Review

Physical activity and skeletal health in adults

Jane A Cauley*, Lora Giangregorio*

The purpose of this Review is to examine the associations between physical activity and skeletal health, with an Lancet Diabetes Endocrinol 2019
emphasis on observational studies with fracture outcomes and randomised controlled trials (RCTs) of physical activity Published Online
interventions in adults older than 40 years. In general, increased physical activity—primarily leisure time activity or November 20, 2019
https://doi.org/10.1016/
moderate or vigorous physical activity—is associated with a 1–40% lower risk of hip and all fractures. The primary
S2213-8587(19)30351-1
limitation of these studies relates to health status; healthy people are more likely to exercise and less likely to fracture.
*Contributed equally
Although there is no sufficiently powered RCT of exercise with a fracture outcome, there is evidence that some types
Graduate School of Public
of exercise prevent falls and bone loss, and meta-analyses support the anti-fracture effectiveness of exercise. RCTs and Health, Department of
meta-analyses suggest that programmes combining impact exercise with moderate or high-intensity progressive Epidemiology, University of
resistance exercise might maintain or improve bone mass and prevent fractures, and that functional strength and Pittsburgh, Pittsburgh, PA,
USA (J A Cauley PhD); and
balance training prevents falls.
BC Matthews Hall and
Lyle S Hallman Institute,
Introduction one on vertebral fractures.26 We graded all of the studies Department of Kinesiology,
Osteoporosis is a major public health problem.1 according to our search strategy criteria. Physical activity University of Waterloo,
Waterloo, ON, Canada
Worldwide, one in two women aged 50 years or older and was typically measured once at baseline, except in one
(L Giangregorio PhD)
one in five men aged 50 years or older will have an study that measured it four times across 15 years.25 The
Correspondence to:
osteoporotic fracture in their lifetime.1–3 In 2005, more studies defined physical activity as work activity,9,10,12,16 Dr Jane A Cauley, Graduate
than 2 million fractures were reported in the USA alone, “leisure time” activity,9,10,12–16,18,23,25 “exercise”, 12,16,19,20 “home School of Public Health,
with a total cost of US$19 billion. The number of activities”,10,13 “commuting activities” (eg, driving a car, Department of Epidemiology,
fractures is expected to increase by 48% to more than biking, or walking),12 “sports”, and overall activity.13,17 One University of Pittsburgh,
Pittsburgh, PA 15261, USA
3 million in the USA by 2025, costing $25·3 billion.4 prospective study measured physical activity objectively jcauley@pitt.edu
Osteoporosis-related fractures impose substantial using wearable devices,22 and the follow-up duration
burden of disability, costs, morbidity, and mortality.1,5 ranged from 2·3 years16 to more than 30 years.9 Six papers
Physical activity, defined as “any bodily movement studied men only,9,13,17,19,22,23 seven studied women
produced by skeletal muscle that requires energy only,11,12,14,18,22,25,26 and five studied both.10,15,16,20,21 Participants’
expenditure”,6 might be a modifiable risk factor for ages ranged from 40 years to 97 years.
osteoporotic fractures. However, the prevalence of physical
inactivity is high; only 16% of US adults aged 65 years or Hip fracture
older met both aerobic and muscle strengthening Trimpou and colleagues9 studied 7495 randomly selected
guidelines.7 Within the EU, less than a third of adults men in Gothenburg, Sweden, who were followed up for
declared that they spend at least 150 min/week being more than 30 years. High physical activity during leisure
physically active.8 time was associated with reduced risk of hip fracture, but
In this Review, we aim to provide a broad perspective high physical activity at work was associated with
on the association between physical activity and fracture increased risk. However, once occupational class was
risk from prospective observational studies and RCTs. added to the multivariable model, the association between
We chose a narrative review rather than a systematic work activity and hip fracture was no longer significant,
review to incorporate different study designs and suggesting confounding by socioeconomic status. The
research questions, to address evolving areas in which strengths of the study include its generalisability, length
there is insufficient evidence to do a systematic review, of follow-up, and adjustment for confounding, and its
and to connect ideas across various content (eg, fall limitations include the non-specific assessment of
prevention, physical activity and fracture epidemiology, physical activity. In the UK, Moayyeri and colleagues10
and clinical trials on the effect of exercise interventions studied about 15 000 men and women enrolled in the
on bone strength). We discuss the types of activity that European Prospective Investigation into Cancer (EPIC)
might prevent osteoporotic fractures, and we highlight Norfolk study. Stair climbing increased the risk of hip
knowledge gaps. fracture in men by a factor of three, perhaps because of
an increased exposure to falls, but there was no association
Prospective observational studies of physical in women. Walking for leisure or transport was suggestive
activity and fractures of reduced risk of hip fracture in women (ptrend=0·049)
We identified 18 prospective observational studies and men (ptrend=0·078). There was no association between
published between 2009 and 2019 that examine the housework activity, cycling, swimming, or television
association between physical activity and incident fractures viewing and hip fracture. This study has many strengths,
in individuals aged 40 years or older (table). These studies including its generalisability, inclusion of both men and
include ten on hip fractures,9–18 eight on low trauma or women, assessment of multiple activity domains, and
non-spinal fractures,10,15,19–24 two on wrist fractures,14,25 and documentation of fractures.

www.thelancet.com/diabetes-endocrinology Published online November 20, 2019 https://doi.org/10.1016/S2213-8587(19)30351-1 1

 Review

A study by Jokinen and collegaues11 involved
1681 women aged 70–73 years for 10 years. There was no
association between leisure activity and hip fractures in
general, but low physical activity was associated with
three times the risk of cervical hip fractures. This study
was limited by only assessing 53 hip fractures but was
unique in its examination by type of hip fracture. The
Umea Fracture and Osteoporosis study12 used a nested
case-control design and identified 81 women with an
incident hip fracture, matching them with two controls
by age and assessment date. Walking above and beyond
commuting activity at least once a week was associated
with an 84% reduction in hip fracture. Moderate to high
spare-time activities were also associated with reducing
the risk of hip fracture. There was no association with
commuting, occupation, training activities, or cycling.
This study involved a younger cohort (40–60 years) than
is often studied, and hip fractures are rare in this age
group. Nevertheless, the study has various strengths,
including its population-based design, confirmation
of fracture, and multivariable adjustments for key
covariates.
Mackey and colleagues13 studied 5682 men enrolled in
the US population-based Osteoporotic Fractures in Men
(MrOS) study. In unadjusted analyses, men with the
highest physical activity (quartile 4) had a 50% reduced
risk of hip fracture. However, in analyses that controlled
for confounding, this association was no longer

Participant Participant Follow-up Exposure Outcome Results Comments Quality

number and sex age range (years) (fractures) rating
(mean,
years)
Hip fractures
Trimpou et al9 7495 men 46–56 >30 PA at work and leisure; 451 hip fractures Leisure PA: HR 0·79 (95% CI 0·68–0·92); Work PA not associated with Good
(2010); (mean age scored 1–4 for PA: from EMR; uses work PA: HR 1·12 (1·01–1·24) fractures after adjustment
Sweden NA) 1=inactive or sedentary; International for social class; adjusted for
2=moderate Classification of age, lifestyle, BMI, and
(≤4 h/week; general Disease codes history of stroke and
office work); 3=more dementia; no BMD given
strenuous (walking or
lifting); 4=regular hard
competitive (training
or heavy manual work)
Moayyeri 6514 women; 40–79 (62) 7·5 PA questionnaire about 504 fractures Low PA: HR 1·00 for both men and Population-based therefore Good
et al10 (2010); 8389 men the past year; measured (164 hip fractures) women; moderate housework PA: HR highly generalisable;
UK, EPIC PA in and around from EMR for any fracture 1·76 (95% CI 1·18–2·60) adjusted for age, height,
Norfolk study home, at work, in for men, 0·58 (0·40–0·85) for women; BMI, lifestyle, and QUS; no
transportation to work, HR for hip fracture 0·85 (0·40–1·80) for association apparent with
and recreational PA men, 0·34 (0·19–0·61) for women; high cycling, swimming, or TV
housework PA: HR for any fracture 2·63 viewing; walking for leisure
(1·55–4·45) for men, 0·60 (0·42–0·86) associated with decreased
for women; HR for hip fracture 1·51 risk of hip fracture in women
(0·60–0·38) for men, 0·43 (0·25–0·74)
for women
Jokinen et al11 1681 women 70–73 10 Paffenbarger leisure 53 confirmed hip No association of PA with all hip Study includes small number Poor
(2010), time PA questionnaire; fractures, including fractures, but association with cervical of hip fractures and has low
Finland measured participation 32 cervical fractures hip fracture; moderate or more PA: power; adjusted for age,
in PA at age 15 years, and 21 trochanter HR 1·00; low PA: HR 3·86 (95% CI BMI, physical performance,
30 years, 50 years, and fractures 1·37–7·74) low mobility, and QUS
currently
Englund et al12 100 000 women 40–60 8·4 Measured commuting 81 confirmed hip Never walking: OR 1·00; walking once Nested case-control, Good
(2011); (57·2) PA, occupational PA, fractures; per week: OR 0·14 (95% CI 0·04–0·53); adjusted for height, weight,
Sweden, leisure PA, and training 237 controls walking two or more times per week: smoking, and menopausal
Umea Fracture PA matched on age OR 0·33 (0·10–1·01); low leisure PA: status; no BMD; no
and OR 1·00; moderate leisure PA: OR 0·19 association of fractures with
Osteoporosis (0·08–0·46); high leisure PA: OR 0·17 commuting PA, occupational
Study (0·05–0·64) PA, training PA, or cycling;
younger cohort and hip
fractures are rare
Mackey et al13 5682 men ≥65 (≈72) 6·3 Used Physical Activity 95 hip fractures Low PA: HR 1·00; moderate PA: HR 0·85 Adjusted for lifestyle, Good
(2011); USA, Scale for Elderly (95% CI 0·52–1·28); high PA: HR 0·79 demographics, physical
MrOS (includes overall (0·40–1·76) performance, and BMD; HR
household and leisure calculated from inverse
time activities); Q1=low probability of treatment
PA; Q2–3=moderate PA; weighting; also gives other
Q4=high PA statistical approaches with
similar results
(Table continues on next page)

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 Review

Participant Participant Follow-up Exposure Outcome Results Comments Quality

number and sex age range (years) (fractures) rating
(mean,
years)
(Continued from previous page)
Armstrong 1 155 304 women 50–84 (56) 8·3 Frequency of strenuous Self-reported Strenuous PA: rarely or never: RR 1·00 No association of PA with Good
et al14 (2012), activity and any fractures: for both ankle and hip fractures; PA wrist fracture; adjusted for
UK, Million exercise 6807 ankle once per week: RR 1·03 (95% CI age, region, socioeconomic
Women Study fractures, 0·99–1·08) for ankle fractures, 0·74 status, lifestyle, hormone
9733 wrist (0·70–0·79) for hip fractures; PA more therapy, and comorbidities;
fractures, and than once per week: RR 1·06 (1·01–1·17) no BMD given
5267 hip fractures for ankle fractures, 0·63 (0·59–0·67)
for hip fractures; ptrend= 0·05 for ankle
fractures, 0·001 for hip fractures.
Any exercise: rarely or never doing any:
RR 1·00 for both ankle and hip
fractures; once per week: RR 1·01
(0·96–1·07) for ankle fractures, 0·78
(0·74–0·84) for hip fractures; two or
three times per week: RR 1·00
(0·95–1·06) for ankle fractures,
0·67 (0·63–0·72) for hip fractures;
four or more times per week: RR 1·11
(1·06–1·16) for ankle fractures,
0·72 (0·68–0·76) for hip fractures;
ptrend=0·004 for ankle fractures, <0·001
for hip fractures
Morseth et al15 3450 men; 55–97 11·6 Measured leisure time 1693 confirmed Sedentary: HR 1·00 for any Adjusted for age, smoking, Good
(2012); 4072 women (66·7) PA (h/week) for low non-vertebral non-vertebral, weight-bearing, or hip BMI, height, and previous
Norway activity (no sweat) and fractures; 194 hip fracture. Non-vertebral fractures: low fractures; no BMD given;
hard activity (sweat, fractures; PA: HR 0·86 (95% CI 0·64–1·17) for no association of PA and
out of breath); PA 274 weight-bearing men, 0·90 (0·77–1·04) for women; non-weight bearing bone
variable in analysis: fractures moderate to high PA: HR 0·71 fracture or distal forearm
sedentary=<3 h/week, (0·53–0·95) for men, 0·90 (0·77–1·05) fracture
moderate=3–6 h/week, for women; ptrend=0·006 for men and
high=≥6 h/week 0·150 for women. Weight-bearing
fractures: low PA: HR 0·72 (0·51–1·03)
for men, 0·82 (0·66–1·01) for women;
moderate to high PA: HR 0·63
(0·45–0·88) for men, 0·77 (0·62–0·95)
for women; ptrend=0·003 for men, 0·013
for women. Hip fractures: low PA:
HR 0·71 (0·47–1·07) for men, 0·86
(0·69–1·08) for women; moderate to
high PA: HR 0·60 (0·41–0·90) for men,
0·74 (0·58–0·94) for women;
ptrend=0·005 for men, 0·016 for women
Lai et al16 84 532 women; ≥45 (≈60) 2·3 Measured number of 293 confirmed hip PA ≤5 METs: RR 1·00; 5–9 METs: RR 0·57 Adjusted for age, sex, Good
(2013); 73 525 men times in past week of fractures (95% CI 0·41–0·79); 9–14 METs: RR 0·60 lifestyle, hormone therapy,
Australia, walking continually (0·44–0·83); PA ≥14 METs: RR 0·49 socioeconomic status, BMI,
45 and Up (≥10 min), vigorous (0·34–0·70); ptrend<0·01 height, previous fractures,
Study activity, or moderate and QUS; PA not significant
activity; PA converted after adjusting for physical
into METs units functioning;
population-based study
Cauley et al17 5994 men ≥65 (≈73) 8·6 Used Physical Activity 178 confirmed hip 1 SD increase in PA; adjusted for age, Adding BMD to the model Good
(2016); USA, Scale for Elderly fractures race, and clinic: HR 0·84 (95% CI attenuated the association
MrOS 0·71–0·99); adjusted for age, race, clinic,
and BMD: HR 0·89 (0·75–1·05)
Gregson et al18 4286 women 59–80 6·7 Composite PA score 140 self-reported No association of fractures with PA; Included women with Poor
(2010); UK, (69·1) developed from usual wrist or hip p=0·30 previous hip or wrist
British duration of walking, fractures fractures; adjusted for age,
Women’s cycling, fitness class, leg length, marital status,
Heart and aerobics, swimming, lifestyle, socioeconomic
Health s tudy jogging, tennis, golf, status, and chronic disease
running, squash,
bowling, or gardening
(Table continues on next page)

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Participant Participant Follow-up Exposure Outcome Results Comments Quality

number and sex age range (years) (fractures) rating
(mean,
years)
(Continued from previous page)
All clinical fractures
Thomas-John 257 men ≥70 (72) 3 Recorded history of 41 low-trauma No association between PA and fracture Selection bias (all individuals Fair
et al19 (2009); exercise fractures from EMR were veterans from a single
USA site); low power; no BMD
given; PA not included in
final multivariable model
Lee et al20 4732 men; 40–69 3·8 Measured regular 195 self-reported, Women: RR 0·58 (95% CI 0·34–0·98); Adjusted for age, BMI, Fair
(2010); Korea 4619 women (≈53) exercise (any exercise low-trauma men: RR 1·26 (0·75–2·13) menopausal status, previous
done for <30 min/day) fractures fracture, hip circumference,
dairy intake, alcohol,
osteoarthritis, rheumatoid
arthritis, and QUS; lower
study power in men (men:
61 fractures; women:
124 fractures)
Rouzi et al21 707 women ≥50 (61) 5·2 Used 7-day PA scale 138 confirmed, low Low PA (Q1) vs Q2, Q3, and Q4: RR 2·87 Adjusted for age, grip Fair
(2012); (0–27); Q1 vs Q2, Q3, trauma, (95% CI 1·88–4·38) strength, BMI, serum
Saudi Arabia and Q4 non-vertebral 25-hydroxyvitamin D-1
fractures alpha hydroxylase, calcium
intake, and BMD; PA
population attributable
risk=49·5% similar to age;
18% lost to follow-up
Cauley et al22 2731 men 72–100 3·5 Objective measures of 1861 confirmed Sedentary activity: Q1 (low PA): HR 0·72 Adjusted for age, race, clinic, Good
(2013); USA, PA; SenseWear Pro non-vertebral (95% CI 0·43–1·20); Q2 PA: HR 0·65 season, health status,
MrOS Armband for 7 days; fractures (0·39–1·08); Q3 PA: HR 0·83 (0·53–1·30); height, weight, smoking,
measured TEE Q4 PA: HR 0·93 (0·60–1·42); ptrend=0·09. diabetes, fracture history,
(kcal/day), active EE, TEE: Q1 (low PA): HR 1·71 (0·94–3·11); Q2 and BMD
and sedentary activity PA: HR 1·70 (1·01–2·85); Q3 PA: HR 0·90
(kcal/day) (0·52–1·56); Q4 PA: HR 1·00 (0·59–1·68);
ptrend=0·020
Nikander 2780 women; ≥50 (≈60) 5 Self-reported leisure 258 self-reported, Walking (for women): never: OR 1·00; No association of fracture Poor
et al23 (2011); 2129 men time PA; measured low-trauma one or two times per week: OR 1·28 and total PA, categories of
Australia, total sedentary time fractures in (95% CI 0·92–1·80); three to five times PA, or sedentary time;
Diabetes, and total PA: total time women; 49 in men per week: OR 1·19 (0·85–1·66); six or adjusted for age, BMI,
Obesity, and spent and frequency of more times per week: OR 1·46 physical functioning, history
Lifestyle Study walking (h/week) or (1·05–2·03); ptrend=0·05 of fracture, cardiovascular
doing other moderate disease, smoking, calcium
to vigorous activities intake, and serum
25-hydroxyvitamin D-1
alpha hydroxylase; no BMD
given
Holloway-Kew 656 men 67–81 (74) 6·3 Recorded sports score: Any fracture (82), Household activity: OR 0·85 (0·51–1·41) Adjusted for age, smoking, Good
et al24 (2018); time in sports MOF (58); for any fracture, 0·84 (0·47–1·50) for falls, comorbidity, calcium
Australia, (accounting for confirmed by MOF; leisure activity: OR 0·98 intake, mobility, and BMD
Geelong Study intensity and duration), radiology records (0·95–1·01) for any fracture, 0·98
household activity, and (0·95–1·02) for MOF; sports
leisure activity participation: OR 0·52 (0·29–0·91) for
any fracture, 0·48 (0·24–0·95) for MOF
Wrist fractures
Rikkonen 8560 women 47–56 15 Measured PA in winter 830 wrist fractures Q1 (low PA): HR 1·00; Q2 PA: HR 1·24 Adjusted for age, BMI, Poor
et al25 (2010); (52·2) and summer in h/week confirmed by (95% CI 1·02–1·52); Q3 PA: HR 1·14 menopausal status, calcium
Finland at baseline, with 5 year, medical record. (0·93–1·40); Q4 PA: HR 1·24 (1·02–1·52) intake, hormone use, and
10 year, and 15 year fracture history; no BMD
follow-up, summed given; population based; PA
and divided into unrelated to overall fracture
quartiles; mostly leisure risk; increased PA associated
activities with decreased femoral neck
bone loss
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Participant Participant Follow-up Exposure
number and sex age range (years)
(mean,
years)
(Continued from previous page)
Vertebral fractures
Nakamura 23 757 women 40–69 10
et al26 (2014); (53·7)
Japan
PA=physical activity. EMR=electronic medical record. HR=hazard ratio. BMD=bone mineral density. EPIC=European Prospective Investigation in Cancer. Lifestyle=alcohol consumption and smoking.
QUS=quantitative ultrasound. MET=metabolic equivalent. NA=not available. OR=odds ratio. MrOS=Osteoporotic Fracture in Men Study. Q=quintile. RR=relative risk. MOF=major osteoporotic fracture (wrist,
spine, proximal humerus, hip). TEE=total energy expenditure. EE=energy expenditure.
Table: Prospective observational studies of physical activity and fractures
significant. This study was underpowered (<100 hip
fractures) but well designed.
The Million Women Study14 is a large, well designed
prospective study of almost 1·2 million UK women
recruited for breast cancer screening, which showed that
increased frequency of strenuous activity and any exercise
was associated with a 37% lower risk of self-reported
hip fracture. Morseth and colleagues15 considered
7522 individuals enrolled in the population-based study
in Tromsø, Norway, including 3450 men and 4072 women.
Moderate to high leisure activity was associated with a
40% reduction in hip fracture in men and a 26% reduction
in women. Lai and colleagues16 analysed individuals
enrolled in the 45 and Up Study, in which increasing
physical activity was associated with a significantly
reduced risk of hip fracture. However, when physical
activity models were adjusted for physical functioning,
the association was no longer significant, suggesting that
effects of activity on functioning account for the fracture
benefit. There was a statistically significant interaction
between physical activity and physical functioning. In
people with high physical functioning, there was no
association with hip fracture, but in people with low
physical functioning, individuals with the lowest physical
activity had an increased risk of hip fracture (RR 3·67,
95% CI 2·33–5·79) compared with those with both high
physical functioning and high activity. These studies had
various strengths and were rated as good.14–16
A second population-based MrOS study, by Cauley and
colleagues,17 followed up on risk factors for hip fracture
among 5994 men. One standard deviation increase in
physical activity was associated with a 16% reduction in
risk of hip fracture in minimally adjusted models. The
association was attenuated, however, after adjusting for
hip bone mineral density (BMD), suggesting that effects
www.thelancet.com/diabetes-endocrinology Published online November 20, 2019 https://doi.org/10.1016/S2213-8587(19)30351-1 5
Review
Outcome Results Comments Quality
(fractures) rating
Measured PA as average Vertebral fracture, Sedentary activities: <3 h/day: No association with walking Good
time per day of heavy or self-reported. RR 1·00; 3–8 h/day: RR 0·60 (95% CI or standing (h/day or
strenuous work or 0·4–0·83); ≥8 h/day: RR 0·22 METs/day); borderline trend
exercise, being (0·05–0·85); ptrend=0·0002 (p=0·070) for increasing
sedentary, walking, and frequency of sports activities
standing; converted and lower vertebral fractures;
into METs; sports adjusted for age,
activity: less than once bodyweight, calcium intake,
per month; once to lifestyle; no BMD given
three times per month;
once or twice per week;
three or more times per
week
of activity on BMD could account for at least part of the
observed reduction in fractures.
All clinical fractures
Thomas-John and colleagues19 studied 257 men from a
Veterans Administration Medical Center, but their
information on physical activity was limited to “a history
of exercise”. There was no association of activity with
fracture, and this study of highly selected men was poor
with little information on physical activity and low power.
Lee and colleagues20 studied 4732 men and 4619 women
enrolled in the Korean Health and Genome Study, a
prospective population-based study from one rural and
one urban community. Women who reported regular
exercise, meaning more than 30 min/day, had a
42% reduced risk of any fracture. There was no association
between physical activity and fractures in men, which
perhaps reflects lower power, because the number of
fractures in men was half that in women.
In the EPIC Norfolk study,10 men who reported
moderate or high housework activity had a significantly
increased risk of any fractures, whereas women who
reported moderate household activity had a reduced risk.
The nature of the household activity could have differed
in men and women; men might have participated in
activities with greater risk of falling than did women.
Nikander23 studied 2780 women and 2129 men, finding
that increased frequency of walking was associated with
an increased risk of fractures in women, perhaps due to
greater exposure to falls. Neither men nor women who
met the current physical activity guidelines were
protected against fractures. There was no association of
fractures with sedentary time. Although this study was
unique in its inclusion of sedentary time, fractures were
self-reported and there were few fractures in men.
 Review
In their Tromsø study, Morseth and colleagues15
collected information on leisure time activity per week,
ranked as low activity (no sweat) and hard activity (sweat,
out of breath). Men with greater leisure time activity had
a reduced risk of any non-vertebral fracture, but this
association was not significant in women. Increasing
leisure activity was associated with a reduced risk of
fracture at weight-bearing sites but not at non-weight-
bearing sites. Rouzi and colleagues21 studied 707 randomly
selected women from Saudi Arabia, finding low physical
activity to be associated with almost three times the risk
of low-trauma fracture. This study was unique in
adjusting for a comprehensive set of physiological and
physical function variables.
A third MrOS study, by Cauley and colleagues,22
involved 2731 men and measured physical activity
objectively by using accelerometry. There was an
increased risk of non-vertebral fracture in men with
low (quintile 1) total energy expenditure (ptrend=0·020)
and active energy expenditure (ptrend=0·040), whereas
there was no statistically significant association
between low sedentary activity and risk of fracture in
men (ptrend=0·09). The results suggested that 30 min
moderate activity per day was associated with reduced
fracture risk.
The Geelong Osteoporosis Study24 is a population-
based study of men in southeast Australia. Information
on physical activity was categorised into sports,
household, and leisure activities, each with separate
scores. Men who reported doing sports had a reduced
risk of any fracture and major osteoporotic fractures
(wrist, spine, proximal humerus, hip), but there was no
association with household activity or leisure activity.
Wrist fractures
In the Million Women Study,14 physical activity had no
effect on ankle and wrist fracture. Gregson and
colleagues18 studied women enrolled in the British
Women’s Heart and Health study, a cohort study of
women randomly selected from general practitioner
lists, which had a 60% response rate. There was no
association between leisure activity and self-reported
combined hip and wrist fracture. The association
between physical activity and hip fracture9,10,12,15,16 and wrist
fracture25 has been shown to vary, whereby it might be
protective against hip fracture but might increase the
risk of wrist fracture. Hence, combining these two
fracture sites may have cancelled out the effects of
physical activity.
Rikkonen and colleagues25 studied 8560 women with a
mean age of 52 years, in a population-based study in
Finland. A long-term activity variable was created by
summing up the average weekly hours spent at baseline
and at each of three follow-up visits. Physical activity was
unrelated to overall fracture risk, but increased activity
was associated with increased risk of wrist fracture. Wrist
fractures followed a seasonal pattern and were related to
6 www.thelancet.com/diabetes-endocrinology Published online November 20, 2019 https://doi.org/10.1016/S2213-8587(19)30351-1
outdoor activities, such as cross-country skiing. These
results are consistent with an earlier study that suggested
that wrist fractures tend to occur in healthier, more
active, younger postmenopausal women than in less
healthy, less active, older postmenopausal women.27
Vertebral fractures
Finally, a Japanese study examined the association between
physical activity and self-reported vertebral fracture in a
large cohort of 23 757 women aged 40–69 years.26 Women
who engaged in strenuous activity (<1 h/day) had a lower
risk of vertebral fracture than did those who did not engage
in strenuous activity (RR 0·52, 95% CI 0·28–0·97). A long
duration of sedentary activity was associated with a reduced
risk of vertebral fractures, and there was no association
between fractures and walking or standing. We rated this
study as poor because of its reliance on self-reported
vertebral fractures. The agreement between self-reported
and confirmed vertebral fractures is low (51%),28 and only a
quarter to a third of vertebral fractures are clinically
recognised.29,30
Discussion of observational studies and future research
Of the 18 prospective studies, we rated 11 as good, four as
fair, and three as poor (table; and according to the criteria
in the search strategy and selection criteria panel). The
high-quality prospective studies mostly suggested that
increasing physical activity—primarily via leisure time
activities or moderate or vigorous activity—was
associated with a reduced risk of hip fractures and all
fractures.9,10,12,14,15,21,24 Two studies associated higher physical
activity at work with an increased risk of fracture in
men.9,10 A single study used objective measures of
physical activity and showed a decreased risk of any non-
vertebral fracture with increasing activity.22 Wrist
fractures could be the exception; increasing physical
activity was associated with an increased risk of fracture
in one study,25 but there was no association in another.18 A
single study, graded as poor, examined vertebral fractures
and found no association.26
Reliance on self-reported physical activity and its vague
definitions prevent researchers from making conclusive
inferences or deriving useful recommendations for
frequency, intensity, time, and type of activity. Lower
intensity activities and unstructured activities, which
account for most total energy expenditure, are more
difficult to quantify using self-report than is time spent
in sports activities. Self-report is subject to recall bias and
overestimated physical activity; current recommendations
are to include objective measurements.31 Higher intensity
activities are easier to recall, yet few older individuals,
especially those at high risk of hip fractures, engage in
moderate to vigorous activity.22 Assignment of metabolic
equivalent values to activities does not take into
consideration the effects of age on energy expenditure.
Future research should consider measuring impact or
intensity with wearable devices. Most of the studies

assessed physical activity only once and could not account
for changes in it through follow-up. Most studies
adjusted for important covariates, such as BMI, which is
important because increased BMI is associated with
reduced physical activity but lower risk of fracture.32 Only
six studies adjusted for a measure of skeletal strength to
test whether the association with physical activity was
independent of bone strength. Early-life exposure to
physical activity is important but was not considered.
As with any observational study, residual confounding
by unmeasured factors is a limitation. The most
important confounding variable in studies of physical
activity in older adults is health status and comorbidity;
only five studies adjusted for comorbidity or health
status. Healthy people exercise, and it is highly likely that
individuals with poor health were under-represented in
these studies. Moreover, exercise and physical activity are
broad terms; teasing out the effects of different activities
or exercise types is difficult in cohort studies that use
self-report or accelerometers.
RCTs of exercise and fracture risk
A common approach of RCTs examining the effects of
exercise on bones is to align exercise mode or intensity
with osteogenic mechanical loading characteristics,33,34
such that exercise interventions include high magnitude
forces from impact (ground reaction forces) or muscle
pull on bones. Examples include progressive impact,
progressive resistance training (muscle pull), or their
combination. Impact activities are those in which one or
both feet leave and return to the ground, applying a
ground reaction force. Running, plyometric exercises
(involving rapid stretch followed by muscle contraction),
jumping, and drop jumps are moderate or high impact
activities (depending on the height and ground reaction
forces). Alternatively, it could be advantageous to design
exercise to reduce the risk of falls, because the majority
of non-vertebral fractures occur from a fall. Examples
include balance training and functional training.35
Individual tailoring of exercise and progression are
important to ensure sufficient training stimulus.
Do RCTs show that exercise can reduce fracture risk?
There is strong evidence that exercise can reduce falls,
particularly exercise that includes functional strength
and balance training.36 In meta-analyses examining the
effects of exercise on falls or fall-related injuries, few
studies report fracture outcomes. A network meta-
analysis revealed that exercise was the only single
intervention that was effective for preventing fall-related
injuries (OR 0·51, 95% CI 0·33–0·79; absolute risk
difference –0·67, 95% CI –1·10 to –0·24).37 A Cochrane
meta-analysis of ten studies (n=4047) reported that
exercise might reduce the number of people having one
or more fall-related fractures (RR 0·73, 95% CI
0·56–0·95), but the evidence was judged to be of low
certainty.36 However, RCTs and meta-analyses support
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Review
the anti-fracture efficacy of exercise in adults older than
60 years.34,37–40
RCTs of exercise and effects on bone health outcomes
When pooled together, RCTs of exercise in older adults
older than 60 years reveal a modest but consistent effect
of exercise on bone strength outcomes. A systematic
review reported that exercise in post­menopausal women
might have modest effects on volumetric BMD (distal
tibia) and cortical volumetric BMD (tibial shaft).41 A
subsequent RCT reported no effect of training on tibial
volumetric BMD with external resistance (more than
twice per week), compared with exercises using only
bodyweight as resistance.42 However, 16–20% of
participants were using bisphosphonates, which could
limit bone cell responses to exercise.
Meta-analyses have reported BMD response to
exercise,43–46 resistance training,47 walking,48 water-based
exercise,49 and tai chi.50,51 Water-based exercise might be
less effective than land-based exercise,49 and tai chi had
little effect on bone health.50,51 A 2011 meta-analysis of the
effects of exercise on BMD in postmenopausal women
pooled RCTs of all exercise types together, reporting a
between-group difference in favour of the effects of
exercise on BMD at the lumbar spine but no significant
difference at the hip.34 Heterogeneity in the effect was
explained in part by exercise mode or intensity. For
example, walking or weight-bearing exercise is often
touted as good for bones, but lower impact activities,
such as walking or tai chi, had no effect on hip BMD and
a modest effect on spinal BMD. Similarly, low-intensity
resistance or balance exercise had no effect on hip or
spinal BMD.34,52 Factors such as training intensity, change
in lean mass, age, and compliance could be associated
with the magnitude of the effect on BMD.51–53
Other research suggests that progressive resistance
training (PRT) combined with impact activities could
best benefit bone strength.34,54 A meta-analysis of
24 studies (1769 postmenopausal women) reported that
PRT combined with high-impact or weight-bearing
exercise significantly increased BMD at the femoral neck
(standardised mean difference [SMD] 0·41, 95% CI
0·18–0·65; p=0·001) and lumbar spine (SMD 0·43,
0·16–0·70; p=0·002).47 A 2012 meta-analysis reported
that the effect of resistance or impact exercise was more
favourable than controls for the femoral neck (n=1632;
standardised effect size of g=0·288; 95% CI 0·10 to 0·47;
p=0·002) and lumbar spine (g=0·179; −0·003 to 0·361;
p=0·05).53 These results suggest that only six patients
would need to be treated with exercise for one
postmenopausal woman to maintain or increase lumbar
spine or hip BMD, translating to a 20-year relative
reduction in fracture risk of 10–11%.53 Whether this
estimate would be true in people with low BMD is not
known.
Another exercise variable is the speed of movement
during exercise. High-velocity PRT trains muscular
 Review
Panel 1: Exercise guidelines or recommendations published in the past 5 years in partnership with one or more osteoporosis
societies
Osteoporosis Canada: Too Fit To Fracture82
Multicomponent exercise programme, including resistance
training, balance exercise, and aerobic physical activity;
recommends against aerobic physical activity to the exclusion
of resistance and balance training
Progressive resistance training
• 2 or more days per week; 8–12 repetitions maximum
Balance exercises
• Daily; sufficient intensity to challenge balance
Aerobic physical activity
• 150 min per week or more of moderate to vigorous physical
activity that involves weight-bearing or impact activity
(moderate if individuals are at high risk)
Posture awareness training
• Attention to posture, spine-sparing strategies, exercises for
back extensor muscles; daily, with emphasis on endurance
UK Royal Osteoporosis Society: Strong, Steady, and
Straight83–85
Weight-bearing or impact exercise
• For example, low jumps, skipping, hopping, jogging, stairs,
marching or brisk walking, and walking
• Most days of the week, at moderate intensity for 50 min
(but at low intensity and for 20 min if individual is frail, less
mobile, or has vertebral or multiple other fractures)
Muscle strengthening
• Two or three times per week, involving 2–3 sets of around
8–12 repetitions maximum
power rather than strength; the emphasis is on moving
against resistance in the shortest amount of time to
improve explosive power (ie, the concentric phase of the
movement is performed rapidly). An RCT of high-velocity
PRT with diverse, moderate impact exercises and balance
training reported statistically significant gains in BMD at
the femoral neck and lumbar spine (1·0–1·1%; p<0·05)
in older men and women without osteoporosis or fracture
history.55 Only four studies have reported on the effects of
exercise on BMD in men older than 45 years, and none
have studied men with osteoporosis.38,56–58
Impact exercise has a modest effect on the BMD of the
femoral neck but not that of the spine, and PRT alone or
in combination with impact exercise could give the most
benefit.56 Objectively measured moderate to vigorous
physical activity was positively associated with peripheral
quantitative CT bone indices at the tibia but not the
radius in 1228 men and women aged 70 years.58
Associations were stronger for peak vertical accelerations
than for other directions.
Many exercise RCTs in men or postmenopausal women
have targeted individuals with normal BMD, or were
heterogeneous with respect to BMD, limiting researchers’
8 www.thelancet.com/diabetes-endocrinology Published online November 20, 2019 https://doi.org/10.1016/S2213-8587(19)30351-1
Balance exercises
• Two or three times per week at a challenging intensity
Spine-caring exercises
• For example, safe movements and back extensor exercises
• Two or three times per week (might need daily for back pain),
with a focus on endurance: ten repetitions held for 3–5 s
Exercise and Sports Science Australia and Osteoporosis
Australia86
Moderate to high impact loading
• 4–7 days per week, 50 jumps per session
• For individuals at moderate risk, more than four times
bodyweight; for individuals at high risk, two to three times
bodyweight
Progressive resistance training
• Twice per week, at high to very high intensity
Balance training
• Four sessions per week at a challenging intensity
European Society for Clinical and Economic Aspects of
Osteoporosis and Osteoarthritis, and the Committees of
Scientific Advisors and National Societies of the
International Osteoporosis Foundation (IOF)87
• Regular weight-bearing exercise should be advised, tailored
to the needs and abilities of the individual patient
• This advice was a guideline for the management of
osteoporosis, rather than a guideline focused on exercise;
the patient resources listed are those from the IOF website,
which might not be associated with the guideline
ability to make inferences about exercise in people with
osteoporosis. Bone adaptations to loading are more
impaired in older than younger bone, and the threshold
for stimulating bone formation with mechanical loading
could be higher in older bone.33,59–61 Moderate-intensity or
high-intensity PRT can increase muscle strength.62
Emerging research is examining whether combined
impact exercise and PRT can increase BMD in people
with low bone mass. A small trial of impact, strength, and
balance exercises in women with osteopenia reported a
modest between-group difference in total hip BMD in
favour of exercise.63 A study of 8 months of high-intensity,
progressive impact exercise and high-intensity PRT
compared with unsuper­vised, low-intensity home exercise
reported significant between-group differences in change
scores for lumbar spine BMD (+2·9% [SD 2·8] for exercise
group vs –1·2% [2·8] for control; p<0·001) and femoral
neck BMD (+0·3% [2·6] vs –1·9% [2·6]; p=0·004).54
Studies like these should be replicated in individuals at
moderate or high risk of fracture. Exercise RCTs in
individuals at high risk of fracture are sparse with small
sample sizes, and often have moderate or high risk of
bias.64

Intermittently supervised home-based exercises
(eg, stretching, training with resistance bands or
bodyweight, or aerobic physical activity) in individuals
with vertebral fracture had no significant effect on
BMD.65 Another study reported that after kyphoplasty,
comprehensive treatment (ie, calcium, vitamin D,
calcitonin, and back extensor strengthening) increased
lumbar BMD compared with calcium and vitamin D
alone, but the risk of bias was high.66 There is less
certainty regarding the balance between benefits and
harms of exercise in people with osteoporosis, because
most studies are not long enough or do not have adequate
sample sizes to assess harms.
Fear of falling, fracture, or injury could present a
barrier to exercise participation in people with low
BMD. People with osteoporosis want to know what type
of exercise programme is safe and effective,67,68 but
qualitative enquiry with clinicians reveals that they are
fearful of recommending exercises to their patients
with osteoporosis that might increase fracture risk.69
They are fearful of providing guidance on lifting, so
they tell patients to avoid lifting more than 10 lbs
(4–5 kg).69 Patients can be referred to community-based,
gentle exercise programmes, but these programmes
often deliver low-intensity exercise with little pro­
gression and are unlikely to increase BMD or muscle
strength.34,62
The benefits of exercise probably outweigh the risks,
and reports of fractures due to exercise have been
infrequent.70 A meta-analysis suggests that exercise does
not increase the risk of hospitalisation or premature
death.71 In fact, sensitivity analyses reveal that in clinical
populations (eg, cardiac disease, cognitive impairment),
exercise participation reduced mortality. Joint pain or
muscle strain are the most commonly reported exercise-
related adverse events.70,72 In trials of moderate-intensity
PRT for 5–24 months in people older than 50 years (total
n=737), in which 43 had osteoporosis based on BMD and
320 were osteopenic, there were no fractures or serious
adverse events that were deemed to be related to
exercise.73–76 In a trial of home exercise in women with
vertebral fractures, there was one fall but no serious
adverse events.77 Although activity-related fractures have
been reported,65,72,78–80 a systematic review suggests that
positive effects probably outweigh the potential harms.70
In a Cochrane review of exercise after osteoporotic
vertebral fracture, there were two exercise-related
fractures in nine trials.64 The LIFTMOR trial81 in high-
intensity PRT reported one muscle strain. In a
subanalysis of half of the sample (n=50), there was no
difference in vertebral fractures on the basis of vertebral
fracture assessment.81 Therefore, in individuals who are
at high risk, it is crucial to coach safe movement both
during exercise and during transitions. Home exercise
might seem practical or cost-effective, but it is difficult to
ensure adequate dosing, progression, or adherence with
limited supervision.
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Review
Assessing what to recommend
Exercise recommendations to optimise bone health
might need to vary between children and adults, and with
baseline fracture risk. In general, national physical
activity guidelines are appropriate, recommending a
minimum of 150 min of moderate to vigorous aerobic
activity per week and strength training twice per week.
Osteoporosis-specific guidelines, summarised in panel 1,
are not that different, but they emphasise moderate-
intensity or high-intensity PRT, and impact and balance
training.88–90 To tailor general physical activity guidelines
to optimise bone health, the recommendation is to choose
daily moderate-impact or high-impact exercises and
ensure that patients do not do aerobic activity to the
exclusion of PRT. Many older adults walk for exercise, but
few participate in strength training or balance training,91,92
as recommended by guidelines.88 The benefits observed
in trials of physical activity or exercise might not be
achieved or sustained if the activities are discontinued or
if adherence is suboptimal, and therefore strategies to
maintain participation should be considered in terms of
their real-world application. Indeed, implementation
science related to physical activity participation for fall
and fracture prevention is an important research priority.88
All adults, including those with osteoporosis, should
participate in a PRT programme targeting major muscle
groups, at moderate or high intensity. A basic PRT
programme (appendix) might include a pull exercise See Online for appendix
(eg, lateral pull down, and seated, kneeling, or standing
row), a push exercise (eg, wall, counter, or floor pushup,
and bench press), lower extremity exercises (eg, squat,
step-ups, and lunges), and a shoulder raise or press.
Exercises for back extensors and abdominals are
recommended to support the spine (eg, modified curl up,
bird-dog, and side plank), and the intensity is prescribed
to promote endurance (eg, repeated or prolonged holds).
Exercise professionals can guide individuals on how to
regress exercises to make them easier (eg, unweighted or
seated), but the exercises need to be progressed to more
challenging versions once the form is learned. Daily
bouts of impact exercise can be introduced, progressively
increasing the magnitude of impact.89 Individuals
unaccustomed to impact exercise might need to start
with PRT to build strength before initiating impact
exercise. Individuals at moderate or high risk of fracture
might consider a progression from lower impact
challenges (eg, heel drops) to moderate impact (eg, hops
and jumps) or high impact (eg, drop jumps) activities.
Although walking is technically a weight-bearing
exercise, the impact is not very high, but if walking is a
preferred activity, it can still be encouraged for other
health benefits. An exercise professional might need to
guide individuals on impact exercise selection and on
progression for both PRT and impact exercises. Initiating
exercise if nutrition is inadequate can cause weight loss
or limit strength gains. For example, the PROT-AGE
group recommends 1·0–1·2 g protein per kg bodyweight
 Review
Panel 2: Opportunities and challenges for future research related to physical activity and bone health
Objective measurement of physical activity in cohort
studies with fracture outcomes
Opportunities
• Assess sedentary activity and bouts of activity and breaks
for sedentary, mild, moderate, and vigorous activity
• Consider whether wearable accelerometers can capture
ground reaction forces or physical activity intensity
Considerations and challenges
• Accelerometry currently does not distinguish between types
of activity
• Difficult to quantify participation in resistance training or
balance exercises
Effects of different types of exercise on individuals at
moderate or high risk of fracture
Opportunities
• Investigate whether exercise increases bone strength
• Evaluate dose duration, frequency, and type of activity
Considerations and challenges
• Participants could be taking medications that affect bone
health, therefore research should stratify by medication use
and study effects of physical activity in combination with
medication
• Individuals might not be willing to enrol if there is the
potential to be randomly allocated to a control group,
therefore researchers should consider a waiting-list control
and active attention control
• Masking of participants is not possible and the control
group could be contaminated, so researchers should
consider active attention control
Interventions that are practical or cost-effective in the real
world and can achieve good adherence
Opportunity
• Develop science of implementation
Considerations and challenges
• Cluster trials of group-exercise interventions in individuals
at high risk aged 75 years or older in senior apartments have
per day for older adults, and more (>1·5–1·8 g/kg
bodyweight per day) for active or frail individuals.94
Exercise guidelines for older adults recommend balance
exercises.88,89 There is strong evidence that exercise can
reduce falls and fall-related injuries36,37 and that the most
effective interventions include functional strength and
balance exercises, either alone or combined with
resistance exercises.36 Tai chi could reduce the rate of falls
by 19% (low certainty evidence) and reduce the risk of
being a faller by 20% (high certainty evidence).36 However,
the effects of walking, dance, or resistance exercise alone
on fall rate or fall risk are uncertain.36 Because most non-
vertebral fractures result from a fall, exercise recom­
mendations for fracture prevention should encourage
10 www.thelancet.com/diabetes-endocrinology Published online November 20, 2019 https://doi.org/10.1016/S2213-8587(19)30351-1
greater complexity in design and analyses and larger sample
sizes; clustered individuals are not independent and their
characteristics are more likely to be similar within a cluster
• Pragmatic trials risk non-adherence and high rates of loss to
follow-up, require large sample sizes, are unblinded, and
lose internal validity to increase generalisability93
• Cost-effectiveness studies need to evaluate long-term
effects on the clinical outcome of fracture
• Health plans might not want to pay for exercise or strength
training
• Interventions that combine behaviour change strategies
with exercise and physical activity prescription risk poor
adherence because of the increased complexity
• Adaption of interventions to individual preferences or goals
brings increased complexity and costs
Randomised controlled trials (RCTs) of exercise with fracture
as a primary outcome
Opportunity
• Develop surrogate outcomes for fracture
Considerations and challenges
• Emerging meta-analyses and pooling studies would help but
challenges include harmonisation of eligibility, interventions,
and outcomes, and differences in study durations
• Large, simple trials with multi-country collaboration might
not include the intensity of exercise and strength training
needed to affect skeletal health
• RCTs of exercise in people with low bone mass or moderate
to high fracture risk need to balance delivery of sufficient
exercise stimulus with risks of falls and fractures
• RCTs need to use appropriate dose and methods to ensure
adequate adherence to establish efficacy
• RCTs directed by rehabilitation or exercise specialists could
be too expensive to implement on a wide scale
functional strength and balance training, such as step-
ups, lunges, or shifting forward and backward to the
limits of stability with both feet together or on one foot.
However, most vertebral fractures do not occur as a result
of a fall,95 and thus exercises to maintain BMD and spine-
sparing strategies should also be encouraged.
Future research related to bone health
We have summarised the opportunities and challenges
for future research related to physical activity and bone
health in panel 2. To our knowledge, there is a single
prospective study of objective physical activity and fracture
outcomes, which is confined to primarily white men older
than 72 years. Information on objective physical activity,

including assessment of sedentary activities and bouts of
activity, could advance the field. RCTs are needed of
exercise in individuals at moderate or high risk of fracture
with a focus on intermediate markers of bone strength.
Developing interventions that are practical and cost-
effective and translatable to the real world are also
needed.34 Future research might explore which training
variables are necessary to observe a benefit to bone health,
to show whether what matters is exercise intensity or
variables such as training volume, speed of movement, or
effort (ie, whether exercise is continued to fatigue).
RCTs with fracture endpoints would be costly, long-
lasting, and perhaps impractical. However, data from
RCTs and meta-analyses exploring the effects of exercise
on fracture risk or on indirect measures, such as BMD or
falls, could provide insights into the dose and type of
exercise. Recently, the Foundation for the National
Institute of Health Bone Quality Project collected patient-
level data from all randomised trials of osteoporosis drugs
to investigate surrogate endpoints for enhancing drug
development in osteoporosis.96 A meta-regression of
38 placebo-controlled trials of 19 therapeutic agents
showed that for a 2% improvement in total hip BMD,
a 28% reduction in vertebral fracture and 16% reduction
in hip fracture can be expected (and for a 6% improvement
in total hip BMD, a 66% reduction in vertebral fracture
and 40% reduction in hip fracture can be expected).96
Although this meta-regression focused on drug trials, the
use of surrogate endpoints such as BMD could be applied
to exercise interventions.
Summary
Observational studies suggest an 11–40% decline in
fracture risk with increasing physical activity. When this
Search strategy and selection criteria
We identified references through searches of PubMed for
articles published from Jan 1, 2009, to March 31, 2019,
using the terms “physical activity”, “exercise”, “fractures”,
“bone strength”, and “osteoporosis”. Relevant articles were
also found in the references of these papers. We limited
articles to those published in English, and to those concerning
adults aged 40 years and older. We excluded articles that were
not prospective and that did not have a fracture outcome.
The lists of articles were reviewed by a single author (JAC).
Incidence studies were graded according to criteria originally
developed for the Fracture Risk Assessment Tool (FRAX)
International Task Force statement to rate studies on fracture
incidence97 as follows: “good” if at least four criteria were met
of prospective study, study population representative of the
entire population, study duration more than 1 year, or
adequate definition of fracture or ICD codes used; and “poor”
if at least four criteria were met of retrospective study, study
duration of 1 year or less, non-population based, inadequate
definition of fracture, or only abstract available.
www.thelancet.com/diabetes-endocrinology Published online November 20, 2019 https://doi.org/10.1016/S2213-8587(19)30351-1 11
Review
evidence is related to clinical practice, the effects of
exercise on fractures, falls, or BMD in older adults could
be both site-specific and exercise mode-specific.
Multicomponent programmes that combine impact
exercise with sufficiently dosed, moderate-intensity or
high-intensity PRT and that are progressive in nature
will be most effective.
Contributors
Both authors contributed equally to the manuscript.
Declaration of interests
We declare no competing interests.
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