Advertisement

Osteoporosis International

, Volume 20, Issue 12, pp 2111–2125 | Cite as

Exercise interventions to reduce fall-related fractures and their risk factors in individuals with low bone density: a systematic review of randomized controlled trials

  • D. de Kam
  • E. Smulders
  • V. Weerdesteyn
  • B. C. M. Smits-EngelsmanEmail author
Review

Abstract

Summary

Exercise can reduce falls and fall-related fractures in healthy individuals; however, evidence for individuals with low BMD is limited. The results from this systematic review indicate that exercise interventions for individuals with low BMD to reduce falls and fractures should include balance, muscle strengthening, and weight-bearing exercises.

Introduction

The purpose of this systematic review was to investigate which exercise interventions are effective in individuals with low bone mineral density (BMD; osteopenia or osteoporosis) in reducing (1) falls and fractures and (2) risk factors for falls and fractures.

Methods

Databases were searched for relevant studies between 1996 and June 2008. Methodological quality was assessed with the Jadad score and the PEDro scale.

Results

Of the 1,369 publications found, 23 met the inclusion criteria. Five additional articles were included after checking reference lists and searching author’s names and related articles. Interventions with balance exercises reduced falls or fall-related fractures and improved balance in the majority of the studies. Muscle strengthening exercises were effective in improving lower extremity strength and back extensor strength; however, not all RCT’s reported positive effects. Bone strength was improved by weight-bearing aerobic exercise with or without muscle strengthening exercise when the duration of the intervention was at least a year.

Conclusions

Exercise can reduce falls, fall-related fractures, and several risk factors for falls in individuals with low BMD. Exercise interventions for patients with osteoporosis should include weight-bearing activities, balance exercise, and strengthening exercises to reduce fall and fracture risk.

Keywords

Accidental falls Bone density Exercise Muscle strength Osteoporosis Postural balance 

Notes

Acknowledgements

The authors would like to thank Prof. Dr. R.F.J.M Laan for his advice.

Conflicts of interest

None.

References

  1. 1.
    van der Klift M, Burger H, de Laet CEDH, Pols HAP, Gijsen R, Poos MJJC (2003) Hoe vaak komt osteoporose voor en hoeveel mensen sterven eraan?. Volksgezondheid Toekomst Verkenning, Nationaal Kompas VolksgezondheidGoogle Scholar
  2. 2.
    Looker AC, Orwoll ES, Johnston CC Jr, Lindsay RL, Wahner HW, Dunn WL, Calvo MS, Harris TB, Heyse SP (1997) Prevalence of low femoral bone density in older U.S. adults from NHANES III. J Bone Miner Res 12:1761–1768CrossRefPubMedGoogle Scholar
  3. 3.
    Cummings SR, Melton LJ (2002) Epidemiology and outcomes of osteoporotic fractures. Lancet 359:1761–1767CrossRefPubMedGoogle Scholar
  4. 4.
    Keene GS, Parker MJ, Pryor GA (1993) Mortality and morbidity after hip fractures. BMJ 307:1248–1250CrossRefPubMedGoogle Scholar
  5. 5.
    Roche JJ, Wenn RT, Sahota O, Moran CG (2005) Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ 331:1374CrossRefPubMedGoogle Scholar
  6. 6.
    Bonaiuti D (2002) Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane.Database.Syst.Rev Issue 2. Art. No.: CD000333Google Scholar
  7. 7.
    Kelley GA, Kelley KS, Tran ZV (2002) Exercise and lumbar spine bone mineral density in postmenopausal women: a meta-analysis of individual patient data. J Gerontol A Biol Sci Med Sci 57:M599–M604PubMedGoogle Scholar
  8. 8.
    Wolff I, van Croonenborg JJ, Kemper HC, Kostense PJ, Twisk JW (1999) The effect of exercise training programs on bone mass: a meta-analysis of published controlled trials in pre- and postmenopausal women. Osteoporos Int 9:1–12CrossRefPubMedGoogle Scholar
  9. 9.
    Zehnacker CH (2007) Effect of weighted exercises on bone mineral density in post menopausal women a systematic review. J Geriatr Phys Ther 30:79–88PubMedGoogle Scholar
  10. 10.
    Bergstrom U, Bjornstig U, Stenlund H, Jonsson H, Svensson O (2008) Fracture mechanisms and fracture pattern in men and women aged 50 years and older: a study of a 12-year population-based injury register, Umea, Sweden. Osteoporos Int 19:1267–1273CrossRefPubMedGoogle Scholar
  11. 11.
    Cummings SR, Nevitt MC, Browner WS, Stone K, Fox KM, Ensrud KE, Cauley J, Black D, Vogt TM (1995) Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med 332:767–773CrossRefPubMedGoogle Scholar
  12. 12.
    Nevitt MC, Cummings SR, Stone KL, Palermo L, Black DM, Bauer DC, Genant HK, Hochberg MC, Ensrud KE, Hillier TA, Cauley JA (2005) Risk factors for a first-incident radiographic vertebral fracture in women > or = 65 years of age: the study of osteoporotic fractures. J Bone Miner Res 20:131–140PubMedGoogle Scholar
  13. 13.
    van Helden S, van Geel AC, Geusens PP, Kessels A, Nieuwenhuijzen Kruseman AC, Brink PR (2008) Bone and fall-related fracture risks in women and men with a recent clinical fracture. J Bone Joint Surg Am 90:241–248CrossRefPubMedGoogle Scholar
  14. 14.
    Jarvinen TL, Sievanen H, Khan KM, Heinonen A, Kannus P (2008) Shifting the focus in fracture prevention from osteoporosis to falls. BMJ 336:124–126CrossRefPubMedGoogle Scholar
  15. 15.
    Weerdesteyn V, Rijken H, Geurts AC, Smits-Engelsman BC, Mulder T, Duysens J (2006) A five-week exercise program can reduce falls and improve obstacle avoidance in the elderly. Gerontology 52:131–141CrossRefPubMedGoogle Scholar
  16. 16.
    Robertson MC, Campbell AJ, Gardner MM, Devlin N (2002) Preventing injuries in older people by preventing falls: a meta-analysis of individual-level data. J Am Geriatr Soc 50:905–911CrossRefPubMedGoogle Scholar
  17. 17.
    Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close JC (2008) Effective exercise for the prevention of falls: a systematic review and meta-analysis. J Am Geriatr Soc 56:2234–2243CrossRefPubMedGoogle Scholar
  18. 18.
    Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH (2003) Interventions for preventing falls in elderly people. Cochrane Database Syst Rev: CD000340Google Scholar
  19. 19.
    Gregg EW, Cauley JA, Seeley DG, Ensrud KE, Bauer DC (1998) Physical activity and osteoporotic fracture risk in older women. Study of Osteoporotic Fractures Research Group. Ann Intern Med 129:81–88PubMedGoogle Scholar
  20. 20.
    Stel VS, Smit JH, Pluijm SM, Lips P (2003) Balance and mobility performance as treatable risk factors for recurrent falling in older persons. J Clin Epidemiol 56:659–668CrossRefPubMedGoogle Scholar
  21. 21.
    Albrand G, Munoz F, Sornay-Rendu E, DuBoeuf F, Delmas PD (2003) Independent predictors of all osteoporosis-related fractures in healthy postmenopausal women: the OFELY study. Bone 32:78–85CrossRefPubMedGoogle Scholar
  22. 22.
    Asikainen TM, Kukkonen-Harjula K, Miilunpalo S (2004) Exercise for health for early postmenopausal women: a systematic review of randomised controlled trials. Sports Med 34:753–778CrossRefPubMedGoogle Scholar
  23. 23.
    Howe TE, Rochester L, Jackson A, Banks PM, Blair VA (2007) Exercise for improving balance in older people. Cochrane Database Syst Rev: CD004963Google Scholar
  24. 24.
    Liu-Ambrose T, Eng JJ, Khan KM, Carter ND, McKay HA (2003) Older women with osteoporosis have increased postural sway and weaker quadriceps strength than counterparts with normal bone mass: overlooked determinants of fracture risk? J Gerontol A Biol Sci Med Sci 58:M862–M866PubMedGoogle Scholar
  25. 25.
    Bonaiuti D, Arioli G, Diana G, Franchignoni F, Giustini A, Monticone M, Negrini S, Maini M (2005) SIMFER Rehabilitation treatment guidelines in postmenopausal and senile osteoporosis. Eura Medicophys 41:315–337PubMedGoogle Scholar
  26. 26.
    Winters-Stone K (2005) Action plan for osteoporosis. ACSMGoogle Scholar
  27. 27.
    Sterck JG, Klein-Nulend J, Lips P, Burger EH (1998) Response of normal and osteoporotic human bone cells to mechanical stress in vitro. Am J Physiol 274:E1113–E1120PubMedGoogle Scholar
  28. 28.
    Bravo G, Gauthier P, Roy PM, Payette H, Gaulin P, Harvey M, Peloquin L, Dubois MF (1996) Impact of a 12-month exercise program on the physical and psychological health of osteopenic women. J Am Geriatr Soc 44:756–762PubMedGoogle Scholar
  29. 29.
    Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, McQuay HJ (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 17:1–12CrossRefPubMedGoogle Scholar
  30. 30.
    Carter ND, Khan KM, Petit MA, Heinonen A, Waterman C, Donaldson MG, Janssen PA, Mallinson A, Riddell L, Kruse K, Prior JC, Flicker L, McKay HA (2001) Results of a 10 week community based strength and balance training programme to reduce fall risk factors: a randomised controlled trial in 65–75 year old women with osteoporosis. Br J Sports Med 35:348–351CrossRefPubMedGoogle Scholar
  31. 31.
    Carter ND, Khan KM, McKay HA, Petit MA, Waterman C, Heinonen A, Janssen PA, Donaldson MG, Mallinson A, Riddell L, Kruse K, Prior JC, Flicker L (2002) Community-based exercise program reduces risk factors for falls in 65- to 75-year-old women with osteoporosis: randomized controlled trial. CMAJ 167:997–1004PubMedGoogle Scholar
  32. 32.
    Iwamoto J, Takeda T, Otani T, Yabe Y (1998) Effect of increased physical activity on bone mineral density in postmenopausal osteoporotic women. Keio J Med 47:157–161PubMedGoogle Scholar
  33. 33.
    Iwamoto J, Takeda T, Ichimura S (2001) Effect of exercise training and detraining on bone mineral density in postmenopausal women with osteoporosis. J Orthop Sci 6:128–132CrossRefPubMedGoogle Scholar
  34. 34.
    Stengel SV, Kemmler W, Pintag R, Beeskow C, Weineck J, Lauber D, Kalender WA, Engelke K (2005) Power training is more effective than strength training for maintaining bone mineral density in postmenopausal women. J Appl Physiol 99:181–188CrossRefPubMedGoogle Scholar
  35. 35.
    Stengel S, Kemmler W, Kalender WA, Engelke K, Lauber D (2007) Differential effects of strength versus power training on bone mineral density in postmenopausal women: a 2-year longitudinal study. Br J Sports Med 41:649–655CrossRefGoogle Scholar
  36. 36.
    Korpelainen R, Keinanen-Kiukaanniemi S, Heikkinen J, Vaananen K, Korpelainen J (2006) Effect of exercise on extraskeletal risk factors for hip fractures in elderly women with low BMD: a population-based randomized controlled trial. J Bone Miner Res 21:772–779CrossRefPubMedGoogle Scholar
  37. 37.
    Korpelainen R, Keinanen-Kiukaanniemi S, Heikkinen J, Vaananen K, Korpelainen J (2006) Effect of impact exercise on bone mineral density in elderly women with low BMD: a population-based randomized controlled 30-month intervention. Osteoporos Int 17:109–118CrossRefPubMedGoogle Scholar
  38. 38.
    Papaioannou A, Adachi JD, Winegard K, Ferko N, Parkinson W, Cook RJ, Webber C, McCartney N (2003) Efficacy of home-based exercise for improving quality of life among elderly women with symptomatic osteoporosis-related vertebral fractures. Osteoporos Int 14:677–682CrossRefPubMedGoogle Scholar
  39. 39.
    Webber CE, Papaioannou A, Winegard KJ, Adachi JD, Parkinson W, Ferko NC, Cook RJ, McCartney N (2003) A 6-mo home-based exercise program may slow vertebral height loss. J Clin Densitom 6:391–400CrossRefPubMedGoogle Scholar
  40. 40.
    Liu-Ambrose T, Khan KM, Eng JJ, Janssen PA, Lord SR, McKay HA (2004) Resistance and agility training reduce fall risk in women aged 75 to 85 with low bone mass: a 6-month randomized, controlled trial. J Am Geriatr Soc 52:657–665CrossRefPubMedGoogle Scholar
  41. 41.
    Liu-Ambrose TY, Khan KM, Eng JJ, Heinonen A, McKay HA (2004) Both resistance and agility training increase cortical bone density in 75- to 85-year-old women with low bone mass: a 6-month randomized controlled trial. J Clin Densitom 7:390–398CrossRefPubMedGoogle Scholar
  42. 42.
    Liu-Ambrose TY, Khan KM, Eng JJ, Gillies GL, Lord SR, McKay HA (2005) The beneficial effects of group-based exercises on fall risk profile and physical activity persist 1 year postintervention in older women with low bone mass: follow-up after withdrawal of exercise. J Am Geriatr Soc 53:1767–1773CrossRefPubMedGoogle Scholar
  43. 43.
    Madureira MM, Takayama L, Gallinaro AL, Caparbo VF, Costa RA, Pereira RM (2007) Balance training program is highly effective in improving functional status and reducing the risk of falls in elderly women with osteoporosis: a randomized controlled trial. Osteoporos Int 18:419–425CrossRefPubMedGoogle Scholar
  44. 44.
    Swanenburg J, de Bruin ED, Stauffacher M, Mulder T, Uebelhart D (2007) Effects of exercise and nutrition on postural balance and risk of falling in elderly people with decreased bone mineral density: randomized controlled trial pilot study. Clin Rehabil 21:523–534CrossRefPubMedGoogle Scholar
  45. 45.
    Iwamoto J, Takeda T, Sato Y, Uzawa M (2005) Effect of whole-body vibration exercise on lumbar bone mineral density, bone turnover, and chronic back pain in post-menopausal osteoporotic women treated with alendronate. Aging Clin Exp Res 17:157–163PubMedGoogle Scholar
  46. 46.
    Bergstrom I, Landgren B, Brinck J, Freyschuss B (2008) Physical training preserves bone mineral density in postmenopausal women with forearm fractures and low bone mineral density. Osteoporos Int 19:177–183CrossRefPubMedGoogle Scholar
  47. 47.
    Hans D, Genton L, Drezner MK, Schott AM, Pacifici R, Avioli L, Slosman DO, Meunier PJ (2002) Monitored impact loading of the hip: initial testing of a home-use device. Calcif Tissue Int 71:112–120CrossRefPubMedGoogle Scholar
  48. 48.
    Hourigan SR, Nitz JC, Brauer SG, O'Neill S, Wong J, Richardson CA (2008) Positive effects of exercise on falls and fracture risk in osteopenic women. Osteoporos Int 19:1077–1086CrossRefPubMedGoogle Scholar
  49. 49.
    Chien MY, Yang RS, Tsauo JY (2005) Home-based trunk-strengthening exercise for osteoporotic and osteopenic postmenopausal women without fracture—a pilot study. Clin Rehabil 19:28–36CrossRefPubMedGoogle Scholar
  50. 50.
    Gold DT, Shipp KM, Pieper CF, Duncan PW, Martinez S, Lyles KW (2004) Group treatment improves trunk strength and psychological status in older women with vertebral fractures: results of a randomized, clinical trial. J Am Geriatr Soc 52:1471–1478CrossRefPubMedGoogle Scholar
  51. 51.
    Hongo M, Itoi E, Sinaki M, Miyakoshi N, Shimada Y, Maekawa S, Okada K, Mizutani Y (2007) Effect of low-intensity back exercise on quality of life and back extensor strength in patients with osteoporosis: a randomized controlled trial. Osteoporos Int 18:1389–1395CrossRefPubMedGoogle Scholar
  52. 52.
    Kemmler WK, Lauber D, Engelke K, Weineck J (2004) Effects of single- vs. multiple-set resistance training on maximum strength and body composition in trained postmenopausal women. J Strength Cond Res 18:689–694CrossRefPubMedGoogle Scholar
  53. 53.
    Malmros B, Mortensen L, Jensen MB, Charles P (1998) Positive effects of physiotherapy on chronic pain and performance in osteoporosis. Osteoporos Int 8:215–221CrossRefPubMedGoogle Scholar
  54. 54.
    Mitchell SL, Grant S, Aitchison T (1998) Physiological effects of exercise on post-menopausal osteoporotic women. Physiotherapy 84:157–163CrossRefGoogle Scholar
  55. 55.
    Devereux K, Robertson D, Briffa NK (2005) Effects of a water-based program on women 65 years and over: a randomised controlled trial. Aust J Physiother 51:102–108PubMedGoogle Scholar
  56. 56.
    Maciaszek J, Osinski W, Szeklicki R, Stemplewski R (2007) Effect of Tai Chi on body balance: randomized controlled trial in men with osteopenia or osteoporosis. Am J Chin Med 35:1–9CrossRefPubMedGoogle Scholar
  57. 57.
    Lajoie Y, Gallagher SP (2004) Predicting falls within the elderly community: comparison of postural sway, reaction time, the Berg balance scale and the activities-specific balance confidence (ABC) scale for comparing fallers and non-fallers. Arch Gerontol Geriatr 38:11–26CrossRefPubMedGoogle Scholar
  58. 58.
    Nguyen T, Sambrook P, Kelly P, Jones G, Lord S, Freund J, Eisman J (1993) Prediction of osteoporotic fractures by postural instability and bone density. BMJ 307:1111–1115CrossRefPubMedGoogle Scholar
  59. 59.
    Orr R, Raymond J, Fiatarone SM (2008) Efficacy of progressive resistance training on balance performance in older adults: a systematic review of randomized controlled trials. Sports Med 38:317–343CrossRefPubMedGoogle Scholar
  60. 60.
    Carter ND, Khan KM, Mallinson A, Janssen PA, Heinonen A, Petit MA, McKay HA (2002) Knee extension strength is a significant determinant of static and dynamic balance as well as quality of life in older community-dwelling women with osteoporosis. Gerontology 48:360–368CrossRefPubMedGoogle Scholar
  61. 61.
    Sinaki M, Itoi E, Wahner HW, Wollan P, Gelzcer R, Mullan BP, Collins DA, Hodgson SF (2002) Stronger back muscles reduce the incidence of vertebral fractures: a prospective 10 year follow-up of postmenopausal women. Bone 30:836–841CrossRefPubMedGoogle Scholar
  62. 62.
    Sinaki M, Itoi E, Rogers JW, Bergstralh EJ, Wahner HW (1996) Correlation of back extensor strength with thoracic kyphosis and lumbar lordosis in estrogen-deficient women. Am J Phys Med Rehabil 75:370–374CrossRefPubMedGoogle Scholar
  63. 63.
    Katzman WB, Sellmeyer DE, Stewart AL, Wanek L, Hamel KA (2007) Changes in flexed posture, musculoskeletal impairments, and physical performance after group exercise in community-dwelling older women. Arch Phys Med Rehabil 88:192–199CrossRefPubMedGoogle Scholar
  64. 64.
    Sinaki M, Brey RH, Hughes CA, Larson DR, Kaufman KR (2005) Balance disorder and increased risk of falls in osteoporosis and kyphosis: significance of kyphotic posture and muscle strength. Osteoporos Int 16:1004–1010CrossRefPubMedGoogle Scholar
  65. 65.
    Arnold CM, Busch AJ, Schachter CL, Harrison L, Olszynski W (2005) The relationship of intrinsic fall risk factors to a recent history of falling in older women with osteoporosis. J Orthop Sports Phys Ther 35:452–460PubMedGoogle Scholar
  66. 66.
    Johnell O, Kanis JA, Oden A, Johansson H, De Laet C, Delmas P, Eisman JA, Fujiwara S, Kroger H, Mellstrom D, Meunier PJ, Melton LJ III, O'Neill T, Pols H, Reeve J, Silman A, Tenenhouse A (2005) Predictive value of BMD for hip and other fractures. J Bone Miner Res 20:1185–1194CrossRefPubMedGoogle Scholar
  67. 67.
    Klein-Nulend J, Bacabac RG, Mullender MG (2005) Mechanobiology of bone tissue. Pathol Biol (Paris) 53:576–580Google Scholar
  68. 68.
    Kelley GA, Kelley KS, Tran ZV (2001) Resistance training and bone mineral density in women: a meta-analysis of controlled trials. Am J Phys Med Rehabil 80:65–77CrossRefPubMedGoogle Scholar
  69. 69.
    Gusi N (2006) Low-frequency vibratory exercise reduces the risk of bone fracture more than walking: a randomized controlled trial. BMC Musculoskel Disord 30Google Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2009

Authors and Affiliations

  • D. de Kam
    • 1
  • E. Smulders
    • 1
  • V. Weerdesteyn
    • 1
    • 1
  • B. C. M. Smits-Engelsman
    • 2
    • 3
    • 4
    Email author
  1. 1.Department of RehabilitationRadboud University Nijmegen Medical CentreNijmegenThe Netherlands
  2. 2.Faculty of Kinesiology and Rehabilitation SciencesKatholieke Universiteit LeuvenLeuvenBelgium
  3. 3.Avans+University for ProfessionalsBredaThe Netherlands
  4. 4.Motor Control Laboratory, Research Center for Movement Control and Neuroplasticity, Department of Biomedical KinesiologyKU LeuvenLeuvenBelgium

Personalised recommendations