The effect of exercise intensity on bone in postmenopausal women (part 1): A systematic review

The CHILL BONES (combining high-intensity impact loading and lifting with mind-body exercise for optimisation of nervous system and skeletal health) trial: protocol for a parallel-group, semi-randomised controlled trial

INTRODUCTION

Animal studies suggest that elevated sympathetic nervous system (SNS) activity can accelerate bone loss. However, this area has not been well researched in humans. High-intensity Resistance and Impact Training (HiRIT) is recognised as an effective treatment for osteoporosis and osteopenia. Alternate forms of exercise such as mind-body exercise may be used to modulate sympathetic activity, which could have an additive benefit for skeletal adaptation when used in conjunction with HiRIT. The aim of this study is to investigate whether the combination of mind-body exercise (Tai Chi) and HiRIT can be used to concurrently modulate SNS activity and improve skeletal health.

METHODS AND ANALYSIS

The CHILL BONES trial is a semi-randomised controlled trial where consenting adults over 60 years, who have low bone mass (total hip, femoral neck and/or lumbar spine T-score <-1.0) will be randomly allocated to participate in 8 months of twice-weekly Tai Chi, HiRIT or combined (Tai Chi+HiRIT) exercise. If participants are unwilling or unable to undertake exercise, they may opt into a non-exercising control group. The primary outcome will be total hip areal bone mineral density (BMD) measured using dual-energy X-ray absorptiometry. Secondary outcomes include femoral neck BMD, lumbar spine BMD, resting and reflexive skin sympathetic nerve activity and heart rate variability. Outcomes will be measured at baseline and post-intervention (8 months). Both intention-to-treat and per-protocol analyses will be undertaken.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Griffith University Human Research Ethics Committee (GUHREC; GU Ref No: 2023/448). Trial findings will be disseminated to participants via a plain-language summary upon completion. Results will be formally reported through peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12623001209684; Australian New Zealand Clinical Trials Registry.

Optimal resistance training parameters for improving bone mineral density in postmenopausal women: a systematic review and meta-analysis

BACKGROUND

This meta-analysis aims to explore the effects of resistance training on bone mineral density (BMD) in postmenopausal women, specifically focusing on different training intensities, durations, frequencies, and periods, across various skeletal sites lumbar spine (LS), femoral neck (FN), total hip (TH), and trochanter (Troch).

METHODS

We systematically searched PubMed, Embase, Web of Science, and the Cochrane Library for studies evaluating the impact of resistance training programs on BMD in postmenopausal women, covering all records up to March 2025. Two reviewers independently screened the studies, extracted data, assessed the risk of bias using the Cochrane Handbook, and performed the meta-analysis using RevMan 5.4 and Stata 18 software.

RESULTS

17 randomized controlled trials involving 690 subjects were included. The results indicate that resistance training significantly improves BMD at the LS (SMD = 0.88, 95% CI [0.21, 1.56], P = 0.01, I2 = 91%), FN (SMD = 0.89, 95% CI [0.40, 1.39], P = 0.0004, I2 = 87%) and TH (SMD = 0.30, 95% CI [0.10, 0.50], P = 0.003, I2 = 25%). However, no significant effect was observed on Troch bone density (SMD = 0.23, 95% CI [-0.01, 0.47], P = 0.06, I2 = 19%). Subgroup analysis further revealed that high-intensity training (≥ 70% 1RM) had a significant effect on the TH and FN (P < 0.05); training three times per week significantly improved bone mineral density at the LS, FN, TH, and Troch (P < 0.05); intervention durations of ≥ 48 weeks had a significant impact on FN and TH (P < 0.05); and sessions lasting 40 min had a significant effect on LS (P < 0.05).

CONCLUSION

Resistance training can beneficially influence BMD in postmenopausal women, particularly at the LS, FN, and TH. A high-intensity training regimen (≥ 70% 1RM) performed three times per week with a longer training duration may be optimal. However, significant heterogeneity among the included studies for LS and FN bone density may affect the accuracy of the pooled results, thereby limiting the generalizability of these findings. More high-quality clinical trials are needed to confirm these findings.

SIRT1 and exercise-induced bone metabolism: a regulatory nexus

Regular exercise positively influences bone health, enhances bone density and strength, and reduces the risk of osteoporosis. Silent information regulator of transcription 1 (SIRT1) is a deacetylase that plays a pivotal role in the regulation of various biological processes. In this review, we explore the role of SIRT1 in modulating bone metabolism in response to exercise. SIRT1 regulates crucial cellular processes, including inflammation, aging, autophagy, and oxidative stress, in bone cells such as bone marrow mesenchymal stem cells, osteoblasts, and osteoclasts, in response to exercise-induced stimuli. Notably, exercise influences bone metabolism by modulating muscle metabolism and neurotransmitters, with SIRT1 acting as a key mediator. A comprehensive understanding of SIRT1's regulatory mechanisms will facilitate a deeper exploration of the principles underlying exercise-induced improvements in bone metabolism, ultimately providing novel insights into the treatment of bone metabolic disorders.

Strength training for osteoporosis prevention during early menopause (STOP-EM): a pilot study protocol for a single centre randomised waitlisted control trial in Canada

INTRODUCTION

Women lose up to 10% of their bone mass around menopause and the decade following. There is a need for proactive approaches to preserve bone mass and quality around menopause. Existing work has found that high-intensity resistance and impact training (HiRIT) can improve bone and muscle measures in late postmenopausal women. However, this has not been investigated in perimenopausal and early postmenopausal women who are in the midst of the menopausal transition.

METHODS AND ANALYSIS

This study is a 9-month randomised controlled feasibility trial evaluating a HiRIT programme in perimenopausal and early postmenopausal women. The primary objective of this study is to determine the feasibility of HiRIT in 40 perimenopausal and early postmenopausal women (45-60 years). Participants will be randomised 1:1 into a supervised HiRIT exercise intervention and waitlisted control. The primary outcomes are recruitment, retention and adherence to the exercise intervention. Secondary outcomes include bone (bone mineral density, microarchitecture and strength), muscle (mass, strength and power), physical function (balance and aerobic fitness) and quality of life measures. Feasibility will be assessed based on a priori criterion for success and secondary outcomes will be assessed via multiple linear regressions. The study will be considered feasible if>50% of interested and eligible participants are recruited, if there is>60% adherence to the two times per week, 9-month exercise intervention and if at least 65% of the sample complete the final study visit. Feasibility outcomes will be used to inform a larger, future trial aimed at identifying the efficacy of the exercise intervention for improving various health outcomes, including bone density and muscle mass. Secondary exploratory outcomes will provide insight into the effect of exercise on muscle and bone in perimenopausal and early postmenopausal women.

ETHICS AND DISSEMINATION

This study has been approved by the Conjoint Health Research Ethics Board of the University of Calgary REB22-1632. The results of this study will be disseminated at national and international conferences and published in academic journals.

TRAIL REGISTRATION NUMBER

ClinicalTrials.gov: NCT05961371. (Protocol V.1.2, 28 September 2023).

Adaptation, Validation, and Feasibility Evaluation of Mindful Standing Yoga Combined with Baduanjin for Older Patients with Primary Osteoporosis

OBJECTIVE

This study aimed to adapt, validate, and evaluate the feasibility of a mindful exercise program (Mindful Standing Yoga combined with Baduanjin) for older patients with primary osteoporosis.

METHODS

The study was conducted in 3 stages. Stage 1 involved a qualitative focus group discussion with 6 experts to gather perspectives on modifying the exercise program. Stage 2 used a Delphi approach with another 6 experts to validate the program. In Stage 3, a feasibility study was conducted with 20 eligible patients (out of 23 initially enrolled) at a traditional Chinese medicine hospital, using a single-group pre- and posttest design. The strenuousness of the adapted exercise was assessed through heart rate (HR) and rating of perceived exertion (RPE). Its effects were measured using the Global Pain Scale (GPS), the Five Facets Mindfulness Questionnaire-Short Form (FFMQ-SF), the Tampa Kinesiophobia-11 Scale, and the Timed Up and Go test. Patient satisfaction and feedback were also collected.

RESULTS

The modified program, consisting of 9 movements and taking 30 min to complete, was validated by experts as suitable, safe, and effective for practice. HR and RPE measurements confirmed it as a low-intensity exercise and not strenuous for the study population. The program significantly improved back pain and mindfulness in the feasibility study, with most participants expressing satisfaction with the protocol.

CONCLUSION

Experts and participants affirmed that the program was appropriate and satisfactory for older patients with primary osteoporosis, particularly those with back pain. Further high-quality randomized controlled trials are needed to validate its effectiveness.

Regular physical activity improves physical function and health-related quality of life among middle-aged and older women who suffered a fragility fracture-a population-based cohort

Fragility fractures are a major problem in our aging society leading to early death and loss of independence for activities of daily living. Physical activity in a long-term follow-up of Portuguese women over 50 years with a fragility fracture was associated with better physical function and quality of life.

PURPOSE

To evaluate the long-term impact of physical activity on physical function and health-related quality of life (HRQoL) in women ≥ 50 years old who suffered a fragility fracture.

METHODS

We evaluated the association of physical activity with physical function and HRQoL in women ≥ 50 years old who self-reported at least one low-impact fracture ≥ 40 years old from the EpiDoC cohort, a population-based cohort. Self-reported data regarding sociodemographics, clinical, and lifestyle behaviors were collected through a semi-structured questionnaire at baseline during a face-to-face clinical interview. During a long-term follow-up, a phone interview was conducted to evaluate physical activity (using a non-validated scale developed for the EpiDoC study), physical function (Health Assessment Questionnaire), and HRQoL (European Quality of Life - 5 Dimension). Women were divided into three groups according to the frequency of physical activity (non-frequent = 0 times/week, frequent = 1-2 times/week, or very frequent =  ≥ 3 times/week). The association of physical activity frequency (non-frequent, frequent, and very frequent) with physical function and HRQoL over time was assessed through linear mixed models considering varying intercepts for each woman.

RESULTS

This study followed 323 post-fracture women, during a mean follow-up of 3.9 ± 3.5 years. Frequent (β =  - 0.1419 [- 0.2783, - 0.0064]) and very frequent (β =  - 0.1908 [- 0.2944, - 0.0881]) physical exercise were associated with improvements in physical function relative to non-frequent physical exercise adjusted for BMI, multimorbidity, hospitalizations, alcohol and smoking habits, and the number of fragility fractures at baseline. As for HRQoL, a positive association was found for exercise frequency, specifically frequent (β = 0.1305 [0.0646, 0.1958]) and very frequent (β = 0.1354 [0.0856, 0.1859]) suggesting improvements for HRQoL, in this follow-up period.

CONCLUSIONS

These findings based on longitudinal data with long-term follow-up suggest that regular physical activity is associated with better function and HRQol among middle-aged and older post-fracture osteoporotic Portuguese women.

Estrogen and estrogen receptors mediate the mechanobiology of bone disease and repair

It is well understood that the balance of bone formation and resorption is dependent on both mechanical and biochemical factors. In addition to cell-secreted cytokines and growth factors, sex hormones like estrogen are critical to maintaining bone health. Although the direct osteoprotective function of estrogen and estrogen receptors (ERs) has been reported extensively, evidence that estrogen signaling also has a role in mediating the effects of mechanical loading on maintenance of bone mass and healing of bone injuries has more recently emerged. Recent studies have underscored the role of estrogen and ERs in many pathways of bone mechanosensation and mechanotransduction. Estrogen and ERs have been shown to augment integrin-based mechanotransduction as well as canonical Wnt/b-catenin, RhoA/ROCK, and YAP/TAZ pathways. Estrogen and ERs also influence the mechanosensitivity of not only osteocytes but also osteoblasts, osteoclasts, and marrow stromal cells. The current review will highlight these roles of estrogen and ERs in cellular mechanisms underlying bone mechanobiology and discuss their implications for management of osteoporosis and bone fractures. A greater understanding of the mechanisms behind interactions between estrogen and mechanical loading may be crucial to addressing the shortcomings of current hormonal and pharmaceutical therapies. A combined therapy approach including high-impact exercise therapy may mitigate adverse side effects and allow an effective long-term solution for the prevention, treatment, and management of bone fragility in at-risk populations. Furthermore, future implications to novel local delivery mechanisms of hormonal therapy for osteoporosis treatment, as well as the effects on bone health of applications of sex hormone therapy outside of bone disease, will be discussed.

Effects of vitamin D3, omega-3s, and a simple strength training exercise program on bone health: the DO-HEALTH randomized controlled trial

Evidence on the effects of Vitamin D, omega-3s, and exercise on areal bone mineral density (aBMD) in healthy older adults is limited. We examined whether vitamin D3, omega-3s, or a simple home-based exercise program (SHEP), alone or in combination, over 3 years, improve lumbar spine (LS), femoral neck (FN), or total hip (TH) aBMD assessed by DXA. Areal BMD was a secondary outcome in DO-HEALTH, a 3-year, multicenter, double-blind, randomized 2 × 2 × 2 factorial design trial in generally healthy older adults age ≥ 70 years. The study interventions were vitamin D3 (2000IU/d), omega-3s (1 g/d), and SHEP (3 × 30 min/wk), applied alone or in combination in eight treatment arms. Mixed effects models were used, adjusting for age, sex, BMI, prior fall, study site, and baseline level of the outcome. Main effects were assessed in the absence of an interaction between the interventions. Subgroup analyses by age, sex, physical activity level, dietary calcium intake, serum 25(OH)D levels, and fracture history were conducted. DXA scans were available for 1493 participants (mean age 75 years; 80.4% were physically active, 44% had 25(OH)D levels <20 ng/mL). At the LS and FN sites, none of the treatments showed a benefit. At the TH, vitamin D versus no vitamin D treatment showed a significant benefit across 3 years (difference in adjusted means [AM]: 0.0035 [95% CI, 0.0011, 0.0059] g/cm). Furthermore, there was a benefit for vitamin D versus no vitamin D treatment on LS aBMD in the male subgroup (interaction P = .003; ∆AM: 0.0070 [95% CI, 0.0007, 0.0132] g/cm). Omega-3s and SHEP had no benefit on aBMD in healthy, active, and largely vitamin D replete older adults. Our study suggests a small benefit of 2000 IU vitamin D daily on TH aBMD overall and LS aBMD among men; however, effect sizes were very modest and the clinical impact of these findings is unclear.

A contactless monitoring system for accurately predicting energy expenditure during treadmill walking based on an ensemble neural network

The monitoring of treadmill walking energy expenditure (EE) plays an important role in health evaluations and management, particularly in older individuals and those with chronic diseases. However, universal and highly accurate prediction methods for walking EE are still lacking. In this paper, we propose an ensemble neural network (ENN) model that predicts the treadmill walking EE of younger and older adults and stroke survivors with high precision based on easy-to-obtain features. Compared with previous studies, the proposed model reduced the estimation error by 13.95% and 66.20% for stroke survivors and younger adults, respectively. Furthermore, a contactless monitoring system was developed based on Kinect, mm-wave radar, and ENN algorithms, and the treadmill walking EE was monitored in real time. This ENN model and monitoring system can be combined with smart devices and treadmill, making them suitable for evaluating, monitoring, and tracking changes in health during exercise and in rehabilitation environments.

The Interconnection Between Muscle and Bone: A Common Clinical Management Pathway

Often observed with aging, the loss of skeletal muscle (sarcopenia) and bone (osteoporosis) mass, strength, and quality, is associated with reduced physical function contributing to falls and fractures. Such events can lead to a loss of independence and poorer quality of life. Physical inactivity (mechanical unloading), especially in older adults, has detrimental effects on the mass and quality of bone as well as muscle, while increases in activity (mechanical loading) have positive effects. Emerging evidence suggests that the relationship between bone and muscle is driven, at least in part, by bone-muscle crosstalk. Bone and muscle are closely linked anatomically, mechanically, and biochemically, and both have the capacity to function with paracrine and endocrine-like action. However, the exact mechanisms involved in this crosstalk remain only partially explored. Given older adults with lower bone mass are more likely to present with impaired muscle function, and vice versa, strategies capable of targeting both bone and muscle are critical. Exercise is the primary evidence-based prevention strategy capable of simultaneously improving muscle and bone health. Unfortunately, holistic treatment plans including exercise in conjunction with other allied health services to prevent or treat musculoskeletal disease remain underutilized. With a focus on sarcopenia and osteoporosis, the aim of this review is to (i) briefly describe the mechanical and biochemical interactions between bone and muscle; (ii) provide a summary of therapeutic strategies, specifically exercise, nutrition and pharmacological approaches; and (iii) highlight a holistic clinical pathway for the assessment and management of sarcopenia and osteoporosis.

What is the evidence for the effect of physical exercise on bone health in menopausal women? An umbrella systematic review

This study aimed to analyze the effects of physical exercise (PE) on bone health in menopausal women through an umbrella review and to assess the quality of systematic reviews (SRs) and meta-analyses (MAs) included. The review was registered in PROSPERO (CRD42020208130) and the Rayyan application was used. The methodological quality of the included studies was evaluated by A MeaSurement Tool to Assess Systematic Reviews (AMSTAR), and Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to assess the level of evidence of the results. The results showed that low-intensity jumping exercises with longer sessions proved to be efficient in the hip segment. Swimming requires further investigation, as it showed high heterogeneity. Aerobic and resistance exercises showed inconsistent results, requiring further studies with these modalities of PE. Concurrent training showed improvements in the lumbar spine, femoral neck, Ward's triangle and trochanter. Finally, combined resistance exercises are effective in preserving bone mineral density (BMD) of the femoral neck and lumbar spine in postmenopausal women. In conclusion, jumping exercises were efficient in the hip, while aerobic and resistance exercises are still inconsistent. Concurrent training showed improvements in BMD of the lumbar spine, femoral neck, Ward's triangle and trochanter. Finally, combined resistance protocols are effective in preserving BMD of the femoral neck and lumbar spine in postmenopausal women.

Effects of Moderate- to High-Impact Exercise Training on Bone Structure Across the Lifespan: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Moderate- to high-impact exercise improves bone mineral density (BMD) across the lifespan, but its effects on bone structure, which predicts fracture independent of areal BMD, are unclear. This systematic review and meta-analysis investigated effects of impact exercise on volumetric BMD (vBMD) and bone structure. Four databases (PubMed, Embase, SPORTDiscus, Web of Science) were searched up to March 2022 for randomized controlled trials (RCTs) investigating the effects of impact exercise, with ground reaction forces equal to or greater than running, compared with sham or habitual activity, on bone vBMD and structure. Bone variables were measured by quantitative computed tomography or magnetic resonance imaging at the tibia, radius, lumbar spine, and femur. Percentage changes in bone variables were compared among groups using mean differences (MD) and 95% confidence intervals (CI) calculated via random effects meta-analyses. Subgroup analyses were performed in children/adolescents (<18 years), adults (18-50 years), postmenopausal women, and older men. Twenty-eight RCTs (n = 2985) were included. Across all studies, impact exercise improved trabecular vBMD at the distal tibia (MD = 0.54% [95% CI 0.17, 0.90%]), total vBMD at the proximal femur (3.11% [1.07, 5.14%]), and cortical thickness at the mid/proximal radius (1.78% [0.21, 3.36%]). There was no effect on vBMD and bone structure at the distal radius, femoral shaft, or lumbar spine across all studies or in any subgroup. In adults, impact exercise decreased mid/proximal tibia cortical vBMD (-0.20% [-0.24, -0.15%]). In postmenopausal women, impact exercise improved distal tibia trabecular vBMD (0.79% [0.32, 1.25%]). There was no effect on bone parameters in children/adolescents in overall analyses, and there were insufficient studies in older men to perform meta-analyses. Impact exercise may have beneficial effects on bone structure and vBMD at various skeletal sites, but additional high-quality RCTs in different age and sex subgroups are needed to identify optimal exercise protocols for improving bone health across the lifespan. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Regular sling core stabilization training improves bone density based on calcium and vitamin D supplementation

BACKGROUND

Primary osteoporosis refers to a disease of aging characterized by reduced bone mass, damage to bone tissue microarchitecture, and predisposition to fracture.Sling core stabilization training emphasizes activating the deep local muscles of the spine under unstable conditions, and enhancing the body's balance and control during exercise.

CASE PRESENTATION

A 70-year-old female went to the Acupuncture and Rehabilitation Department due to low back pain caused by osteoporosis.The patient received sling core stabilization training three times a week based on Calcium and Vitamin D Supplementation. After training, the patient's back pain was significantly relieved and insisted one year. In the physical examination of bone mineral density, the results showed that the value of bone mineral density was better than last year.The patients adhered to sling core stabilization training and observed the changes of bone mineral density every year basis on calcium and vitamin D supplementation.

DISCUSSION

However, cases of calcium and vitamin D supplementation-based regular sling core stabilization training that improves bone density in osteoporosis patients have been rarely reported. Our group shared cases and analyzed possible mechanisms, hoping to provide reference for the prevention and treatment of primary osteoporosis.

Menopause Osteoporosis and Bone Intervention Using Lifestyle Exercise: A Randomized Controlled Study

Background

The aim of the study was to examine the feasibility for postmenopausal women of a bone-strengthening jumping intervention, which has been previously successful for premenopausal women.

Materials and Methods

Forty-nine participants (mean ± standard deviation [SD] age = 57.8 ± 4.3 years) were randomized into either an exercise intervention or sham-control group in a double-blinded fashion. The intervention consisted of 10 maximal, rest-inserted countermovement jumps, performed three times a week on a hard surface without shoes for 8 months. Sham-control participants performed unilateral balance exercises of equivalent duration.

Results

The jumps were well tolerated, with women in the jumping group completing 95% of the prescribed exercise. Of the participants who completed the study (n = 23 intervention, n = 16 control), there were no significant differences in broadband ultrasound attenuation (BUA) using quantitative ultrasound (QUS) of the calcaneum within and between groups (mean ± SD BUA = 64.9 ± 7.3 and 66.6 ± 6.5 dB/MHz for intervention pre- and post-trial, respectively, versus mean ± SD BUA = 63.6 ± 4.2 and 64.4 ± 4.5 dB/MHz for sham-controls pre- and post-trial, respectively) or for any QUS parameters, although there was a 3% increase in BUA for intervention participants.

Conclusions

Recruitment and participation rates were feasible for this duration of study and the exercise was acceptable. For a future study of this nature, 48 participants would be required to ensure adequate power, especially as lifestyle variations and post-menopausal hypoestrogenism prevent substantial gains in bone strength with high-impact exercise.

Exercise to Prevent and Manage Frailty and Fragility Fractures

PURPOSE OF REVIEW

This review identifies exercise-based recommendations to prevent and manage frailty and fragility fractures from current clinical practice guidelines. We also critically assess recently published literature in relation to exercise interventions to mitigate frailty and fragility fractures.

RECENT FINDINGS

Most guidelines presented similar recommendations that included the prescription of individually tailored, multicomponent exercise programs, discouragement of prolonged sitting and inactivity, and combining exercise with optimal nutrition. To target frailty, guidelines recommend supervised progressive resistance training (PRT). For osteoporosis and fragility fractures, exercise should include weight-bearing impact activities and PRT to target bone mineral density (BMD) at the hip and spine, and also incorporate balance and mobility training, posture exercises, and functional exercise relevant to activities of daily living to reduce falls risk. Walking as a singular intervention has limited benefits for frailty and fragility fracture prevention and management. Current evidence-based clinical practice guidelines for frailty, osteoporosis, and fracture prevention recommend a multifaceted and targeted approach to optimise muscle mass, strength, power, and functional mobility as well as BMD.

Osteoporosis

Osteoporosis is the most common bone disease in adults and confers significant morbidity and mortality in women. Universal screening is recommended for women above the age of 65 years; however, screening rates remain low. Bisphosphonates are the treatment of choice despite a decline in their use due to concerns about rare side effects. Treatment of osteoporosis dramatically decreases the likelihood of fragility fractures.

Comparative efficacy different resistance training protocols on bone mineral density in postmenopausal women: A systematic review and network meta-analysis

Objective: To systematically review the effects of different resistance training (RT) protocols on bone mineral density (BMD) in postmenopausal women. Methods: Randomized controlled trials (RCTs) on the resistance training in improving bone mineral density for postmenopausal women were searched in databases including ProQuest, PubMed, Cochrane Library, Embase, and Web of Science. The retrieval time range was from the establishment of the database to May 2022. The included literature was independently screened and relevant data was extracted by two reviewers. The systematic review followed the Joanna Briggs Institute (JBI) methodology for reviews of quantitative evidence. Quality of risk was assessed using the Physical Therapy Evidence Database (PEDro) scale, risk of bias was assessedusing the Cochrane RoB2 tool and a network Meta-analysis was performed on the data using Stata 16.0. Results: A total of 19 studies, which included 919 subjects, were eventually acquired. The results of the network Meta-analysis showed that moderate intensity resistance training was superior in improving lumbar spine bone mineral density (LS BMD) and femoral neck bone mineral density (FN BMD) compared to the control group (as per usual daily life), with a statistically significant difference (p < 0.05). There was, however, no statistically significant difference between the groups in terms of increasing total hip bone mineral density (TH BMD) and trochanter bone mineral density (Troch BMD), although moderate intensity training tends to increase bone mineral density (p > 0.05). In addition, when training frequency is taken into consideration, 3 days/week of moderate intensity training (3MI) was superior to 2 days/week (2MI) in improving lumbar spine bone mineral density , and moderate intensity training was superior to low and high intensity resistance trainings at training frequency of 3 day/week, with statistically significant differences (p < 0.05). The cumulative probability ranking results indicated that 3MI was the optimal option in improving lumbar spine, femoral neck, total hip and Troch bone mineral density. Subgroup analyses combining interventions time showed that for lumbar spine and femoral neck bone mineral density, 3MI protocol with intervention duration within 1 year (≤48 weeks) had a significant advantage over other interventions, while this advantage was no longer significant with the intervention duration of more than 1 year (>48 weeks). Conclusion: Current evidence shows that moderate intensity resistance training for 3 days/week can be preferred clinically to improve bone mineral density in postmenopausal women, and it is recommended that the duration of the same training should not exceed 1 year. Nevertheless, more high-quality studies are needed to verify the above conclusion.

A comparison of different exercise intensities for improving bone mineral density in postmenopausal women with osteoporosis: A systematic review and meta-analysis

Objective

This study aimed to compare the effects of moderate- and high-intensity resistance and impact training (MiRIT and HiRIT, respectively) on changes in bone mineral density (BMD) in postmenopausal women with osteoporosis.

Methods

Randomized controlled trials that compared the intervention effects of MiRIT and HiRIT were used as selection criteria to assess study patients with osteoporosis or an osteoporotic condition. Database searches were conducted on August 25, 2022, using CENTRAL, PubMed, CINAHL Web of Science, EMBASE, and MEDLINE. A risk of bias assessment was performed using Revised Cochrane risk of bias tool for the assessment of randomized controlled trials. Point estimates and 95 % confidence intervals of change in BMD derived using dual-energy X-ray absorptiometry were collected as outcomes, and a meta-analysis was performed using the amount of change in BMD before and after the intervention. Adverse event data were also collected.

Results

The search yielded six studies (391 patients, mean age 53-65 years) that met the inclusion criteria. The intervention duration ranged from 24 weeks to 13 months. Compared with the MiRIT group, the HiRIT group showed significantly improved BMD of the lumbar spine (standardized mean difference 2.37 [0.10-4.65]). However, a high degree of heterogeneity was observed for three studies (154 patients, I2 = 98 %). Almost all studies reported minimal adverse events. The certainty of evidence was extremely low because of the risk of bias, inconsistency among studies, and imprecision in terms of sample size.

Conclusion

Postmenopausal women with osteoporosis may achieve more significantly improved lumbar spine BMD with HiRIT than with MiRIT.

The utility of dried blood spot measurement of bone turnover markers in biological anthropology

OBJECTIVES

Bone is a dynamic organ under continual turnover influenced by life history stage, energy dynamics, diet, climate, and disease. Bone turnover data have enormous potential in biological anthropology for testing evolutionary and biocultural hypotheses, yet few studies have integrated these biomarkers. In the present article we systematically review the current availability, future viability, and applicability of measuring bone turnover markers (BTMs) in dried blood spot (DBS) samples obtained from finger prick whole blood.

METHODS

Our review considers clinical and public health relevance, biomarker stability in DBS, assay availability, and cost. We consider biomarkers of bone formation such as osteocalcin (bone matrix protein), PINP (N-terminal propeptide of type I collagen), and alkaline phosphatase (osteoblast enzyme), as well as biomarkers of bone resorption such as CTX (marker of collagen breakdown) and TRACP5b (tartrate-resistant acid phosphatase 5b; osteoclast enzyme).

RESULTS

Two BTMs have been validated for DBS: osteocalcin (formation) and TRACP5b (resorption). Prime candidates for future development are CTX and PINP, the formation and resorption markers used for clinical monitoring of response to osteoporosis treatment.

CONCLUSION

BTMs are a field-friendly technique for longitudinal monitoring of skeletal biology during growth, reproduction and aging, combining minimized risk to study participants with maximized ease of sample storage and transport. This combination allows new insights into the effects of energy availability, disease, and physical activity level on bone, and questions about bone gain and loss across life history and in response to environmental factors; these issues are important in human biology, paleoanthropology, bioarchaeology, and forensic anthropology.

Correlation of muscle mass and bone mineral density in the NHANES US general population, 2017-2018

The appendicular skeletal muscle mass index (ASMI) is commonly used to evaluate human skeletal muscle mass. Muscle, an adjacent tissue of bone, is closely related to bone growth and development. The purpose of this study was to explore the association between the ASMI and lumbar bone mineral density (BMD) to identify potential risk factors for osteoporosis. We analyzed the data collected by the NHANES from 2017 to 2018, and finally included 948 participants aged 40 to 59 years. We evaluated the correlation between the ASMI and lumbar spine BMD using univariate and multiple linear regression models. The ASMI was calculated from height and appendicular skeletal muscle mass obtained by dual energy X-ray absorptiometry. Lumbar spine BMD was obtained by dual energy X-ray absorptiometry and used as an observation in our study. In all the models, ASMI was significantly associated with lumbar spine BMD (model 1: β = 0.013, P < .001; model 2: β = 0.013, P < .001). In the subgroup analysis stratified by sex, this positive correlation was present in both sexes (male: β = 0.023, P < .001, β = 0.022, < 0.001; female: β = 0.030, P < .001, β = 0.031, P < .001). This study showed that the ASMI was positively associated with lumbar BMD, and that this correlation is present in both men and women.

The effect and safety of Tai Chi on bone health in postmenopausal women: A meta-analysis and trial sequential analysis

Background

Tai Chi may be a promising exercise to prevent and control bone loss in postmenopausal women. This meta-analysis and trial sequential analysis aimed to evaluate the effect and safety of Tai Chi on bone health in postmenopausal women.

Method

Seven databases were searched from their inceptions to 11 May 2022 to collect randomized controlled trials (RCTs) investigating the effect and safety of Tai Chi on bone health in postmenopausal women. Two independent reviewers identified the eligible studies, extracted data, and assessed the risk of bias of included studies using the revised Cochrane risk-of-bias tool for randomized trials. The primary outcome was the bone mineral density (BMD), and secondary outcomes included bone turnover markers and calcaneus quantitative ultrasound. Subgroup analyses were conducted based on the duration of Tai Chi. Sensitivity analyses and publication bias assessment were performed. RevMan software (version 5.4.1) and R software (version 3.6.1) were used for data synthesis. The certainty of evidence was rated with the Grading of recommendations assessment, development, and evaluation (GRADE) system. We also performed the trial sequential analysis to evaluate the reliability of the evidence.

Results

A total of 25 reports involving 24 studies were included. Four studies were considered as high overall risk of bias, and the rest were some concerns. Among included studies, there were three comparisons including Tai Chi vs. non-intervention, Tai Chi vs. other exercises, and Tai Chi plus nutraceutical vs. nutraceutical. Compared with non-intervention, Tai Chi was more effective to improve BMD of lumbar spine (MD = 0.04, 95% CI 0.02 to 0.07, I2 = 0%, low certainty), femoral neck (MD = 0.04, 95% CI 0.02 to 0.06, I2 = 0%, low certainty), and trochanter (MD = 0.02, 95% CI 0.00 to 0.03, I2 = 0%, very low certainty), but there was no significant difference in increasing the BMD of Ward's triangle (MD = 0.02, 95% CI −0.01 to 0.04, I2 = 0%, very low certainty). Trial sequential analysis showed that the effect of Tai Chi vs. non-intervention on the BMD of lumbar spine and femoral neck was reliable, but the effect on the BMD of trochanter and Ward's triangle needed further verification. The subgroup analyses suggested that Tai Chi training for over 6 months had greater improvement in BMD of the lumbar spine, femoral neck, and trochanter than non-intervention. No significant differences were observed in the above outcomes of Tai Chi vs. other exercises, and Tai Chi plus nutraceutical vs. nutraceutical. There was insufficient evidence to support the effect of Tai Chi on bone turnover markers and calcaneus quantitative ultrasound. Few Tai Chi relevant adverse events occurred.

Conclusion

Tai Chi may be an optional and safe exercise for improving BMD loss in postmenopausal women, and practicing Tai Chi for more than 6 months may yield greater benefits. However, more rigorously designed RCTs are required to verify the benefits and to explore the optimal protocol of Tai Chi exercise for bone health.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=309148, identifier: CRD42022309148.

High-Intensity Exercise and Geometric Indices of Hip Bone Strength in Postmenopausal Women on or off Bone Medication: The MEDEX-OP Randomised Controlled Trial

To compare the effects of high-intensity resistance and impact training (HiRIT) to low-intensity, Pilates-based exercise (LiPBE) on proximal femur geometry and explore the influence of antiresorptive medication on those effects. Postmenopausal women with low bone mass, on or off antiresorptive bone medications were randomly allocated, stratified on medication intake, to eight months of twice-weekly, supervised HiRIT (Onero™) or LiPBE (Buff Bones®). 3D hip software was used to analyse proximal femur DXA scans. Outcomes included femoral neck (FN) and total hip (TH), volumetric (e.g. vBMC, vBMD) and geometric (e.g. cortical thickness, cross-sectional area [CSA], section modulus [Z]) indices of bone strength. Data were analysed using analysis of variance. Scans of 102 women were examined: LiPBE, 43; HiRIT, 37; LiPBE-med, 11; HiRIT-med, 11. HiRIT improved TH trabecular vBMC and vBMD (3.1 ± 1.1% versus - 1.2 ± 1.2%, p = 0.008; and 1.5 ± 1.0% versus - 1.6 ± 1.2%, p = 0.042, respectively) and FN and TH total vBMC (2.0 ± 0.8% versus - 0.2 ± 0.7%, p = 0.032; and 0.7 ± 0.4% versus - 0.8 ± 0.6%, p = 0.032, respectively), compared to losses in LiPBE. HiRIT also increased Z while LiPBE did not (p = 0.035). The combination of HiRIT and medication achieved greater improvements in FN total and trabecular vBMD, total BMC, CSA and Z than HiRIT alone. HiRIT improved geometric parameters of proximal femur strength, while LiPBE exercise was largely ineffective. Medication may enhance some HiRIT effects. Findings suggest reduced hip fracture risk in response to HiRIT.Trial registration number ACTRN12617001511325.

Physical activity as a risk or protective factor for falls and fall-related fractures in non-frail and frail older adults: a longitudinal study

Background

Physical activity may be both a risk and protective factor for falls and fall-related fractures. Despite its positive effects on muscle and bone health, physical activity also increases exposure to situations where falls and fractures occur. This paradox could possibly be explained by frailty status. Therefore, the aim of this study was to investigate the associations between physical activity and both falls and fractures, and to determine whether frailty modifies the association of physical activity with falls, and fractures.

Methods

Data of 311 community-dwelling participants aged 75 years or older from the Longitudinal Aging Study Amsterdam, who participated in a three-year longitudinal study with five nine-monthly measurements between 2015/2016 and 2018/2019. Their mean age was 81.1 (SD 4.8) years and frailty was present in 30.9% of the participants. Physical activity in minutes per day was objectively assessed with an inertial sensor (Actigraph) for seven consecutive days. Falls and fractures were assessed every nine months using self-report during an interview over a follow-up period of three years. Frailty was determined at baseline using the frailty index. Associations were estimated using longitudinal logistic regression analyses based on generalized estimating equations.

Results

No association between physical activity and falls was found (OR = 1.00, 95% CI: 0.99–1.00). Fall risk was higher in frail compared to non-frail adults (OR = 2.21, 95% CI: 1.33–3.68), but no effect modification was seen of frailty on the association between physical activity and falls. Also no relation between physical activity and fractures was found (OR = 1.00, 95% CI: 0.99–1.01). Fracture risk was higher in frail compared to non-frail adults (OR = 2.81, 95% CI: 1.02–7.75), but also no effect modification of frailty was present in the association between physical activity and fractures.

Conclusions

No association between physical activity and neither falls nor fractures was found, and frailty appeared not to be an effect modifier. However, frailty was a risk factor for falls and fractures in this population of older adults. Our findings suggest that physical activity can be safely recommended in non-frail and frail populations for general health benefits, without increasing the risk of falls.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03383-y.

Environmental and personal factors for osteoporosis or osteopenia from a large health check-up database: a retrospective cohort study in Taiwan

Background

Osteoporosis is an important public health issue in aging societies because of its associated morbidity, mortality, and decreased quality of life. The study aims to identify the association of low bone mineral density, including osteoporosis and osteopenia, with environmental and personal factors.

Methods

The data of participants aged ≥ 20 years with multiple visits were obtained from a health check-up database in Taiwan from 2008 to 2016. Multivariable logistic regressions were performed to identify the selected factors associated with low bone mineral density for multiple visit data.

Results

A total of 194,910 participants with 359,943 visits were included in this study. The prevalence of low bone mineral density (BMD) in the study population was 10.6% (n = 20.615). Older women, ever and current smokers (odds ratio (OR) = 1.04 [95% confidence interval (CI) = 1.01, 1.08]), or participants who were underweight (OR = 1.72 [1.64, 1.81]), consumed a vegetarian diet (OR = 1.32 [1.25, 1.39]), or had higher triglyceride levels (OR = 1.04 [1.01, 1.06]) were significantly associated with a higher risk of low BMD. Participants who had higher educational years (OR = 0.43 [0.41, 0.46]), higher physical activity (OR = 0.93 [0.89, 0.97]), appropriate sleep duration and better quality (OR = 0.98 [0.97, 0.99]), dairy intake (≥ 1 slice of yogurt or cheese/week, OR = 0.97 [0.95, 0.99]), higher uric acid (OR = 0.93 [0.91, 0.95]), higher walkability (OR = 0.997 [0.995,0.999]), and higher solar radiation exposure (OR = 0.997 [0.97,0.99]) were significantly associated with a lower risk of low BMD.

Conclusion

Interventions in different directions, such as having better health behaviors, increasing sun exposure, and residing in a highly walkable environment, are beneficial for reducing the risk of low BMD.

The Effect of Endurance and Endurance-Strength Training on Bone Health and Body Composition in Centrally Obese Women-A Randomised Pilot Trial

There is no consensus exercise programme to reduce body weight and improve body composition simultaneously preventing bone loss or stimulating osteogenesis. This pilot study compared the effect of endurance and endurance-strength training on body composition and bone metabolism in centrally obese women. Recruited subjects were randomly assigned to three-month endurance (n = 22) or endurance-strength training (n = 22). Body composition, bone mineral density (BMD) and content (BMC) were assessed before and after the intervention and markers of bone formation and resorption were measured. Both training significantly decreased fat mass; however, endurance-strength training had a more favourable effect on lean mass for the gynoid area (p = 0.0211) and legs (p = 0.0381). Endurance training significantly decreased total body BMC and BMD (p = 0.0440 and p = 0.0300), whereas endurance-strength training only reduced BMD (p = 0.0063). Changes in densitometric parameters did not differ between the groups but endurance training increased osteocalcin levels (p = 0.04845), while endurance-strength training increased tartrate-resistant acid phosphatase 5b concentrations (p = 0.00145). In conclusion, both training programmes were effective in the reduction of fat mass simultaneously negatively affecting bone health. However, endurance-strength training seemed to be more effective in increasing lean mass. The study protocol was registered in the ClinicalTrials.gov database under the number NCT03444207, date of registration: 23 February 2018 (retrospective registration).

Acute effects of the resistance exercise associated with different blood flow restriction pressures on bone remodeling biomarkers

Background

The present study analyzed the acute responses of parathyroid hormone (PTH) and bone-specific alkaline phosphatase (BSAP) to the low-intensity resistance exercise with blood flow restriction using different occlusion pressures.

Methods

Twelve women completed the three protocols of this crossover study: resistance exercise without blood flow restriction (RE), resistance exercise with blood flow restriction and occlusion pressure corresponding to 70% of systolic blood pressure (RE + BFR70), and resistance exercise with blood flow restriction and occlusion pressure corresponding 130% of systolic blood pressure (RE + BFR130). All exercises were performed in a guided squat apparatus with load corresponded to 30% of one-repetition maximum test.

Results

Relative to resting levels, PTH concentrations decreased significantly (p = .000) post-exercise in all groups and increased significantly (p = .000) 15 min post-exercise in RE + BFR70 and RE + BFR130 groups; PTH concentrations returned to resting levels after the 30-min recovery period in all groups. There was no significant difference (p >.05) between BSAP values at rest and 30 min post-exercise.

Conclusion

In conclusion, our results showed that protocols with blood flow restriction using occlusion pressures equivalent to 70% and 130% of systolic blood pressure were more effective than RE alone to induce PTH peaks, and to promote a metabolic condition favorable to bone anabolism.

Exercise Prescription for Osteoporosis: Back to Basics

This Perspectives provides a back-to-basics rationale for the ideal exercise prescription for osteoporosis. The relevance of fundamental principles of mechanical loading and bone adaptation determined from early animal studies is revisited. The application to human trials is presented, including recent advances. A model of broadscale implementation is described, and areas for further investigation are identified.

Exercise and physical activity in individuals at risk of fracture

This is a review of evidence and practical tips on exercise for individuals with osteoporosis, including individuals with hip and vertebral fractures. Balance and functional training, with or without strength training, can prevent falls. Several types of exercise can improve outcomes that are important to patients, such as physical functioning or quality of life. Individuals with osteoporosis should prioritize balance, functional and resistance training ≥ twice weekly, where exercises, volume, intensity, and progression are aligned with the patient's goals and abilities. Patients who want to participate in other activities (e.g., walking, impact exercise, yoga, Pilates) can do them in addition to, but not instead of, balance and functional or strength training, if they can be done safely or modified. Avoid generic advice like "Don't bend or twist", which is difficult or impossible to operationalize, and may create fear and activity avoidance. Instead, be specific about the types of activities to avoid or modify, and provide tips on how to make daily activities safer, or signpost to resources from national osteoporosis societies. For example, not all bending or twisting is bad; it is activities that involve rapid, repetitive, sustained, weighted, or end range of motion twisting or flexion of the spine that may need to be modified, especially in individuals at high risk of fracture.

The effect of low-intensity whole-body vibration with or without high-intensity resistance and impact training on risk factors for proximal femur fragility fracture in postmenopausal women with low bone mass: study protocol for the VIBMOR randomized controlled trial

BACKGROUND

The prevailing medical opinion is that medication is the primary (some might argue, only) effective intervention for osteoporosis. It is nevertheless recognized that osteoporosis medications are not universally effective, tolerated, or acceptable to patients. Mechanical loading, such as vibration and exercise, can also be osteogenic but the degree, relative efficacy, and combined effect is unknown. The purpose of the VIBMOR trial is to determine the efficacy of low-intensity whole-body vibration (LIV), bone-targeted, high-intensity resistance and impact training (HiRIT), or the combination of LIV and HiRIT on risk factors for hip fracture in postmenopausal women with osteopenia and osteoporosis.

METHODS

Postmenopausal women with low areal bone mineral density (aBMD) at the proximal femur and/or lumbar spine, with or without a history of fragility fracture, and either on or off osteoporosis medications will be recruited. Eligible participants will be randomly allocated to one of four trial arms for 9 months: LIV, HiRIT, LIV + HiRIT, or control (low-intensity, home-based exercise). Allocation will be block-randomized, stratified by use of osteoporosis medications. Testing will be performed at three time points: baseline (T0), post-intervention (T1; 9 months), and 1 year thereafter (T2; 21 months) to examine detraining effects. The primary outcome measure will be total hip aBMD determined by dual-energy X-ray absorptiometry (DXA). Secondary outcomes will include aBMD at other regions, anthropometrics, and other indices of bone strength, body composition, physical function, kyphosis, muscle strength and power, balance, falls, and intervention compliance. Exploratory outcomes include bone turnover markers, pelvic floor health, quality of life, physical activity enjoyment, adverse events, and fracture. An economic evaluation will also be conducted.

DISCUSSION

No previous studies have compared the effect of LIV alone or in combination with bone-targeted HiRIT (with or without osteoporosis medications) on risk factors for hip fracture in postmenopausal women with low bone mass. Should either, both, or combined mechanical interventions be safe and efficacious, alternative therapeutic avenues will be available to individuals at elevated risk of fragility fracture who are unresponsive to or unwilling or unable to take osteoporosis medications.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (www. anzctr.org.au ) (Trial number ANZCTR12615000848505, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id = 368962 ); date of registration 14/08/2015 (prospectively registered). Universal Trial Number: U1111-1172-3652.

Accelerometer-based prediction of ground reaction force in head-out water exercise with different exercise intensity countermovement jump

Background

Water jumping exercise is an alternative method to achieve maintenance of bone health and reduce exercise injuries. Clarifying the ground reaction force (GRF) of moderate and high cardiopulmonary exercise intensities for jumping movements can help quantify the impact force during different exercise intensities. Accelerometers have been explored for measuring skeletal mechanical loading by estimating the GRFs. Predictive regression equations for GRF using ACC on land have already been developed and performed outside laboratory settings, whereas a predictive regression equation for GRF in water exercises is not yet established. The purpose of this study was to determine the best accelerometer wear-position for three exercise intensities and develop and validate the ground reaction force (GRF) prediction equation.

Methods

Twelve healthy women (23.6 ± 1.83 years, 158.2 ± 5.33 cm, 53.1 ± 7.50 kg) were recruited as participants. Triaxial accelerometers were affixed 3 cm above the medial malleolus of the tibia, fifth lumbar vertebra, and seventh cervical vertebra (C7). The countermovement jump (CMJ) cadence started at 80 beats/min and increased by 5 beats per 20 s to reach 50%, 65%, and 80% heart rate reserves, and then participants jumped five more times. One-way repeated analysis of variance was used to determine acceleration differences among wear-positions and exercise intensities. Pearson’s correlation was used to determine the correlation between the acceleration and GRF per body weight on land (GRF_VL_BW). Backward regression analysis was used to generate GRF_VL_BW prediction equations from full models with C7 acceleration (C7 ACC), age, percentage of water deep divided by body height (PWDH), and bodyweight as predictors. Paired t-test was used to determine GRF_VL_BW differences between values from the prediction equation and force plate measurement during validation. Lin’s CCC and Bland–Altman plots were used to determine the agreement between the predicted and force plate-measured GRF_VL_BW.

Results

The raw full profile data for the resultant acceleration showed that the acceleration curve of C7 was similar to that of GRFv. The predicted formula was − 1.712 + 0.658 * C7ACC + 0.016 * PWDH + 0.008 * age + 0.003*weight. Lin’s CCC score was 0.7453, with bias of 0.369%.

Conclusion

The resultant acceleration measured at C7 was identified as the valid estimated GRF_VL_BW during CMJ in water.

Effect of External Mechanical Stimuli on Human Bone: a narrative review

Bone is a living composite material that has the capacity to adapt and respond to both internal and external stimuli. This capacity allows bone to adapt its structure to habitual loads and repair microdamage. Although human bone evolved to adapt to normal physiologic loading (for example from gravitational and muscle forces), these same biological pathways can potentially be activated through other types of external stimuli such as pulsed electromagnetic fields, mechanical vibration, and others. This review summarizes what is currently known about how human bone adapts to various types of external stimuli. We highlight how studies on sports-specific athletes and other exercise interventions have clarified the role of mechanical loading on bone structure. We also discuss clinical scenarios, such as spinal cord injury, where mechanical loading is drastically reduced, leading to rapid bone loss and permanent alterations to bone structure. Finally, we highlight areas of emerging research and unmet clinical need.

A Comparison of Bone-Targeted Exercise With and Without Antiresorptive Bone Medication to Reduce Indices of Fracture Risk in Postmenopausal Women With Low Bone Mass: The MEDEX-OP Randomized Controlled Trial

The goal of the MEDEX-OP trial was to compare the efficacy of a known effective high-intensity resistance and impact training (HiRIT) with a low-intensity exercise control (Buff Bones® [BB]), alone or in combination with antiresorptive bone medication, on indices of fracture risk (bone mass, body composition, muscle strength, functional performance), compliance, and safety. Primary study outcomes were 8-month change in lumbar spine (LS) and total hip (TH) bone mineral density (BMD). Healthy postmenopausal women with low bone mass (T-score ≤ -1.0) on or off stable doses (≥12 months) of antiresorptive medication were recruited. A total of 115 women (aged 63.6 ± 0.7 years; body mass index [BMI] 25.5 kg/m² ; femoral neck [FN] T-score -1.8 ± 0.1) were randomly allocated to 8-month, twice-weekly, 40-minute HiRIT (5 sets of 5 repetitions, >80% to 85% 1 repetition maximum) or BB (low-intensity, Pilates-based training), stratified by medication intake, resulting in four groups: HiRIT (n = 42), BB (n = 44), HiRIT-med (n = 15), BB-med (n = 14). HiRIT improved LS BMD (1.9 ± 0.3% versus 0.1 ± 0.4%, p < 0.001) and stature (0.2 ± 0.1 cm versus -0.0 ± 0.1 cm, p = 0.004) more than BB. Both programs improved functional performance, but HiRIT effects were larger for leg and back muscle strength and the five times sit-to-stand test (p < 0.05). There was a positive relationship between maximum weight lifted and changes in LS BMD and muscle strength in the HiRIT groups. Exploratory analyses suggest antiresorptive medication may enhance exercise efficacy at the proximal femur and lumbar spine. Exercise compliance was good (82.4 ± 1.3%) and both programs were well tolerated (7 adverse events: HiRIT 4; BB 3). HiRIT improved indices of fracture risk significantly more than Buff Bones®. More trials combining bone medication and bone-targeted exercise are needed. © 2021 American Society for Bone and Mineral Research (ASBMR).

Management of osteoporosis in postmenopausal women: the 2021 position statement of The North American Menopause Society

OBJECTIVE

To review evidence regarding osteoporosis screening, prevention, diagnosis, and management in the past decade and update the position statement published by The North American Menopause Society (NAMS) in 2010 regarding the management of osteoporosis in postmenopausal women as new therapies and paradigms have become available.

DESIGN

NAMS enlisted a panel of clinician experts in the field of metabolic bone diseases and/or women's health to review and update the 2010 NAMS position statement and recommendations on the basis of new evidence and clinical judgement. The panel's recommendations were reviewed and approved by the NAMS Board of Trustees.

RESULTS

Osteoporosis, especially prevalent in older postmenopausal women, increases the risk of fractures that can be associated with significant morbidity and mortality. Postmenopausal bone loss, related to estrogen deficiency, is the primary contributor to osteoporosis. Other important risk factors for postmenopausal osteoporosis include advanced age, genetics, smoking, thinness, and many diseases and drugs that impair bone health. An evaluation of these risk factors to identify candidates for osteoporosis screening and recommending nonpharmacologic measures such as good nutrition (especially adequate intake of protein, calcium, and vitamin D), regular physical activity, and avoiding smoking and excessive alcohol consumption are appropriate for all postmenopausal women. For women at high risk for osteoporosis, especially perimenopausal women with low bone density and other risk factors, estrogen or other therapies are available to prevent bone loss. For women with osteoporosis and/or other risk factors for fracture, including advanced age and previous fractures, the primary goal of therapy is to prevent new fractures. This is accomplished by combining nonpharmacologic measures, drugs to increase bone density and to improve bone strength, and strategies to reduce fall risk. If pharmacologic therapy is indicated, government-approved options include estrogen agonists/antagonists, bisphosphonates, RANK ligand inhibitors, parathyroid hormone-receptor agonists, and inhibitors of sclerostin.

CONCLUSIONS

Osteoporosis is a common disorder in postmenopausal women. Management of skeletal health in postmenopausal women involves assessing risk factors for fracture, reducing modifiable risk factors through dietary and lifestyle changes, and the use of pharmacologic therapy for patients at significant risk of osteoporosis or fracture. For women with osteoporosis, lifelong management is necessary. Treatment decisions occur continuously over the lifespan of a postmenopausal woman. Decisions must be individualized and should include the patient in the process of shared decision-making.

Current Lack of Evidence for an Effect of Physical Activity Intervention Combined with Pharmacological Treatment on Bone Turnover Biomarkers in People with Osteopenia and Osteoporosis: A Systematic Review

The process of bone loss occurs silently and progressively with age, often appearing as osteopenia or osteoporosis or related fractures. Given the rapid raise in disease burden and socio-economic costs of these conditions worldwide, drug therapy combined with physical activity can be a useful strategy and bone biomarkers, can represent a useful evaluation tool to assess their effects. The objective of this systematic review, conducted according to PRISMA statement, was to investigate the effects of physical activity interventions combined with drug treatments on bone biomarkers in people with osteopenia and osteoporosis. Through PubMed, Cochrane, Cinahl, Embase, Trip, a comprehensive literature search was performed. Each study's quality was assessed according to the Cochrane risk-of-bias tool. Out of 582 identified articles, 50 full texts were screened. Only one matched the eligibility criteria. The study, scored as high quality, showed, in both experimental and control groups, an increase of CTX and P1NP bone biomarkers, without statistically significant differences. Based on available evidence, no exhaustive conclusion can be drawn. However, this systematic review critically analyses the literature, highlighting the knowledge gap on combined treatments efficacy assessed by bone biomarkers. Moreover, an outlook is provided for the planning of future studies.

Muscle Performance Changes with Age in Active Women

The purpose of this study was to examine age-related differences in muscle performance in women divided into young (YW, 20–39 years, n = 29) middle-aged (MAW, 40–59 years, n = 33), and older (OW, ≥60 years, n = 40) age groups. Methods: Hand grip strength, vertical jump performance, and knee extensor (KE) strength (0 deg/s, 60 deg/s, and 240 deg/s), speed of movement (SoM; at 1 Nm, 20%, 40%, and 60% isometric strength), and endurance (30-repetition test at 60 degs/s and 240 deg/s) were assessed. Computed tomography-acquired muscle cross-sectional area (mCSA) was measured and included to determine specific strength (KE strength/mCSA). Results: Hand grip strength was similar across groups, while jump performance declined with age (YW and MAW > OW, p < 0.001). KE strength declined significantly with age (all conditions p < 0.01), while specific strength was similar across groups. SoM was significantly higher for YW and MAW compared to OW (both p < 0.01). An age × velocity interaction revealed YW KE endurance was similar between conditions, whereas MAW and OW displayed significantly better endurance during the 60 deg/s condition. OW displayed impaired KE endurance at 240 deg/s (vs. YW and MAW, p < 0.01) but improved at 60 deg/s (vs. YW, p < 0.01). Dynamic torque decline increased with age (YW < OW, p = 0.03) and was associated with intramuscular adipose tissue (r = 0.21, p = 0.04). Conclusions: Performance declines were most evident among OW, but few performance deficits had emerged in MAW. Interestingly, strength declines disappeared after normalizing to mCSA and endurance appears to be velocity-dependent.

Osteoporosis in Men: A Review of an Underestimated Bone Condition

Osteoporosis is called the 'silent disease' because, although it does not give significant symptoms when it is not complicated, can cause fragility fractures, with serious consequences and death. Furthermore, the consequences of osteoporosis have been calculated to weigh heavily on the costs of health systems in all the countries. Osteoporosis is considered a female disease. Actually, the hormonal changes that occur after menopause certainly determine a significant increase in osteoporosis and the risk of fractures in women. However, while there is no doubt that women are more exposed to osteoporosis and fragility fractures, the literature clearly indicates that physicians tend to underestimate the osteoporosis in men. The review of the literature done by the authors shows that osteoporosis and fragility fractures have a high incidence also in men; and, furthermore, the risk of fatal complications in hip fractured men is higher than that for women. The authors report the evidence of the literature on male osteoporosis, dwelling on epidemiology, causes of osteoporosis in men, diagnosis, and treatment. The analysis of the literature shows that male osteoporosis is underscreened, underdiagnosed, and undertreated, both in primary and secondary prevention of fragility fractures.