IV, Random, 95% CI) 0.41 [-0.64, 1.45]


trochanter


7 Bone mineral content % change:

spine

1 Mean Difference (IV, Fixed, 95% CI) Subtotals only

7.1 Immediately

postintervention

1 76 Mean Difference (IV, Fixed, 95% CI) 1.43 [-9.18, 12.04]

7.2 Follow-up at 15 months

post intervention



femoral neck


8.1 Immediately

postintervention



postintervention


Comparison 2. Static weight bearing exercise versus control


studies

No. of



hip




Comparison 3. Dynamic weight bearing exercise low force versus control


studies

No. of



spine



femoral neck

5 485 Mean Difference (IV, Random, 95% CI) -1.20 [-4.45, 2.05]


trochanter



Ward’s triangle



wrist


6 Bone mineral density mean

regression slope % change:

wrist


7 Fractures 2 Odds Ratio (M-H, Random, 95% CI) Subtotals only

7.1 Vertebral year 1 2 229 Odds Ratio (M-H, Random, 95% CI) 0.54 [0.11, 2.65]

7.2 Vertebral year 2 1 97 Odds Ratio (M-H, Random, 95% CI) 4.18 [0.45, 38.82]

7.3 Total number of fractures 2 229 Odds Ratio (M-H, Random, 95% CI) 0.92 [0.21, 3.96]

Comparison 4. Dynamic weight bearing exercise high force versus control


studies

No. of



spine



hip



mid femur



proximal tibia


5 Calcium bone index % change:

trunk and upper thighs



trochanter



femoral neck



spine


8.1 Immediately

postintervention



postintervention





femoral neck


9.1 Immediately

postintervention



postintervention


10 Bone mineral content %

change: wrist


10.1 Immediately

postintervention

1 76 Mean Difference (IV, Fixed, 95% CI) -3.41 [-15.64, 8.82]


postintervention

1 50 Mean Difference (IV, Fixed, 95% CI) -0.70 [-14.96, 13.

56]


change: ankle



change: tibia


13 Bone mineral density %

change: total body


14 Volumetric bone density %

change: tibial trabecular


00]

15 Volumetric bone density %

change: tibial cortical




Comparison 5. Non-weight bearing exercise low force versus control


studies

No. of



spine



total hip



femoral neck



Ward’s triangle



trochanter



total body




Comparison 6. Non-weight bearing exercise high force versus control


studies

No. of



spine



total hip



femoral neck



Ward’s triangle



trochanter



total body


Comparison 7. Combination versus control


studies

No. of



spine


1.1 immediately

postintervention


1.2 Follow-up at 1 year 1 28 Mean Difference (IV, Fixed, 95% CI) 3.33 [1.13, 5.53]

1.3 Follow-up at 5 years 1 34 Mean Difference (IV, Fixed, 95% CI) -1.60 [-5.64, 2.44]


total hip



trochanter


3.1 immediately

postintervention




total body


4.1 immediately

postintervention



5 Calcium bone index % change:

trunk and upper thighs



neck of femur


6.1 immediately

postintervention


6.2 Follow-up at 5 years 1 34 Mean Difference (IV, Fixed, 95% CI) 0.70 [-3.33, 4.73]




Ward’s triangle


7.1 immediately

postintervention




arms


8.1 immediately

postintervention





Comparison 8. Dynamic weight bearing exercise high force plus HRT versus HRT


studies

No. of



proximal tibia


11]


hip



mid femur



spine



trochanter



femoral neck



total body


Comparison 9. Non-weight bearing exercise high force plus bisphosphonates versus bisphosphonates


studies

No. of



spine



hip



femoral neck



trochanter





Ward’s triangle



total body



total body


Comparison 10. Dynamic weight bearing exercise high force plus bisphosphonates versus bisphosphonates


studies

No. of



spine


1.1 immediately

postintervention



postintervention


13]


femoral neck


2.1 Immediately

postintervention



postintervention


35]


wrist


3.1 Immediately

postintervention



postintervention


33]


distal tibia



tibial shaft


Comparison 11. Non-weight bearing exercise high force plus antioxidants versus antioxidants


studies

No. of



spine


89]


femoral neck


13]



Comparison 12. Dynamic weight bearing exercise low force plus Ca2+ versus Ca2+


studies

No. of



femoral neck



spine



trochanter



distal tibia



Ward’s triangle


Comparison 13. Non-weight bearing exercise low force plus calcium versus calcium


studies

No. of



spine



total hip



femoral neck



trochanter



total body


Comparison 14. Non-weight bearing exercise high force plus calcium versus calcium


studies

No. of



femoral neck



trochanter



total hip



spine





total body


Comparison 15. Dynamic weight bearing exercise low force plus calcium/VitD versus calcium/VitD


studies

No. of



spine


2 Bone mineral density %

change:wrist


Analysis 1.1. Comparison 1 Any exercise versus control, Outcome 1 Total number of fractures.

Review: Exercise for preventing and treating osteoporosis in postmenopausal women

Comparison: 1 Any exercise versus control

Outcome: 1 Total number of fractures

Study or subgroup Exercise Control Odds Ratio Weight Odds Ratio

n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

Chan 2004 1/67 3/65 14.5 % 0.31 [ 0.03, 3.09 ]

Ebrahim 1997 6/49 4/48 30.2 % 1.53 [ 0.40, 5.82 ]

Karinkanta 2007 4/112 1/38 15.2 % 1.37 [ 0.15, 12.65 ]

Korpelainen 2006 6/84 16/76 40.1 % 0.29 [ 0.11, 0.78 ]

Total (95% CI) 312 227 100.0 % 0.61 [ 0.23, 1.64 ]

Total events: 17 (Exercise), 24 (Control)

Heterogeneity: Tau2 = 0.37; Chi2 = 4.77, df = 3 (P = 0.19); I2 =37%

Test for overall effect: Z = 0.97 (P = 0.33)

Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours exercise Favours control



Analysis 1.2. Comparison 1 Any exercise versus control, Outcome 2 Bone mineral density % change: spine.



Outcome: 2 Bone mineral density % change: spine

Study or subgroup Exercise ControlMean

Difference WeightMean

Difference

N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Bemben 2000 17 0.64 (11.55) 8 -0.69 (12.3) 0.1 % 1.33 [ -8.81, 11.47 ]

Bergstrom 2008 48 -0.31 (11.3) 44 -0.69 (14.9) 0.2 % 0.38 [ -5.06, 5.82 ]

Bocalini 2009 15 -0.13 (0.35) 10 -0.98 (0.35) 66.9 % 0.85 [ 0.57, 1.13 ]

Bravo 1996 61 0.55 (24.2) 63 -1.29 (27.4) 0.1 % 1.84 [ -7.25, 10.93 ]

Chan 2004 54 0.1 (3.12) 49 -0.89 (4.01) 2.7 % 0.99 [ -0.41, 2.39 ]

Chilibeck 2002 10 -0.6 (3.6) 12 -0.1 (3.12) 0.6 % -0.50 [ -3.35, 2.35 ]

Chuin 2009 8 0 (19.45) 7 -0.99 (23.11) 0.0 % 0.99 [ -20.80, 22.78 ]

Ebrahim 1997 49 -1.71 (20.12) 48 -1.81 (18.8) 0.1 % 0.10 [ -7.65, 7.85 ]

Englund 2005 21 13.09 (28.51) 19 1.05 (22.33) 0.0 % 12.04 [ -3.76, 27.84 ]

Going 2003 71 0 (2.59) 59 -0.56 (2.31) 7.4 % 0.56 [ -0.28, 1.40 ]

Grove 1992 10 1.75 (2.07) 5 -6.1 (16.7) 0.0 % 7.85 [ -6.84, 22.54 ]

Hatori 1993 12 1.1 (2.9) 12 -1.7 (2.8) 1.0 % 2.80 [ 0.52, 5.08 ]

Iwamoto 2001 15 4.42 (1.11) 20 1.01 (3.16) 2.4 % 3.41 [ 1.92, 4.90 ]

Kerr 2001 54 -0.15 (7.25) 36 -0.01 (11.88) 0.3 % -0.14 [ -4.48, 4.20 ]

Lau 1992 11 -1.9 (0.99) 12 -2.5 (1.3) 5.9 % 0.60 [ -0.34, 1.54 ]

Lord 1996 68 1.07 (2.59) 70 0.36 (3.91) 4.3 % 0.71 [ -0.39, 1.81 ]

Maddalozzo 2007 29 0.21 (18.91) 29 -4.38 (15.66) 0.1 % 4.59 [ -4.35, 13.53 ]

Nelson 1994 20 1 (3.6) 19 -1.8 (3.5) 1.1 % 2.80 [ 0.57, 5.03 ]

Newstead 2004 23 0.99 (14) 26 0.97 (13.73) 0.1 % 0.02 [ -7.76, 7.80 ]

Pruitt 1996 14 0.6 (16.47) 11 0 (24.1) 0.0 % 0.60 [ -16.05, 17.25 ]

Revel 1993 34 4.73 (49.97) 33 0.41 (31.13) 0.0 % 4.32 [ -15.55, 24.19 ]

Sinaki 1989 34 -1.4 (1.8) 31 -1.2 (2.2) 5.4 % -0.20 [ -1.18, 0.78 ]

Smidt 1992 22 -1.79 (3.68) 27 -2.35 (3.45) 1.3 % 0.56 [ -1.45, 2.57 ]

Von Stengel 2009 44 1.17 (23.25) 47 0.31 (24.75) 0.1 % 0.86 [ -9.00, 10.72 ]

Total (95% CI) 744 697 100.0 % 0.85 [ 0.62, 1.07 ]

Heterogeneity: Chi2 = 27.13, df = 23 (P = 0.25); I2 =15%

Test for overall effect: Z = 7.23 (P < 0.00001)


-4 -2 0 2 4

Favours control Favours exercise



Analysis 1.3. Comparison 1 Any exercise versus control, Outcome 3 Bone mineral density % change:

femoral neck.



Outcome: 3 Bone mineral density % change: femoral neck



Difference

N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

Bemben 2000 17 0.37 (16.45) 8 -1.06 (21) 0.4 % 1.43 [ -15.09, 17.95 ]

Bocalini 2009 15 -0.09 (1.9) 10 -1.58 (0.36) 11.7 % 1.49 [ 0.50, 2.48 ]

Bravo 1996 61 0.27 (19.6) 63 -0.53 (20.8) 1.7 % 0.80 [ -6.31, 7.91 ]

Chan 2004 54 -0.94 (3.85) 49 -1.8 (3.52) 10.4 % 0.86 [ -0.56, 2.28 ]

Chilibeck 2002 10 -0.1 (2.85) 12 -0.4 (2.77) 7.6 % 0.30 [ -2.06, 2.66 ]

Chuin 2009 8 0 (12.43) 7 0 (10.24) 0.7 % 0.0 [ -11.48, 11.48 ]

Ebrahim 1997 49 -0.25 (16) 48 -2.75 (20.77) 1.6 % 2.50 [ -4.89, 9.89 ]

Englund 2005 21 0 (12.46) 19 0 (18.13) 1.0 % 0.0 [ -9.74, 9.74 ]

Going 2003 71 0.57 (4.14) 59 -0.47 (4.12) 10.4 % 1.04 [ -0.39, 2.47 ]

Kerr 2001 54 0.47 (9.11) 36 -0.11 (15.6) 2.5 % 0.58 [ -5.07, 6.23 ]

Korpelainen 2006 84 -0.59 (1.23) 76 -1.04 (1.16) 13.0 % 0.45 [ 0.08, 0.82 ]

Lau 1992 11 -6.6 (2.86) 12 -1.1 (0.54) 9.5 % -5.50 [ -7.22, -3.78 ]

Lord 1996 68 1.52 (5.19) 70 3.12 (6.52) 8.8 % -1.60 [ -3.56, 0.36 ]

Maddalozzo 2007 29 -1.46 (16.84) 29 -3.19 (17.03) 1.2 % 1.73 [ -6.99, 10.45 ]

Nelson 1994 20 0.9 (4.5) 19 2.5 (3.8) 7.0 % -1.60 [ -4.21, 1.01 ]

Newstead 2004 23 0 (9.67) 26 -1.27 (17.9) 1.4 % 1.27 [ -6.66, 9.20 ]

Pruitt 1996 15 0.07 (18.12) 11 0.79 (16.3) 0.5 % -0.72 [ -14.02, 12.58 ]

Smidt 1992 22 1.06 (4.02) 27 -0.25 (3.84) 8.0 % 1.31 [ -0.91, 3.53 ]

Tolomio 2009 58 0 (18.18) 67 -1.18 (14.56) 2.4 % 1.18 [ -4.65, 7.01 ]

Total (95% CI) 690 648 100.0 % -0.08 [ -1.08, 0.92 ]

Heterogeneity: Tau2 = 1.96; Chi2 = 58.64, df = 18 (P<0.00001); I2 =69%



-4 -2 0 2 4




Analysis 1.4. Comparison 1 Any exercise versus control, Outcome 4 Bone mineral density % change: Ward’s

triangle.



Outcome: 4 Bone mineral density % change: Ward’s triangle



Difference


Bemben 2000 17 0.9 (22.34) 8 -0.53 (21.6) 0.6 % 1.43 [ -16.92, 19.78 ]

Chilibeck 2002 10 -0.9 (3.79) 12 0.8 (2.46) 25.9 % -1.70 [ -4.43, 1.03 ]

Englund 2005 21 5.26 (26.08) 19 -3.12 (24.4) 0.8 % 8.38 [ -7.27, 24.03 ]

Lau 1992 11 -6 (3.01) 12 -2.4 (1.05) 54.9 % -3.60 [ -5.48, -1.72 ]

Pruitt 1996 15 4.42 (22.5) 11 1.54 (23.29) 0.6 % 2.88 [ -14.98, 20.74 ]

Smidt 1992 22 1.11 (6.07) 27 3.11 (5.78) 17.3 % -2.00 [ -5.34, 1.34 ]

Total (95% CI) 96 89 100.0 % -2.67 [ -4.06, -1.28 ]

Heterogeneity: Chi2 = 4.06, df = 5 (P = 0.54); I2 =0.0%



-10 -5 0 5 10




Analysis 1.5. Comparison 1 Any exercise versus control, Outcome 5 Bone mineral density % change: hip.



Outcome: 5 Bone mineral density % change: hip



Difference


Bemben 2000 17 0.05 (16.8) 8 -0.63 (22.4) 0.4 % 0.68 [ -16.78, 18.14 ]

Bergstrom 2008 48 0.57 (11.7) 44 -0.35 (13.3) 3.6 % 0.92 [ -4.22, 6.06 ]

Cheng 2002 10 1.66 (16.5) 13 -1.35 (12.7) 0.7 % 3.01 [ -9.33, 15.35 ]

Chilibeck 2002 10 -0.2 (2.21) 12 -0.7 (2.77) 13.4 % 0.50 [ -1.58, 2.58 ]

Kerr 2001 54 0.04 (6.5) 36 -0.57 (11.82) 5.0 % 0.61 [ -3.62, 4.84 ]

Korpelainen 2006 84 -0.27 (1.62) 76 0.82 (1.7) 26.8 % -1.09 [ -1.61, -0.57 ]

Maddalozzo 2007 29 -0.45 (16.61) 29 2.61 (1136.42) 0.0 % -3.06 [ -416.71, 410.59 ]

Newstead 2004 23 1.14 (16.07) 26 0 (15.37) 1.3 % 1.14 [ -7.69, 9.97 ]

Pruitt 1996 15 0.88 (12.9) 11 0.96 (16.38) 0.8 % -0.08 [ -11.76, 11.60 ]

Sakai 2010 20 0.238 (1.76) 11 -2.18 (2.54) 16.4 % 2.42 [ 0.73, 4.10 ]

Tolomio 2009 58 -2.5 (23.34) 67 0.4 (21.05) 1.7 % -2.90 [ -10.74, 4.94 ]

Verschueren 2004 47 -0.03 (0.04) 24 -0.62 (0.35) 28.5 % 0.59 [ 0.45, 0.73 ]

Von Stengel 2009 44 0 (20.61) 47 -0.93 (22.21) 1.3 % 0.93 [ -7.87, 9.73 ]

Total (95% CI) 459 404 100.0 % 0.41 [ -0.64, 1.45 ]




-10 -5 0 5 10




Analysis 1.6. Comparison 1 Any exercise versus control, Outcome 6 Bone mineral density % change:

trochanter.



Outcome: 6 Bone mineral density % change: trochanter



Difference


Bemben 2000 17 0.32 (18.17) 8 -0.67 (22.6) 0.1 % 0.99 [ -16.89, 18.87 ]

Chan 2004 54 1.19 (3.12) 49 0.56 (3.2) 14.4 % 0.63 [ -0.59, 1.85 ]

Chilibeck 2002 10 0.2 (3.48) 12 -0.2 (3.46) 2.5 % 0.40 [ -2.51, 3.31 ]

Englund 2005 21 6.35 (16.87) 19 2.94 (22.88) 0.1 % 3.41 [ -9.16, 15.98 ]

Going 2003 71 1.08 (3.24) 59 -0.14 (3.89) 13.9 % 1.22 [ -0.03, 2.47 ]

Kerr 2001 54 0.01 (8.9) 36 -0.01 (16.44) 0.6 % 0.02 [ -5.85, 5.89 ]

Korpelainen 2006 84 -0.32 (1.98) 76 -1.62 (2.01) 56.3 % 1.30 [ 0.68, 1.92 ]

Lord 1996 68 0.69 (4.64) 70 0.73 (5.28) 7.9 % -0.04 [ -1.70, 1.62 ]

Maddalozzo 2007 29 0.29 (18.72) 29 -1.61 (19.58) 0.2 % 1.90 [ -7.96, 11.76 ]

Smidt 1992 22 0.15 (3.45) 27 -0.29 (4.9) 3.9 % 0.44 [ -1.90, 2.78 ]

Total (95% CI) 430 385 100.0 % 1.03 [ 0.56, 1.49 ]




-10 -5 0 5 10




Analysis 1.7. Comparison 1 Any exercise versus control, Outcome 7 Bone mineral content % change: spine.



Outcome: 7 Bone mineral content % change: spine



Difference


1 Immediately postintervention

Uusi-Rasi 2003 37 1.43 (20.25) 39 0 (26.65) 100.0 % 1.43 [ -9.18, 12.04 ]

Subtotal (95% CI) 37 39 100.0 % 1.43 [ -9.18, 12.04 ]

Heterogeneity: not applicable


2 Follow-up at 15 months post intervention

Uusi-Rasi 2003 26 -0.64 (17.37) 24 -3.08 (23.1) 100.0 % 2.44 [ -8.96, 13.84 ]

Subtotal (95% CI) 26 24 100.0 % 2.44 [ -8.96, 13.84 ]



-100 -50 0 50 100




Analysis 1.8. Comparison 1 Any exercise versus control, Outcome 8 Bone mineral content % change:

femoral neck.



Outcome: 8 Bone mineral content % change: femoral neck



Difference



Uusi-Rasi 2003 37 -0.34 (18.4) 39 -0.34 (22.05) 100.0 % 0.0 [ -9.11, 9.11 ]

Subtotal (95% CI) 37 39 100.0 % 0.0 [ -9.11, 9.11 ]



2 Follow-up at 15 months postintervention

Uusi-Rasi 2003 26 1.65 (14.99) 25 -1.33 (22.05) 100.0 % 2.98 [ -7.41, 13.37 ]

Subtotal (95% CI) 26 25 100.0 % 2.98 [ -7.41, 13.37 ]



-100 -50 0 50 100


Analysis 2.1. Comparison 2 Static weight bearing exercise versus control, Outcome 1 Bone mineral density

% change: hip.


Comparison: 2 Static weight bearing exercise versus control




Difference


Sakai 2010 20 0.238 (1.76) 11 -2.18 (2.54) 100.0 % 2.42 [ 0.73, 4.10 ]

Total (95% CI) 20 11 100.0 % 2.42 [ 0.73, 4.10 ]




-100 -50 0 50 100




Analysis 3.1. Comparison 3 Dynamic weight bearing exercise low force versus control, Outcome 1 Bone

mineral density % change: spine.


Comparison: 3 Dynamic weight bearing exercise low force versus control




Difference


Bravo 1996 61 0.55 (24.2) 63 -1.29 (27.4) 0.4 % 1.84 [ -7.25, 10.93 ]

Chan 2004 54 0.1 (3.12) 49 -0.89 (4.01) 19.0 % 0.99 [ -0.41, 2.39 ]

Ebrahim 1997 49 -1.71 (20.12) 48 -1.81 (18.8) 0.6 % 0.10 [ -7.65, 7.85 ]

Grove 1992 5 0 (12.6) 5 -6.1 (16.7) 0.1 % 6.10 [ -12.24, 24.44 ]

Hatori 1993 12 1.1 (2.9) 12 -1.7 (2.8) 7.1 % 2.80 [ 0.52, 5.08 ]

Lau 1992 11 -1.9 (0.99) 12 -2.5 (1.3) 42.1 % 0.60 [ -0.34, 1.54 ]

Lord 1996 68 1.07 (2.59) 70 0.36 (3.91) 30.5 % 0.71 [ -0.39, 1.81 ]

Total (95% CI) 260 259 100.0 % 0.87 [ 0.26, 1.48 ]




-10 -5 0 5 10





mineral density % change: femoral neck.






Difference


Bravo 1996 61 0.27 (19.6) 63 -0.53 (20.8) 11.9 % 0.80 [ -6.31, 7.91 ]

Chan 2004 54 -0.94 (3.85) 49 -1.8 (3.52) 26.2 % 0.86 [ -0.56, 2.28 ]

Ebrahim 1997 49 -0.25 (16) 48 -2.75 (20.77) 11.4 % 2.50 [ -4.89, 9.89 ]

Lau 1992 11 -6.6 (2.86) 12 -1.1 (0.54) 25.6 % -5.50 [ -7.22, -3.78 ]

Lord 1996 68 1.52 (5.19) 70 3.12 (6.52) 25.0 % -1.60 [ -3.56, 0.36 ]

Total (95% CI) 243 242 100.0 % -1.20 [ -4.45, 2.05 ]




-20 -10 0 10 20



mineral density % change: trochanter.






Difference


Chan 2004 54 1.19 (3.12) 49 0.56 (3.2) 64.7 % 0.63 [ -0.59, 1.85 ]

Lord 1996 68 0.69 (4.64) 70 0.73 (5.28) 35.3 % -0.04 [ -1.70, 1.62 ]

Total (95% CI) 122 119 100.0 % 0.39 [ -0.59, 1.38 ]




-20 -10 0 10 20





mineral density % change: Ward’s triangle.






Difference


Lau 1992 11 -6 (3.01) 12 -2.4 (1.05) 100.0 % -3.60 [ -5.48, -1.72 ]

Total (95% CI) 11 12 100.0 % -3.60 [ -5.48, -1.72 ]




-100 -50 0 50 100



mineral density % change: wrist.



Outcome: 5 Bone mineral density % change: wrist



Difference


Prince 1991 41 -2.6 (3.2) 42 -2.7 (3.3) 100.0 % 0.10 [ -1.30, 1.50 ]

Total (95% CI) 41 42 100.0 % 0.10 [ -1.30, 1.50 ]




-4 -2 0 2 4





mineral density mean regression slope % change: wrist.



Outcome: 6 Bone mineral density mean regression slope % change: wrist



Difference


Preisinger 1995 39 -0.3 (1.25) 64 -1.7 (1.6) 100.0 % 1.40 [ 0.85, 1.95 ]

Total (95% CI) 39 64 100.0 % 1.40 [ 0.85, 1.95 ]




-10 -5 0 5 10




Analysis 3.7. Comparison 3 Dynamic weight bearing exercise low force versus control, Outcome 7

Fractures.



Outcome: 7 Fractures


n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

1 Vertebral year 1

Chan 2004 0/67 1/65 24.5 % 0.32 [ 0.01, 7.96 ]

Ebrahim 1997 2/49 3/48 75.5 % 0.64 [ 0.10, 4.00 ]

Subtotal (95% CI) 116 113 100.0 % 0.54 [ 0.11, 2.65 ]


Heterogeneity: Tau2 = 0.0; Chi2 = 0.14, df = 1 (P = 0.71); I2 =0.0%


2 Vertebral year 2

Ebrahim 1997 4/49 1/48 100.0 % 4.18 [ 0.45, 38.82 ]

Subtotal (95% CI) 49 48 100.0 % 4.18 [ 0.45, 38.82 ]




3 Total number of fractures

Chan 2004 1/67 3/65 32.2 % 0.31 [ 0.03, 3.09 ]

Ebrahim 1997 6/49 4/48 67.8 % 1.53 [ 0.40, 5.82 ]

Subtotal (95% CI) 116 113 100.0 % 0.92 [ 0.21, 3.96 ]




0.01 0.1 1 10 100




Analysis 4.1. Comparison 4 Dynamic weight bearing exercise high force versus control, Outcome 1 Bone



Comparison: 4 Dynamic weight bearing exercise high force versus control




Difference


Going 2003 71 0 (2.59) 59 -0.56 (2.31) 97.8 % 0.56 [ -0.28, 1.40 ]

Grove 1992 5 1.8 (12.1) 5 -6.1 (16.7) 0.2 % 7.90 [ -10.18, 25.98 ]

Maddalozzo 2007 29 0.21 (18.91) 29 -4.38 (15.66) 0.9 % 4.59 [ -4.35, 13.53 ]

Newstead 2004 23 0.99 (14) 26 0.97 (13.73) 1.1 % 0.02 [ -7.76, 7.80 ]

Total (95% CI) 128 119 100.0 % 0.60 [ -0.23, 1.44 ]




-20 -10 0 10 20





mineral density % change: hip.






Difference


Cheng 2002 10 1.66 (16.5) 13 -1.35 (12.7) 0.0 % 3.01 [ -9.33, 15.35 ]

Maddalozzo 2007 29 -0.45 (16.61) 29 2.61 (1136.42) 0.0 % -3.06 [ -416.71, 410.59 ]

Newstead 2004 23 1.14 (16.07) 26 0 (15.37) 0.0 % 1.14 [ -7.69, 9.97 ]

Verschueren 2004 25 0.93 (0.04) 24 -0.62 (0.35) 100.0 % 1.55 [ 1.41, 1.69 ]

Total (95% CI) 87 92 100.0 % 1.55 [ 1.41, 1.69 ]




-4 -2 0 2 4



mineral density % change: mid femur.



Outcome: 3 Bone mineral density % change: mid femur



Difference


Cheng 2002 10 0 (6.6) 13 -0.12 (5.15) 100.0 % 0.12 [ -4.84, 5.08 ]

Total (95% CI) 10 13 100.0 % 0.12 [ -4.84, 5.08 ]




-100 -50 0 50 100





mineral density % change: proximal tibia.



Outcome: 4 Bone mineral density % change: proximal tibia



Difference


Cheng 2002 10 3.31 (31.6) 13 0 (24) 100.0 % 3.31 [ -20.22, 26.84 ]

Total (95% CI) 10 13 100.0 % 3.31 [ -20.22, 26.84 ]




-100 -50 0 50 100


Analysis 4.5. Comparison 4 Dynamic weight bearing exercise high force versus control, Outcome 5 Calcium

bone index % change: trunk and upper thighs.



Outcome: 5 Calcium bone index % change: trunk and upper thighs



Difference


Chow 1987 17 4.21 (15.18) 15 -1.09 (20.88) 100.0 % 5.30 [ -7.50, 18.10 ]

Total (95% CI) 17 15 100.0 % 5.30 [ -7.50, 18.10 ]




-20 -10 0 10 20











Difference


Going 2003 71 1.08 (3.24) 59 -0.14 (3.89) 98.4 % 1.22 [ -0.03, 2.47 ]

Maddalozzo 2007 29 0.29 (18.72) 29 -1.61 (19.58) 1.6 % 1.90 [ -7.96, 11.76 ]

Total (95% CI) 100 88 100.0 % 1.23 [ -0.01, 2.47 ]




-10 -5 0 5 10









Difference


Going 2003 71 0.57 (4.14) 59 -0.47 (4.12) 94.4 % 1.04 [ -0.39, 2.47 ]

Maddalozzo 2007 29 -1.46 (16.84) 29 -3.19 (17.03) 2.5 % 1.73 [ -6.99, 10.45 ]

Newstead 2004 23 0 (9.67) 26 -1.27 (17.9) 3.0 % 1.27 [ -6.66, 9.20 ]

Total (95% CI) 123 114 100.0 % 1.06 [ -0.32, 2.45 ]




-10 -5 0 5 10





mineral content % change: spine.






Difference



Uusi-Rasi 2003 37 1.43 (20.25) 39 0 (26.65) 100.0 % 1.43 [ -9.18, 12.04 ]

Subtotal (95% CI) 37 39 100.0 % 1.43 [ -9.18, 12.04 ]




Uusi-Rasi 2003 26 -0.64 (17.37) 24 -3.08 (23.1) 100.0 % 2.44 [ -8.96, 13.84 ]

Subtotal (95% CI) 26 24 100.0 % 2.44 [ -8.96, 13.84 ]



-100 -50 0 50 100





mineral content % change: femoral neck.






Difference



Uusi-Rasi 2003 37 -0.34 (18.4) 39 -0.34 (22.05) 100.0 % 0.0 [ -9.11, 9.11 ]

Subtotal (95% CI) 37 39 100.0 % 0.0 [ -9.11, 9.11 ]




Uusi-Rasi 2003 26 1.65 (14.99) 25 -1.33 (22.05) 100.0 % 2.98 [ -7.41, 13.37 ]

Subtotal (95% CI) 26 25 100.0 % 2.98 [ -7.41, 13.37 ]



-100 -50 0 50 100





mineral content % change: wrist.



Outcome: 10 Bone mineral content % change: wrist



Difference



Uusi-Rasi 2003 37 -2.25 (23.48) 39 1.16 (30.62) 100.0 % -3.41 [ -15.64, 8.82 ]

Subtotal (95% CI) 37 39 100.0 % -3.41 [ -15.64, 8.82 ]




Uusi-Rasi 2003 26 -5.07 (20.93) 24 -4.37 (29.44) 100.0 % -0.70 [ -14.96, 13.56 ]

Subtotal (95% CI) 26 24 100.0 % -0.70 [ -14.96, 13.56 ]



-100 -50 0 50 100



mineral content % change: ankle.



Outcome: 11 Bone mineral content % change: ankle



Difference


Uusi-Rasi 2003 37 0.4 (19.44) 39 -1.67 (21.29) 100.0 % 2.07 [ -7.09, 11.23 ]

Total (95% CI) 37 39 100.0 % 2.07 [ -7.09, 11.23 ]




-100 -50 0 50 100





mineral content % change: tibia.



Outcome: 12 Bone mineral content % change: tibia



Difference


Uusi-Rasi 2003 37 -0.13 (16.09) 39 -0.99 (15.35) 100.0 % 0.86 [ -6.22, 7.94 ]

Total (95% CI) 37 39 100.0 % 0.86 [ -6.22, 7.94 ]




-100 -50 0 50 100



mineral density % change: total body.



Outcome: 13 Bone mineral density % change: total body



Difference


Going 2003 71 0 (1.17) 59 -0.37 (1.01) 99.8 % 0.37 [ 0.00, 0.74 ]

Newstead 2004 23 1.14 (16.07) 26 0 (15.37) 0.2 % 1.14 [ -7.69, 9.97 ]

Total (95% CI) 94 85 100.0 % 0.37 [ 0.00, 0.75 ]




-10 -5 0 5 10




Analysis 4.14. Comparison 4 Dynamic weight bearing exercise high force versus control, Outcome 14

Volumetric bone density % change: tibial trabecular.



Outcome: 14 Volumetric bone density % change: tibial trabecular



Difference


Russo 2003 14 -1.84 (31.56) 15 -0.69 (19.1) 100.0 % -1.15 [ -20.30, 18.00 ]

Total (95% CI) 14 15 100.0 % -1.15 [ -20.30, 18.00 ]




-100 -50 0 50 100



Volumetric bone density % change: tibial cortical.



Outcome: 15 Volumetric bone density % change: tibial cortical



Difference


Russo 2003 14 -0.17 (4.79) 15 -0.66 (4.6) 100.0 % 0.49 [ -2.93, 3.91 ]

Total (95% CI) 14 15 100.0 % 0.49 [ -2.93, 3.91 ]




-50 -25 0 25 50





Fractures.





n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI


Karinkanta 2007 3/74 1/38 100.0 % 1.56 [ 0.16, 15.56 ]

Subtotal (95% CI) 74 38 100.0 % 1.56 [ 0.16, 15.56 ]




0.01 0.1 1 10 100


Analysis 5.1. Comparison 5 Non-weight bearing exercise low force versus control, Outcome 1 Bone mineral

density % change: spine.


Comparison: 5 Non-weight bearing exercise low force versus control




Difference


Bemben 2000 7 -0.52 (15.3) 8 -0.69 (12.3) 0.5 % 0.17 [ -14.01, 14.35 ]

Kerr 2001 30 0.32 (10.13) 36 -0.01 (11.88) 3.3 % 0.33 [ -4.98, 5.64 ]

Pruitt 1996 7 0.46 (23.2) 11 0 (24.1) 0.2 % 0.46 [ -21.86, 22.78 ]

Revel 1993 34 4.73 (49.97) 33 0.41 (31.13) 0.2 % 4.32 [ -15.55, 24.19 ]

Sinaki 1989 34 -1.4 (1.8) 31 -1.2 (2.2) 95.8 % -0.20 [ -1.18, 0.78 ]

Total (95% CI) 112 119 100.0 % -0.17 [ -1.13, 0.79 ]




-10 -5 0 5 10





density % change: total hip.



Outcome: 2 Bone mineral density % change: total hip



Difference


Bemben 2000 7 0.32 (24) 8 -0.63 (22.4) 4.3 % 0.95 [ -22.65, 24.55 ]

Kerr 2001 30 -0.65 (9.91) 36 -0.57 (11.82) 87.9 % -0.08 [ -5.32, 5.16 ]

Pruitt 1996 7 0.98 (19.95) 11 0.96 (16.38) 7.7 % 0.02 [ -17.65, 17.69 ]

Total (95% CI) 44 55 100.0 % -0.03 [ -4.94, 4.89 ]




-100 -50 0 50 100





density % change: femoral neck.






Difference


Bemben 2000 7 -0.11 (24.5) 8 -1.06 (21) 7.2 % 0.95 [ -22.31, 24.21 ]

Kerr 2001 30 0.03 (12.16) 36 -0.11 (15.6) 86.6 % 0.14 [ -6.56, 6.84 ]

Pruitt 1996 7 1.16 (31.13) 11 0.79 (16.3) 6.2 % 0.37 [ -24.62, 25.36 ]

Total (95% CI) 44 55 100.0 % 0.21 [ -6.02, 6.45 ]




-100 -50 0 50 100



density % change: Ward’s triangle.






Difference


Bemben 2000 7 2.27 (29.5) 8 -0.53 (21.6) 61.1 % 2.80 [ -23.69, 29.29 ]

Pruitt 1996 7 4.22 (40.83) 11 1.54 (23.29) 38.9 % 2.68 [ -30.55, 35.91 ]

Total (95% CI) 14 19 100.0 % 2.75 [ -17.96, 23.47 ]




-100 -50 0 50 100





density % change: trochanter.






Difference


Bemben 2000 7 0 (25.6) 8 -0.67 (22.6) 8.3 % 0.67 [ -23.92, 25.26 ]

Kerr 2001 30 -0.02 (14.24) 36 -0.01 (16.44) 91.7 % -0.01 [ -7.41, 7.39 ]

Total (95% CI) 37 44 100.0 % 0.05 [ -7.04, 7.14 ]




-100 -50 0 50 100



density % change: total body.






Difference


Bemben 2000 7 0.09 (6) 8 -0.61 (8.6) 28.9 % 0.70 [ -6.73, 8.13 ]

Kerr 2001 30 0.79 (9.48) 36 -0.71 (10.14) 71.1 % 1.50 [ -3.24, 6.24 ]

Total (95% CI) 37 44 100.0 % 1.27 [ -2.73, 5.27 ]




-100 -50 0 50 100




Analysis 6.1. Comparison 6 Non-weight bearing exercise high force versus control, Outcome 1 Bone



Comparison: 6 Non-weight bearing exercise high force versus control




Difference


Bemben 2000 10 -0.8 (17.6) 8 -0.69 (12.3) 0.0 % -0.11 [ -13.95, 13.73 ]

Bocalini 2009 15 -0.13 (0.35) 10 -0.98 (0.35) 95.4 % 0.85 [ 0.57, 1.13 ]

Chilibeck 2002 10 -0.6 (3.6) 12 -0.1 (3.12) 0.9 % -0.50 [ -3.35, 2.35 ]

Chuin 2009 8 0 (19.45) 7 -0.99 (23.11) 0.0 % 0.99 [ -20.80, 22.78 ]

Kerr 2001 24 -0.65 (10.39) 36 -0.01 (11.88) 0.2 % -0.64 [ -6.33, 5.05 ]

Nelson 1994 20 1 (3.6) 19 -1.8 (3.5) 1.5 % 2.80 [ 0.57, 5.03 ]

Pruitt 1996 7 0.75 (23.4) 11 0 (24.1) 0.0 % 0.75 [ -21.68, 23.18 ]

Smidt 1992 22 -1.79 (3.68) 27 -2.35 (3.45) 1.8 % 0.56 [ -1.45, 2.57 ]

Total (95% CI) 116 130 100.0 % 0.86 [ 0.58, 1.13 ]




-10 -5 0 5 10





mineral density % change: total hip.






Difference


Bemben 2000 10 -0.21 (23.5) 8 -0.63 (22.4) 0.0 % 0.42 [ -20.87, 21.71 ]

Chilibeck 2002 10 -0.2 (2.21) 12 -0.7 (2.77) 0.7 % 0.50 [ -1.58, 2.58 ]

Kerr 2001 24 0.57 (8.62) 36 -0.57 (11.82) 0.1 % 1.14 [ -4.04, 6.32 ]

Pruitt 1996 8 0.81 (16.82) 11 0.96 (16.38) 0.0 % -0.15 [ -15.30, 15.00 ]

Verschueren 2004 22 -0.51 (0.26) 24 -0.62 (0.35) 99.1 % 0.11 [ -0.07, 0.29 ]

Total (95% CI) 74 91 100.0 % 0.11 [ -0.06, 0.29 ]




-4 -2 0 2 4











Difference


Bemben 2000 10 0.77 (22.6) 8 -1.06 (21) 0.2 % 1.83 [ -18.37, 22.03 ]

Bocalini 2009 15 -0.09 (1.9) 10 -1.58 (0.36) 64.7 % 1.49 [ 0.50, 2.48 ]

Chilibeck 2002 10 -0.1 (2.85) 12 -0.4 (2.77) 11.3 % 0.30 [ -2.06, 2.66 ]

Chuin 2009 8 0 (12.43) 7 0 (10.24) 0.5 % 0.0 [ -11.48, 11.48 ]

Kerr 2001 24 1.04 (13.77) 36 -0.11 (15.6) 1.1 % 1.15 [ -6.35, 8.65 ]

Nelson 1994 20 0.9 (4.5) 19 2.5 (3.8) 9.3 % -1.60 [ -4.21, 1.01 ]

Pruitt 1996 8 -0.49 (22.28) 11 0.79 (16.3) 0.2 % -1.28 [ -19.48, 16.92 ]

Smidt 1992 22 1.06 (4.02) 27 -0.25 (3.84) 12.8 % 1.31 [ -0.91, 3.53 ]

Total (95% CI) 117 130 100.0 % 1.03 [ 0.24, 1.82 ]




-10 -5 0 5 10





mineral density % change: Ward’s triangle.






Difference


Bemben 2000 10 -0.94 (34.2) 8 -0.53 (21.6) 0.7 % -0.41 [ -26.36, 25.54 ]

Chilibeck 2002 10 -0.9 (3.79) 12 0.8 (2.46) 59.1 % -1.70 [ -4.43, 1.03 ]

Pruitt 1996 8 4.51 (26.95) 11 1.54 (23.29) 0.8 % 2.97 [ -20.23, 26.17 ]

Smidt 1992 22 1.11 (6.07) 27 3.11 (5.78) 39.4 % -2.00 [ -5.34, 1.34 ]

Total (95% CI) 50 58 100.0 % -1.77 [ -3.87, 0.33 ]




-100 -50 0 50 100











Difference


Bemben 2000 10 0.65 (25.8) 8 -0.67 (22.6) 0.6 % 1.32 [ -21.06, 23.70 ]

Chilibeck 2002 10 0.2 (3.48) 12 -0.2 (3.46) 36.6 % 0.40 [ -2.51, 3.31 ]

Kerr 2001 24 0 (11.4) 36 -0.01 (16.44) 6.3 % 0.01 [ -7.04, 7.06 ]

Smidt 1992 22 0.15 (3.45) 27 -0.29 (4.9) 56.5 % 0.44 [ -1.90, 2.78 ]

Total (95% CI) 66 83 100.0 % 0.40 [ -1.36, 2.17 ]




-10 -5 0 5 10



mineral density % change: total body.






Difference


Bemben 2000 10 -1.13 (11) 8 -0.61 (8.6) 1.4 % -0.52 [ -9.58, 8.54 ]

Chilibeck 2002 10 0.1 (1.26) 12 -0.5 (1.39) 92.4 % 0.60 [ -0.51, 1.71 ]

Kerr 2001 24 -0.62 (6.76) 36 -0.71 (10.14) 6.2 % 0.09 [ -4.19, 4.37 ]

Total (95% CI) 44 56 100.0 % 0.55 [ -0.51, 1.62 ]




-4 -2 0 2 4




Analysis 7.1. Comparison 7 Combination versus control, Outcome 1 Bone mineral density % change: spine.


Comparison: 7 Combination versus control




Difference


1 immediately postintervention

Bergstrom 2008 48 -0.31 (11.3) 44 -0.69 (14.9) 6.8 % 0.38 [ -5.06, 5.82 ]

Englund 2005 21 13.09 (28.51) 19 1.05 (22.33) 0.8 % 12.04 [ -3.76, 27.84 ]

Iwamoto 2001 15 4.42 (1.11) 20 1.01 (3.16) 90.3 % 3.41 [ 1.92, 4.90 ]

Von Stengel 2009 44 1.17 (23.25) 47 0.31 (24.75) 2.1 % 0.86 [ -9.00, 10.72 ]

Subtotal (95% CI) 128 130 100.0 % 3.22 [ 1.80, 4.64 ]



2 Follow-up at 1 year

Iwamoto 2001 8 4.29 (2.34) 20 0.96 (3.39) 100.0 % 3.33 [ 1.13, 5.53 ]

Subtotal (95% CI) 8 20 100.0 % 3.33 [ 1.13, 5.53 ]



3 Follow-up at 5 years

Englund 2005 18 3.2 (6.6) 16 4.8 (5.4) 100.0 % -1.60 [ -5.64, 2.44 ]

Subtotal (95% CI) 18 16 100.0 % -1.60 [ -5.64, 2.44 ]



-20 -10 0 10 20




Analysis 7.2. Comparison 7 Combination versus control, Outcome 2 Bone mineral density % change: total

hip.






Difference


Bergstrom 2008 48 0.57 (11.7) 44 -0.35 (13.3) 1.0 % 0.92 [ -4.22, 6.06 ]

Korpelainen 2006 84 -0.27 (1.62) 76 0.82 (1.7) 98.2 % -1.09 [ -1.61, -0.57 ]

Tolomio 2009 58 -2.5 (23.34) 67 0.4 (21.05) 0.4 % -2.90 [ -10.74, 4.94 ]

Von Stengel 2009 44 0 (20.61) 47 -0.93 (22.21) 0.3 % 0.93 [ -7.87, 9.73 ]

Total (95% CI) 234 234 100.0 % -1.07 [ -1.58, -0.56 ]




-10 -5 0 5 10




Analysis 7.3. Comparison 7 Combination versus control, Outcome 3 Bone mineral density % change:

trochanter.






Difference



Englund 2005 21 6.35 (16.87) 19 2.94 (22.88) 0.2 % 3.41 [ -9.16, 15.98 ]

Korpelainen 2006 84 -0.32 (1.98) 76 -1.62 (2.01) 99.8 % 1.30 [ 0.68, 1.92 ]

Subtotal (95% CI) 105 95 100.0 % 1.31 [ 0.69, 1.92 ]




Englund 2005 18 -12 (7.9) 16 -8.5 (10.8) 100.0 % -3.50 [ -9.93, 2.93 ]

Subtotal (95% CI) 18 16 100.0 % -3.50 [ -9.93, 2.93 ]



-10 -5 0 5 10




Analysis 7.4. Comparison 7 Combination versus control, Outcome 4 Bone mineral density % change: total

body.






Difference



Chubak 2006 87 0.43 (1.5) 86 0.29 (1.61) 99.7 % 0.14 [ -0.32, 0.60 ]

Englund 2005 21 2.06 (13.12) 19 2.04 (14.43) 0.3 % 0.02 [ -8.56, 8.60 ]

Subtotal (95% CI) 108 105 100.0 % 0.14 [ -0.32, 0.60 ]




Englund 2005 18 0.7 (2.6) 16 1.4 (1.8) 100.0 % -0.70 [ -2.19, 0.79 ]

Subtotal (95% CI) 18 16 100.0 % -0.70 [ -2.19, 0.79 ]



-10 -5 0 5 10


Analysis 7.5. Comparison 7 Combination versus control, Outcome 5 Calcium bone index % change: trunk

and upper thighs.



Outcome: 5 Calcium bone index % change: trunk and upper thighs



Difference


Chow 1987 16 7.95 (19.28) 15 -1.09 (20.88) 100.0 % 9.04 [ -5.13, 23.21 ]

Total (95% CI) 16 15 100.0 % 9.04 [ -5.13, 23.21 ]




-100 -50 0 50 100




Analysis 7.6. Comparison 7 Combination versus control, Outcome 6 Bone mineral density % change: neck

of femur.



Outcome: 6 Bone mineral density % change: neck of femur



Difference



Englund 2005 21 0 (12.46) 19 0 (18.13) 0.1 % 0.0 [ -9.74, 9.74 ]

Korpelainen 2006 84 -0.59 (1.23) 76 -1.04 (1.16) 99.5 % 0.45 [ 0.08, 0.82 ]

Tolomio 2009 58 0 (18.18) 67 -1.18 (14.56) 0.4 % 1.18 [ -4.65, 7.01 ]

Subtotal (95% CI) 163 162 100.0 % 0.45 [ 0.08, 0.82 ]




Englund 2005 18 -7.8 (6.2) 16 -8.5 (5.8) 100.0 % 0.70 [ -3.33, 4.73 ]

Subtotal (95% CI) 18 16 100.0 % 0.70 [ -3.33, 4.73 ]



Test for subgroup differences: Chi2 = 0.01, df = 1 (P = 0.90), I2 =0.0%

-10 -5 0 5 10




Analysis 7.7. Comparison 7 Combination versus control, Outcome 7 Bone mineral density % change:

Ward’s triangle.






Difference



Englund 2005 21 5.26 (26.08) 19 -3.12 (24.4) 100.0 % 8.38 [ -7.27, 24.03 ]

Subtotal (95% CI) 21 19 100.0 % 8.38 [ -7.27, 24.03 ]




Englund 2005 18 -12.8 (9.9) 16 -10.8 (7.8) 100.0 % -2.00 [ -7.96, 3.96 ]

Subtotal (95% CI) 18 16 100.0 % -2.00 [ -7.96, 3.96 ]



-100 -50 0 50 100




Analysis 7.8. Comparison 7 Combination versus control, Outcome 8 Bone mineral density % change: arms.



Outcome: 8 Bone mineral density % change: arms



Difference



Englund 2005 21 1.49 (14.77) 19 1.47 (15.63) 100.0 % 0.02 [ -9.43, 9.47 ]

Subtotal (95% CI) 21 19 100.0 % 0.02 [ -9.43, 9.47 ]




Englund 2005 18 1 (5.3) 16 1.6 (3.7) 100.0 % -0.60 [ -3.65, 2.45 ]

Subtotal (95% CI) 18 16 100.0 % -0.60 [ -3.65, 2.45 ]



-100 -50 0 50 100


Analysis 7.9. Comparison 7 Combination versus control, Outcome 9 Fractures.





n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI


Karinkanta 2007 1/38 1/38 11.2 % 1.00 [ 0.06, 16.59 ]

Korpelainen 2006 6/84 16/76 88.8 % 0.29 [ 0.11, 0.78 ]

Subtotal (95% CI) 122 114 100.0 % 0.33 [ 0.13, 0.85 ]


Heterogeneity: Tau2 = 0.0; Chi2 = 0.67, df = 1 (P = 0.41); I2 =0.0%


0.01 0.1 1 10 100




Analysis 8.1. Comparison 8 Dynamic weight bearing exercise high force plus HRT versus HRT, Outcome 1

Bone mineral density % change: proximal tibia.


Comparison: 8 Dynamic weight bearing exercise high force plus HRT versus HRT

Outcome: 1 Bone mineral density % change: proximal tibia

Study or subgroup Exercise plus HRT HRTMean


Difference


Cheng 2002 9 2.81 (16.92) 10 5.14 (25.8) 100.0 % -2.33 [ -21.77, 17.11 ]

Total (95% CI) 9 10 100.0 % -2.33 [ -21.77, 17.11 ]




-100 -50 0 50 100

Favours HRT Favours exercise plus HRT


Bone mineral density % change: hip.






Difference


Cheng 2002 9 4.45 (10.04) 10 4.8 (14.55) 34.4 % -0.35 [ -11.50, 10.80 ]

Maddalozzo 2007 33 0.11 (16.95) 34 -0.34 (16.8) 65.6 % 0.45 [ -7.63, 8.53 ]

Total (95% CI) 42 44 100.0 % 0.17 [ -6.37, 6.72 ]




-20 -10 0 10 20





Bone mineral density % change: mid femur.



Outcome: 3 Bone mineral density % change: mid femur



Difference


Cheng 2002 9 0.81 (3.67) 10 0.46 (4.5) 100.0 % 0.35 [ -3.33, 4.03 ]

Total (95% CI) 9 10 100.0 % 0.35 [ -3.33, 4.03 ]




-10 -5 0 5 10



Bone mineral density % change: spine.






Difference


Going 2003 71 0.79 (1.93) 65 0.94 (2.39) 99.2 % -0.15 [ -0.88, 0.58 ]

Maddalozzo 2007 33 0.99 (16.8) 34 -0.7 (17.78) 0.8 % 1.69 [ -6.59, 9.97 ]

Total (95% CI) 104 99 100.0 % -0.14 [ -0.87, 0.60 ]




-4 -2 0 2 4





Bone mineral density % change: trochanter.






Difference


Going 2003 71 1.87 (3.33) 65 0 (4.16) 98.2 % 1.87 [ 0.60, 3.14 ]

Maddalozzo 2007 33 0.75 (20.05) 34 -0.75 (19.08) 1.8 % 1.50 [ -7.88, 10.88 ]

Total (95% CI) 104 99 100.0 % 1.86 [ 0.60, 3.13 ]




-10 -5 0 5 10



Bone mineral density % change: femoral neck.






Difference


Going 2003 71 1.35 (3.26) 65 0.79 (3.26) 97.9 % 0.56 [ -0.54, 1.66 ]

Maddalozzo 2007 33 -0.67 (16.12) 34 -2.61 (14.79) 2.1 % 1.94 [ -5.47, 9.35 ]

Total (95% CI) 104 99 100.0 % 0.59 [ -0.50, 1.67 ]




-4 -2 0 2 4





Bone mineral density % change: total body.






Difference


Going 2003 71 0.36 (0.98) 65 0.35 (0.97) 100.0 % 0.01 [ -0.32, 0.34 ]

Total (95% CI) 71 65 100.0 % 0.01 [ -0.32, 0.34 ]




-1 -0.5 0 0.5 1


Analysis 9.1. Comparison 9 Non-weight bearing exercise high force plus bisphosphonates versus

bisphosphonates, Outcome 1 Bone mineral density % change: spine.


Comparison: 9 Non-weight bearing exercise high force plus bisphosphonates versus bisphosphonates


Study or subgroup Exercise plus bisphos bisphosMean


Difference


Chilibeck 2002 12 0.2 (3.46) 14 3.6 (2.62) 100.0 % -3.40 [ -5.79, -1.01 ]

Total (95% CI) 12 14 100.0 % -3.40 [ -5.79, -1.01 ]




-100 -50 0 50 100

Favours bisphos Favours exercise+bisph




bisphosphonates, Outcome 2 Bone mineral density % change: hip.






Difference


Chilibeck 2002 12 0 (2.42) 14 0.1 (2.24) 100.0 % -0.10 [ -1.90, 1.70 ]

Total (95% CI) 12 14 100.0 % -0.10 [ -1.90, 1.70 ]




-10 -5 0 5 10



bisphosphonates, Outcome 3 Bone mineral density % change: femoral neck.






Difference


Chilibeck 2002 12 0 (2.77) 14 0.3 (2.99) 100.0 % -0.30 [ -2.52, 1.92 ]

Total (95% CI) 12 14 100.0 % -0.30 [ -2.52, 1.92 ]




-20 -10 0 10 20





bisphosphonates, Outcome 4 Bone mineral density % change: trochanter.






Difference


Chilibeck 2002 12 0.4 (3.12) 14 0.9 (2.62) 100.0 % -0.50 [ -2.74, 1.74 ]

Total (95% CI) 12 14 100.0 % -0.50 [ -2.74, 1.74 ]




-10 -5 0 5 10



bisphosphonates, Outcome 5 Bone mineral density % change: Ward’s triangle.






Difference


Chilibeck 2002 12 -0.3 (6.93) 14 1.2 (5.99) 100.0 % -1.50 [ -6.52, 3.52 ]

Total (95% CI) 12 14 100.0 % -1.50 [ -6.52, 3.52 ]




-20 -10 0 10 20





bisphosphonates, Outcome 6 Bone mineral density % change: total body.






Difference


Chilibeck 2002 12 0.1 (2.08) 14 0.4 (2.24) 100.0 % -0.30 [ -1.96, 1.36 ]

Total (95% CI) 12 14 100.0 % -0.30 [ -1.96, 1.36 ]




-4 -2 0 2 4



bisphosphonates, Outcome 7 Bone mineral content % change: total body.



Outcome: 7 Bone mineral content % change: total body



Difference


Chilibeck 2002 12 0.3 (2.77) 14 1.8 (1.87) 100.0 % -1.50 [ -3.35, 0.35 ]

Total (95% CI) 12 14 100.0 % -1.50 [ -3.35, 0.35 ]




-10 -5 0 5 10




Analysis 10.1. Comparison 10 Dynamic weight bearing exercise high force plus bisphosphonates versus

bisphosphonates, Outcome 1 Bone mineral content % change: spine.


Comparison: 10 Dynamic weight bearing exercise high force plus bisphosphonates versus bisphosphonates


Study or subgroup Exercise+bisphos BisphosMean


Difference



Iwamoto 2005 25 9.06 (27.12) 25 7.38 (25.15) 35.4 % 1.68 [ -12.82, 16.18 ]

Uusi-Rasi 2003 38 4.07 (21.83) 38 3.55 (25.75) 64.6 % 0.52 [ -10.21, 11.25 ]

Subtotal (95% CI) 63 63 100.0 % 0.93 [ -7.70, 9.56 ]




Uusi-Rasi 2003 29 1.22 (20.38) 22 3.55 (26.87) 100.0 % -2.33 [ -15.79, 11.13 ]

Subtotal (95% CI) 29 22 100.0 % -2.33 [ -15.79, 11.13 ]



-20 -10 0 10 20

Favours bispohos Favours exercise+bisphos




bisphosphonates, Outcome 2 Bone mineral content % change: femoral neck.






Difference



Uusi-Rasi 2003 38 0.34 (20.41) 38 0.99 (24.6) 100.0 % -0.65 [ -10.81, 9.51 ]

Subtotal (95% CI) 38 38 100.0 % -0.65 [ -10.81, 9.51 ]




Uusi-Rasi 2003 29 -0.66 (18.82) 22 0.35 (21.7) 100.0 % -1.01 [ -12.37, 10.35 ]

Subtotal (95% CI) 29 22 100.0 % -1.01 [ -12.37, 10.35 ]



-20 -10 0 10 20





bisphosphonates, Outcome 3 Bone mineral content % change: wrist.



Outcome: 3 Bone mineral content % change: wrist



Difference



Uusi-Rasi 2003 38 0 (29.97) 38 -0.52 (34.41) 100.0 % 0.52 [ -13.99, 15.03 ]

Subtotal (95% CI) 38 38 100.0 % 0.52 [ -13.99, 15.03 ]




Uusi-Rasi 2003 28 -2.73 (32.53) 22 -2.41 (34.06) 100.0 % -0.32 [ -18.97, 18.33 ]

Subtotal (95% CI) 28 22 100.0 % -0.32 [ -18.97, 18.33 ]



-20 -10 0 10 20



bisphosphonates, Outcome 4 Bone mineral content % change: distal tibia.



Outcome: 4 Bone mineral content % change: distal tibia



Difference


Uusi-Rasi 2003 38 0.41 (17.42) 38 0.23 (20.32) 100.0 % 0.18 [ -8.33, 8.69 ]

Total (95% CI) 38 38 100.0 % 0.18 [ -8.33, 8.69 ]




-100 -50 0 50 100





bisphosphonates, Outcome 5 Bone mineral content % change: tibial shaft.



Outcome: 5 Bone mineral content % change: tibial shaft



Difference


Uusi-Rasi 2003 38 -0.15 (11.94) 38 -0.55 (17.41) 100.0 % 0.40 [ -6.31, 7.11 ]

Total (95% CI) 38 38 100.0 % 0.40 [ -6.31, 7.11 ]




-100 -50 0 50 100


Analysis 11.1. Comparison 11 Non-weight bearing exercise high force plus antioxidants versus antioxidants,

Outcome 1 Bone mineral density % change: spine.


Comparison: 11 Non-weight bearing exercise high force plus antioxidants versus antioxidants


Study or subgroup Exercise plus antiox AntioxMean


Difference


Chuin 2009 8 -0.92 (14.27) 8 0 (21.37) 100.0 % -0.92 [ -18.73, 16.89 ]

Total (95% CI) 8 8 100.0 % -0.92 [ -18.73, 16.89 ]




-100 -50 0 50 100

Favours antiox Favours exercise+antiox



Analysis 11.2. Comparison 11 Non-weight bearing exercise high force plus antioxidants versus antioxidants,

Outcome 2 Bone mineral density % change: femoral neck.


Comparison: 11 Non-weight bearing exercise high force plus antioxidants versus antioxidants


Study or subgroup Exercise plus antiox AntioxMean


Difference


Chuin 2009 8 -1.06 (21.06) 8 1.18 (18.38) 100.0 % -2.24 [ -21.61, 17.13 ]

Total (95% CI) 8 8 100.0 % -2.24 [ -21.61, 17.13 ]




-100 -50 0 50 100

Favours antiox Favours exercise+antiox

Analysis 12.1. Comparison 12 Dynamic weight bearing exercise low force plus Ca2+ versus Ca2+, Outcome 1

Bone mineral density % change: femoral neck.


Comparison: 12 Dynamic weight bearing exercise low force plus Ca2+

versus Ca2+


Study or subgroup Exercise plus Ca2+ Ca2+Mean


Difference


Lau 1992 15 5 (2.35) 12 -3.5 (1.84) 49.5 % 8.50 [ 6.92, 10.08 ]

Prince 1995 42 0.28 (0.34) 42 -0.18 (0.2) 50.5 % 0.46 [ 0.34, 0.58 ]

Total (95% CI) 57 54 100.0 % 4.44 [ -3.44, 12.32 ]




-20 -10 0 10 20

Favours Ca2+ Favours exercise % Ca2+




Bone mineral density % change: spine.



versus Ca2+




Difference


Lau 1992 15 -1.1 (0.59) 12 -0.08 (0.3) 100.0 % -1.02 [ -1.36, -0.68 ]

Total (95% CI) 15 12 100.0 % -1.02 [ -1.36, -0.68 ]




-1 -0.5 0 0.5 1



Bone mineral density % change: trochanter.



versus Ca2+




Difference


Lau 1992 15 11 (5.94) 12 2 (1.05) 48.4 % 9.00 [ 5.94, 12.06 ]

Prince 1995 42 0.81 (0.41) 42 0.5 (0.23) 51.6 % 0.31 [ 0.17, 0.45 ]

Total (95% CI) 57 54 100.0 % 4.51 [ -4.00, 13.03 ]




-20 -10 0 10 20





Bone mineral density % change: distal tibia.



versus Ca2+

Outcome: 4 Bone mineral density % change: distal tibia



Difference


Prince 1995 42 -1.05 (0.41) 42 -1.65 (0.23) 100.0 % 0.60 [ 0.46, 0.74 ]

Total (95% CI) 42 42 100.0 % 0.60 [ 0.46, 0.74 ]




-1 -0.5 0 0.5 1



Bone mineral density % change: Ward’s triangle.



versus Ca2+




Difference


Lau 1992 15 17 (8.67) 12 2.5 (1.3) 100.0 % 14.50 [ 10.05, 18.95 ]

Total (95% CI) 15 12 100.0 % 14.50 [ 10.05, 18.95 ]




-50 -25 0 25 50

Favours Ca2+ Favours exercise



Analysis 13.1. Comparison 13 Non-weight bearing exercise low force plus calcium versus calcium, Outcome

1 Bone mineral density % change: spine.


Comparison: 13 Non-weight bearing exercise low force plus calcium versus calcium




Difference


Kerr 2001 30 0.32 (10.13) 36 -0.01 (11.88) 100.0 % 0.33 [ -4.98, 5.64 ]

Total (95% CI) 30 36 100.0 % 0.33 [ -4.98, 5.64 ]




-10 -5 0 5 10



2 Bone mineral density % change: total hip.






Difference


Kerr 2001 30 -0.65 (9.91) 36 -0.57 (11.82) 100.0 % -0.08 [ -5.32, 5.16 ]

Total (95% CI) 30 36 100.0 % -0.08 [ -5.32, 5.16 ]




-100 -50 0 50 100





3 Bone mineral density % change: femoral neck.






Difference


Kerr 2001 30 0.03 (12.16) 36 -0.11 (15.6) 100.0 % 0.14 [ -6.56, 6.84 ]

Total (95% CI) 30 36 100.0 % 0.14 [ -6.56, 6.84 ]




-100 -50 0 50 100



4 Bone mineral density % change: trochanter.






Difference


Kerr 2001 30 -0.02 (14.24) 36 -0.01 (16.44) 100.0 % -0.01 [ -7.41, 7.39 ]

Total (95% CI) 30 36 100.0 % -0.01 [ -7.41, 7.39 ]




-100 -50 0 50 100





5 Bone mineral density % change: total body.






Difference


Kerr 2001 30 0.79 (9.48) 36 -0.71 (10.14) 100.0 % 1.50 [ -3.24, 6.24 ]

Total (95% CI) 30 36 100.0 % 1.50 [ -3.24, 6.24 ]




-100 -50 0 50 100


Analysis 14.1. Comparison 14 Non-weight bearing exercise high force plus calcium versus calcium,

Outcome 1 Bone mineral density % change: femoral neck.


Comparison: 14 Non-weight bearing exercise high force plus calcium versus calcium




Difference


Kerr 2001 24 1.04 (13.77) 36 -0.11 (15.6) 100.0 % 1.15 [ -6.35, 8.65 ]

Total (95% CI) 24 36 100.0 % 1.15 [ -6.35, 8.65 ]




-20 -10 0 10 20





Outcome 2 Bone mineral density % change: trochanter.






Difference


Kerr 2001 24 0 (11.4) 36 -0.01 (16.44) 100.0 % 0.01 [ -7.04, 7.06 ]

Total (95% CI) 24 36 100.0 % 0.01 [ -7.04, 7.06 ]




-20 -10 0 10 20



Outcome 3 Bone mineral density % change: total hip.






Difference


Kerr 2001 24 0.57 (8.62) 36 -0.57 (11.82) 100.0 % 1.14 [ -4.04, 6.32 ]

Total (95% CI) 24 36 100.0 % 1.14 [ -4.04, 6.32 ]




-20 -10 0 10 20





Outcome 4 Bone mineral density % change: spine.






Difference


Kerr 2001 24 -0.65 (10.39) 36 -0.01 (11.88) 100.0 % -0.64 [ -6.33, 5.05 ]

Total (95% CI) 24 36 100.0 % -0.64 [ -6.33, 5.05 ]




-20 -10 0 10 20



Outcome 5 Bone mineral density % change: total body.






Difference


Kerr 2001 24 -0.62 (6.76) 36 -0.71 (10.14) 100.0 % 0.09 [ -4.19, 4.37 ]

Total (95% CI) 24 36 100.0 % 0.09 [ -4.19, 4.37 ]




-20 -10 0 10 20




Analysis 15.1. Comparison 15 Dynamic weight bearing exercise low force plus calcium/VitD versus

calcium/VitD, Outcome 1 Bone mineral density % change: spine.


Comparison: 15 Dynamic weight bearing exercise low force plus calcium/VitD versus calcium/VitD


Study or subgroup

Exerciseplus

Ca2+/VitD Ca2+/VitDMean


Difference


Martin 1993 16 0.81 (4.53) 19 -0.61 (3.4) 100.0 % 1.42 [ -1.28, 4.12 ]

Total (95% CI) 16 19 100.0 % 1.42 [ -1.28, 4.12 ]




-4 -2 0 2 4

Favours Ca2+/VitD Favours exercise%Ca2+/Vit

Analysis 15.2. Comparison 15 Dynamic weight bearing exercise low force plus calcium/VitD versus

calcium/VitD, Outcome 2 Bone mineral density % change:wrist.


Comparison: 15 Dynamic weight bearing exercise low force plus calcium/VitD versus calcium/VitD

Outcome: 2 Bone mineral density % change:wrist

Study or subgroup

Exerciseplus

Ca2+/VitD Ca2+/VitDMean


Difference


Martin 1993 16 4.01 (11.97) 19 2.37 (5.96) 100.0 % 1.64 [ -4.81, 8.09 ]

Total (95% CI) 16 19 100.0 % 1.64 [ -4.81, 8.09 ]




-10 -5 0 5 10

Favours Ca2+/VitD Favours exercise%Ca2+/Vit



A P P E N D I C E S

Appendix 1. MEDLINE search strategy

MEDLINE (searched 10/12/2010)

1 osteoporosis/

2 osteoporo$.mp.

3 osteopenia.mp.

4 bone density/

5 bone densit$.mp.

6 exp “bone and bones”/

7 bone loss$.mp.

8 bone mass$.mp.

9 bone mineral densit$.mp.

10 bone mineral content$.mp.

11 bone age.mp.

12 bone defect$.mp.

13 bone deminerali?ation.mp.

14 bone mineral$.mp.

15 bone strength.mp.

16 decalcifi$.mp.

17 deminerali?ed bone.mp.

18 or/1-17

19 randomized controlled trial.pt.

20 controlled clinical trial.pt.

21 randomi?ed.ab.

22 placebo.ab.

23 clinical trials as topic.sh.

24 randomly.ab.

25 trial.ti.

26 or/19-25

27 (animals not (humans and animals)).sh.

28 26 not 27

29 exp exercise/

30 exp exercise therapy/

31 exerci$.mp.

32 exp sports/

33 sport$.mp.

34 physical fitness/

35 physical fitness.mp.

36 physical activit$.mp.

37 vibration/tu

38 vibration therap$.mp.

39 or/29-38

40 exp menopause/

41 (menopaus$ or postmenopaus$ or post-menopaus$ or (post adj menopause$)).mp.

42 or/40-41

43 18 and 28 and 39 and 42

44 limit 43 to yr=“2000-Current”



Appendix 2. EMBASE search strategy

EMBASE (searched 10/12/2010)

1 osteoporosis/

2 osteoporo$.mp.

3 osteopenia.mp.

4 bone density/

5 bone mass/

6 bone densit$.mp.

7 exp bone/

8 bone loss$.mp.

9 bone mass$.mp.

10 bone mineral/



13 or/1-12

14 Randomized Controlled Trial/

15 Double Blind Procedure/

16 Single Blind Procedure/

17 Triple Blind Procedure/

18 randomi?ed.ti,ab.

19 randomisation/

20 Placebo/

21 placebo$.mp.

22 ((controlled or comparative or placebo or randomi?ed) adj3 (trial or study)).mp.

23 (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$ or order$)).mp.

24 ((singl$ or doubl$ or trebl$ or tripl$) adj7 (blind$ or mask$)).mp.

25 or/14-24

26 limit 25 to human

27 exp exercise/

28 exp sport/

29 fitness/

30 exp physical activity/

31 sport$.mp.

32 exercis$.mp.



35 vibration therapy/


37 or/27-36

38 postmenopause/

39 postmenopause osteoporosis/

40 menopause/


42 or/38-41

43 42 and 37 and 26 and 13

44 limit 43 to yr=“2000 -Current”



Appendix 3. CINAHL search strategy

CINAHL (Searched 17/12/2010)

1 (MH “Osteoporosis+”)

2 TI osteoporosis OR AB osteoporosis

3 TI osteopenia OR AB osteopenia

4 MH bone density

5 TI bone densit* OR AB bone densit*

6 (MH “Bone and Bones+”)

7 TI bone loss* OR AB bone loss*

8 TI bone mass* OR AB bone mass*

9 TI bone mineral densit* OR AB bone mineral densit*

10 TI bone mineral content* OR AB bone mineral content*

11 TI bone age OR AB bone age

12 TI bone defect* OR AB bone defect*

13 TI bone deminerali?ation OR AB bone deminerali?ation

14 TI bone mineral* OR AB bone mineral*

15 TI bone strength OR AB bone strength

16 TI decalcifi* OR AB decalcifi*

17 TI deminerali?ed bone OR AB deminerali?ed bone

18 S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9 or S10 or S11 or S12 or S13 or S14 or S15 or S16 or S17

19 (MH “double-blind studies”)

20 (MH “single-blind studies”)

21 (MH “triple-blind studies”)

22 TI randomi?ed OR AB randomi?ed

23 (MH “random assignment”)

24 (MH “crossover design”)

25 (MH “placebos”)

26 TI placebo* OR AB placebo*

27 TI controlled N3 trial OR TI controlled N3 study OR TI comparative N3 trial OR TI comparative N3 study OR TI placebo

N3 trial OR TI placebo N3 study OR TI randomi?ed N3 trial OR TI randomi?ed N3 study

28 AB controlled N3 trial OR AB controlled N3 study OR AB comparative N3 trial OR AB comparative N3 study OR AB

placebo N3 trial OR AB placebo N3 study OR AB randomi?ed N3 trial OR AB randomi?ed N3 study

29 TI random* N7 allocat* OR TI random* N7 allot* OR TI random* N7 assign* OR TI random* N7 basis* OR TI random*

N7 divid* OR TI random* N7 order*

30 AB random* N7 allocat* OR AB random* N7 allot* OR AB random* N7 assign* OR AB random* N7 basis* OR AB

random* N7 divid* OR AB random* N7 order*

31 TI singl* N7 blind* OR TI doubl* N7 blind* OR TI trebl* N7 blind* OR TI tripl* N7 blind* OR TI singl* N7 mask* OR

TI doubl* N7 mask* OR TI trebl* N7 mask* OR TI tripl* N7 mask*

32 AB singl* N7 blind* OR AB doubl* N7 blind* OR AB trebl* N7 blind* OR AB tripl* N7 blind* OR AB singl* N7 mask*

OR AB doubl* N7 mask* OR AB trebl* N7 mask* OR AB tripl* N7 mask*

33 S19 or S20 or S21 or S22 or S23 or S24 or S25 or S26 or S27 or S28 or S29 or S30 or S31 or S32

34 (MH “animals”)

35 33 not 34

36 (MH “exercise+”)

37 TI exerci* OR AB exerci*

38 (MH “sports+”)

39 TI sport* OR AB sport*

40 MH “physical fitness+”

41 MH physical activity

42 TI physical fitness OR AB physical fitness

43 TI physical activit* OR AB physical activit*

44 MH vibration/tu



45 TI vibration therap* OR AB vibration therap*

46 S36 or S37 or S38 or S39 or S40 or S41 or S42 or S43 or S44 or S45

47 MH menopause

48 MH postmenopause

49 TI menopaus* OR AB menopaus* OR TI post-menopaus* OR AB post-menopaus* OR TI postmenopaus* OR AB

postmenopaus* OR TI post N1 menopaus* OR AB post N1 menopaus*

50 S47 OR S48 OR S49

51 S18 AND S35 AND S46 AND S50

52 S18 AND S35 AND S46 AND S50 Limiters - Published Date from: 20000101-20101231

Appendix 4. PEDro keyword and text word search strategy

PEDro (Searched December 15, 2010)

Search 1

Osteoporo* or bone in Abstract & Title AND

Fitness training in Therapy

Search 2

Osteoporo* or bone in Abstract & Title AND

Strength training in Therapy

Appendix 5. CCTR search strategy

CCTR (Searched 10/12/2010)

1 osteoporosis/

2 osteoporo$.mp.

3 osteopenia.mp.

4 bone density/

5 bone densit$.mp.

6 exp “bone and bones”/

7 bone loss$.mp.

8 bone mass$.mp.



11 bone age.mp.

12 bone defect$.mp.

13 bone deminerali?ation.mp.

14 bone mineral$.mp.

15 bone strength.mp.

16 decalcifi$.mp.

17 deminerali?ed bone.mp.

18 or/1-17



21 randomi?ed.ab.

22 placebo.ab.

23 clinical trials as topic.sh.



24 randomly.ab.

25 trial.ti.

26 or/19-25

27 animals/

28 26 not 27

29 exp exercise/

30 exp exercise therapy/

31 exerci$.mp.

32 exp sports/

33 sport$.mp.

34 physical fitness/



37 vibration/tu


39 or/29-38

40 exp menopause/


42 or/40-41

43 18 and 28 and 39 and 42


Appendix 6. AMED search strategy

AMED (Searched 10/12/2010)

1 osteoporosis/

2 osteoporo$.mp.

3 osteopenia.mp.

4 bone density/

5 bone densit$.mp.

6 exp bones/

7 bone loss$.mp.

8 bone mass$.mp.



11 or/1-10



14 randomi?ed.ti,ab.

15 Placebos/

16 placebo$.ti,ab.

17 double-blind method/

18 single-blind method/

19 random allocation/

20 ((controlled or comparative or placebo or randomi?ed) adj3 (trial or study)).mp.

21 (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$ or order$)).mp.

22 ((singl$ or doubl$ or trebl$ or tripl$) adj7 (blind$ or mask$)).mp.

23 or/12-22

24 animals/

25 23 not 24

26 exp exercise/

27 exp Sports/



28 Physical Fitness/

29 sport$.mp.

30 exerci$.mp.



33 vibration/

34 vibration therapy.mp.

35 or/26-34

36 exp menopause/


38 or/36-37

39 11 and 25 and 35 and 38


W H A T ’ S N E W

Last assessed as up-to-date: 2 January 2011.

Date Event Description

17 May 2011 New search has been performed The methodology has been updated to include risk of bias

and summary of findings tables. The exercise interventions

have been re-categorised which included reclassification of

interventions from the original studies. The search was up-

dated to include vibrations plates and included all studies up

to Jan 2011. Of the 43 included studies 27 are new stud-

ies; and on further scrutiny of the included studies from

the original version one was excluded and a further study

was actually follow-up data for another included study. New

comparisons are based on the reclassification of exercise cat-

egories. All analyses are new, based on the new categories of

exercise interventions and the conclusions have changed

17 May 2011 New citation required and conclusions have changed This review update involves new authors and conclusions

have changed

H I S T O R Y

Protocol first published: Issue 3, 1997

Review first published: Issue 3, 2002



Date Event Description

27 September 2008 Amended Converted to new review format.

CMSG ID: C035-R

C O N T R I B U T I O N S O F A U T H O R S

TEH - designed and reviewed the protocol for the updated review; extracted and entered data and assessed quality; conducted

methodological analysis; and wrote and reviewed the manuscript.

BS - designed and reviewed the protocol for the review; extracted data and assessed quality; conducted methodological analysis; and

wrote and reviewed the manuscript.

LD - applied the inclusion and exclusion criteria for accepting studies in the review; classified the studies; helped with classifying the

interventions; extracted and entered data and assessed quality; and contributed to and reviewed the manuscript.

FD - applied the inclusion and exclusion criteria for accepting studies in the review; classified the studies; helped with classifying the

interventions; extracted data and assessed quality; and contributed to and reviewed the manuscript.

AM - applied the inclusion and exclusion criteria for accepting studies in the review; classified the studies; helped with classifying the

interventions; extracted data and assessed quality; and contributed to and reviewed the manuscript.

CR - applied the inclusion and exclusion criteria for accepting studies into the review; classified the studies; helped with classifying the

interventions; extracted data and assessed quality; and provided critical comments on drafts of the review.

RH - contributed methodological expertise and reviewed early drafts of the document.

LC - wrote the search strategies and identified the literature.

GS - applied the inclusion and exclusion criteria for accepting studies into the review; classified the studies; helped with classifying the

interventions; extracted data and assessed quality; and reviewed earlier drafts of the review; provided translation into English.

D E C L A R A T I O N S O F I N T E R E S T

None known

S O U R C E S O F S U P P O R T

Internal sources

• University of Ottawa, Canada.

• Clinical Epidemiology Unit, Ottawa Hospital, Civic Campus, Canada.

• Institute of Population Health, Canada.

• Glasgow Caledonian University, UK.



External sources

• The Chartered Society of Physiotherapy, UK.

• National Institute for Health Research, UK.

Cochrane Incentive Award 2010

I N D E X T E R M S

Medical Subject Headings (MeSH)

∗Exercise [physiology]; Bone Density [physiology]; Fractures, Bone [∗prevention & control; therapy]; Osteoporosis, Postmenopausal

[∗prevention & control; therapy]; Randomized Controlled Trials as Topic

MeSH check words

Female; Humans



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