The Effectiveness of Physical Exercise on Bone Density in Osteoporotic Patients

Abstract

Physical exercise is considered an effective means to stimulate bone osteogenesis in osteoporotic patients. The authors reviewed the current literature to define the most appropriate features of exercise for increasing bone density in osteoporotic patients. Two types emerged: (1) weight-bearing aerobic exercises , i.e., walking, stair climbing, jogging, and Tai Chi. Walking alone did not appear to improve bone mass; however it is able to limit its progressive loss. In fact, in order for the weight-bearing exercises to be effective, they must reach the mechanical intensity useful to determine an important ground reaction force. (2) Strength and resistance exercises : these are carried out with loading (lifting weights) or without (swimming, cycling). For this type of exercise to be effective a joint reaction force superior to common daily activity with sensitive muscle strengthening must be determined. These exercises appear extremely site-specific, able to increase muscle mass and BMD only in the stimulated body regions. Other suggested protocols are multicomponent exercises and whole body vibration. Multicomponent exercises consist of a combination of different methods (aerobics, strengthening, progressive resistance, balancing, and dancing) aimed at increasing or preserving bone mass. These exercises seem particularly indicated in deteriorating elderly patients, often not able to perform exercises of pure reinforcement. However, for these protocols to be effective they must always contain a proportion of strengthening and resistance exercises. Given the variability of the protocols and outcome measures, the results of these methods are difficult to quantify. Training with whole body vibration (WBV): these exercises are performed with dedicated devices, and while it seems they have effect on enhancing muscle strength, controversial findings on improvement of BMD were reported. WBV seems to provide good results, especially in improving balance and reducing the risk of falling; in this, WBV appears more efficient than simply walking. Nevertheless, contraindications typical of senility should be taken into account.

Full text

Review Article
The Effectiveness of Physical Exercise on Bone Density in
Osteoporotic Patients
Maria Grazia Benedetti ,1Giulia Furlini,1Alessandro Zati,1and Giulia Letizia Mauro2
1Physical Medicine and Rehabilitation Unit, IRCCS-Istituto Ortopedico Rizzoli, Bologna, Italy
2Rehabilitation Unit, Paolo Giaccone Hospital, Palermo, Italy
Correspondence should be addressed to Maria Grazia Benedetti; benedetti@ior.it
Received 16 July 2018; Revised 28 October 2018; Accepted 4 December 2018; Published 23 December 2018
Guest Editor: ´
Angel Matute-Llorente
Copyright ©  Maria Grazia Benedetti et al. is is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Physical exercise is considered an eective means to stimulate bone osteogenesis in osteoporotic patients. e authors reviewed
the current literature to dene the most appropriate features of exercise for increasing bone density in osteoporotic patients.
Two types emerged: () weight-bearing aerobic exercises, i.e., walking, stair climbing, jogging, and Tai Chi. Walking alone did not
appear to improve bone mass; however it is able to limit its progressive loss. In fact, in order for the weight-bearing exercises to
be eective, they must reach the mechanical intensity useful to determine an important ground reaction force. () Strength and
resistance exercises: these are carried out with loading (liing weights) or without (swimming, cycling). For this type of exercise
to be eective a joint reaction force superior to common daily activity with sensitive muscle strengthening must be determined.
ese exercises appear extremely site-specic, able to increase muscle mass and BMD only in the stimulated body regions. Other
suggested protocols are multicomponent exercises and whole body vibration. Multicomponent exercises consist of a combination
of dierent methods (aerobics, strengthening, progressive resistance, balancing, and dancing) aimed at increasing or preserving
bone mass. ese exercises seem particularly indicated in deteriorating elderly patients, oen not able to perform exercises of pure
reinforcement. However, for these protocols to be eective they must always contain a proportion of strengthening and resistance
exercises. Given the variability of the protocols and outcome measures, the results of these methods are dicult to quantify.
Trai n i n g w ith whole body vibration (WBV): these exercises are performed with dedicated devices, and while it seems they have
eect on enhancing musclestrength, controversial ndings on improvement of BMD were reported. WBV seems to provide good
results, especially in improving balance and reducing the risk of falling; in this, WBV appears more ecient than simply walking.
Nevertheless, contraindications typical of senility should be taken into account.
1. Introduction
According to the literature, the level of bone loss in a
postmenopausal woman increases with age, respectively,
with a loss of .%, .%, and .% per year for the -,
-, and> age groups []. More precisely, the loss is
.% per year for the spine and .% - .% for the femoral
neck in the rst - years []. In the following years, the
loss is less rapid as it is the immediate postmenopausal
period characterized by a greater speed and entity of bone
loss []. Although exercise is widely recommended as one
of the primary preventive strategies to reduce the risk of
osteoporosis [], its eects on bone are controversial. In fact,
notalltypesofexercisehavethesamepositiveeectonbone
mineral density (BMD). While there is evidence that exercise
induces an increase in bone mass in younger subjects, this
eect in adults and elderly people remains questionable
[]. In elderly people, the results of the studies indicate that
exercise may increase the thickness and resistance of cortical
bone at loaded skeletal sites []. However, it seems that the
improvement on bone strength induced by exercise in older
adults is likely to be due to a lower loss of endocortical bone
and/or an increase in tissue density, rather than an increase
in bone size (periosteal apposition), typical of young subjects.
Supposing that trabecular bone architecture can adapt to
increased loading, the eects of physical activity on thickness,
number, separation, and orientation of trabecular elements
in human bones are not known due to the limited resolution
Hindawi
BioMed Research International
Volume 2018, Article ID 4840531, 10 pages
https://doi.org/10.1155/2018/4840531

BioMed Research International
of most current commonly used imaging techniques
[].
erefore, there is considerable interest in dening the
adequate dosage and characteristics of exercises to improve
bone strength in osteoporosis, in order to develop appropriate
guidelines, given the fact that economic and social costs
appear to be in a progressive and constant growth in relation
to the aging of the population [, ].
In the past years, many studies [, –] have reported
very consistent results on the benecial eects of exercise
onBMDofthelumbarspineandthefemurinmenopausal
women and, in general, in old age. Various exercises have
been described to stimulate bone growth and preserve the
bone mass; the optimal interventions are those favoring
a mechanical stimulus on bone both through antigravity
loading and the stress exerted on muscles [–]. In general,
therapeutic exercises for osteoporosis can be ranked in two
types of activities:
(i) Weight-bearing aerobic exercises,suchasimpactactiv-
ities or any other exercise in which arms, feet, and legs
are bearing the weight, (i.e., walking, stair climbing,
jogging, volleyball, tennis and similar sports, Tai Chi,
and dancing).
(ii) Strength end/or resistance exercises,inwhichthejoints
are moved against some kind of resistance, in the form
of free weights, machines, tubing, or one's own body
weight [].
However, it is still not clear which exercise is the best suited
and how long it would take to obtain an appropriate result.
For example, the SIOMMS guidelines [] recommend per-
forming a minimum of physical activity, such as walking, for
 minutes every day, despite the lack of available evidence.
Meanwhile the position paper in the American College of
Sports Medicine [] suggests, during adulthood, to carry
out weight-bearing endurance activities (i.e., tennis, stair
climbing, and jogging), activities that involve jumping (vol-
leyball, basketball), and resistance exercise (weight liing)
with moderate or high intensity, - times a week for -
minutes, possibly in combination.
e eects of exercise on bone tissue have gained an
important contribution also from studies on sport athletes.
Numerous publications have linked physical exercise, bone
metabolism markers, and bone mineral density []. While
the isolated exercise (single bout training) seems to give
a eeting osteogenetic stimulation, a longer training, for
example,  times a day for  weeks, seems to provide a
better stimulation. Furthermore, aerobic exercise seems to
be particularly eective in the enzymatic activation of the
osteoblasts. ese observations underscore the importance
of combining aerobic and anaerobic exercises in osteogenetic
protocols. Furthermore, aer a longer period of training (-
 months), the sedentary and untrained individuals obtained
better results in BMD than the already trained individuals
with signicant osteogenetic activity without increasing the
reabsorption indexes. Probably individuals already trained
with the continuation of exercise only maintained the good
bone metabolic level already reached, which can not indef-
initely increase. Regarding the type of exercise, sport shows
us clearly how the activities performed in weight bearing,
including high impact and endurance mechanical compo-
nents, are more eective in increasing the BMD of limited
or nonimpact exercises. In fact, BMD is on average higher
in athletes with sporting activities involving jumping (volley-
ball, basketball ball rugby, soccer, and martial arts) compared
to those who do not have these mechanical characteristics,
such as swimming, rowing, and cycling []. Furthermore
there are evidences that high level of physical activity during
youth, as seen in female athletes, seems to have a benecial
eect on bone mass and helps to prevent bone loss due to
aging [].
In clinical practice, however, the prescription of exer-
cise in the elderly and osteoporotic patient must always
be preceded by a careful evaluation: indeed, it is essential
to dene the type, intensity, and duration of a proposed
program. e decision is based on the subject’s muscle
strength, range of motion, balance, gait, cardiopulmonary
function, comorbidities, bone density, and histor y of previous
fractures, as well as the risk of falling [, , ]. In fact, the
most intense exercises, such as high impact activities, that are
eective in increasing bone mass in young subjects may not
be indicated for some elderly osteoporotic subjects []. e
progression of the exercise must always be respected, and, in
patients with severe osteoporosis, the activities involving the
exion or rotation of the trunk must be avoided.
Regarding aquatic exercise, a recent systematic review
supports the evidence of a trend showing its eectiveness in
maintaining or even improving BMD [].
2. Materials and Methods
2.1. Search Criteria. Main search engines (PubMed,
Cochrane Library, and Pedro) were explored using the
keywords: exercise AND osteoporosis in title, resistance
exercise AND osteoporosis, weight bearing exercise AND
osteoporosis, vibration AND osteoporosis. e following
lters were applied: articles in English language on humans
aged  and over. e research took into account the existing
systematic reviews and meta-analyses, focusing also on the
individual articles included in the reviews. A subsequent
selection regarding only exercise and primary osteoporosis,
based on the titles and abstracts analysis of the articles, was
performed.
2.2. Methodological Problems Emerging from the Studies.
Several critical issues in the evaluation of evidence, limiting
in some way the conclusion of this review, were highlighted in
theCochranereviews[,].Regardingthemethods,among
the several exercises proposed in the literature there were
relevant dierences in the type and in the setting where
the exercises were carried out, the intensity, the duration,
frequency of the sessions, and the total duration of the
program. Furthermore, the sample size, patients’ compliance
or adherence to the study, the presence of a control group,

BioMed Research International 
the number of postmenopausal years, and the follow-ups
reported in the studies were very diverse.
With regard to the criteria used to evaluate and mea-
sure the eectiveness of the exercises, the studies generally
referred to the measurement of BMD detected at the femur
(the whole hip, neck, trochanteric and intertrochanteric
region, and the Ward’s triangle), lumbar spine, distal radius,
forearm, tibia, ankle, and total body. In addition to BMD,
other studies had also considered aspects such as bone
quality, fracture risk reduction, BMC, cortical bone den-
sity, body mass, and muscle strength. Although BMD is
a relatively good predictor of fracture risk in the elderly
population, current research indicates that up to % of low-
impact trauma fractures occur in individuals who are not
osteoporotic but have a normal or slightly reduced BMD,
resulting in osteopenia. is discovery highlights the limits of
bone densitometry (DXA) in providing accurate BMD mea-
surements or its ability to provide relevant information about
the main determinants of bone strength, such as size, shape,
and bone structure. Minor changes in bone mass distribution,
cortical and trabecular structure, and bone geometry can lead
to large increases in bone strength dependent on changes in
BMD []. e most advanced studies now are focusing on
the use of some noninvasive bone imaging techniques, such
as quantitative peripheral computed tomography (pQCT),
magnetic resonance imaging (MRI), and DXA-based hip
structural analysis (HSA) [, ].
3. Results and Discussion
Forty-four systematic reviews were retrieved in PubMed
using the keywords “exercise AND osteoporosis”,  using
the keywords “resistance exercise AND osteoporosis”, 
with “weight bearing exercise AND osteoporosis”, and 
using “vibration AND osteoporosis”. irty-three systematic
reviews were retrieved from Pedro and  Cochrane review
from Cochran Library using the keywords “exercise AND
osteoporosis”. Of these, once eliminated duplicates and
papers not primarily focused on exercise and osteoporosis, 
systematic reviews and meta-analyses were considered with
respect to dierent type of exercise (Table ) and  with
respect to whole body vibration (Table ).
3.1. Weight-Bearing Aerobic Exercise. One of the most com-
mon forms of aerobic training is walking, an exercise very
well accepted by the older people, because it is harmless,
self-managed, and easily practicable. e eects of walking
on BMD have been widely considered, although the results
are not always consistent in the various studies [–, ].
e meta-analyses showed the absence of signicant eects
on the lumbar spine or on the femoral neck attempted by
the only walking [, ]. Likewise, from the studies analysed
by Gomez Cabello et al. [], there is no evidence of a
close correlation between BMD increasing and gait exercise.
However, the eectiveness of walking in maintaining the level
ofBMDandinpreventingitslossisalreadyanexcellentresult
of this simple type of exercise.
Furthermore, it is important to consider some parameters
that can inuence the eects of walking, such as walking
speedily/slowly or strongly/weekly. Actually, there is evidence
that an intervention of more than  months in duration can
provide signicant and positive eects on femoral neck BMD
in peri- and postmenopausal women [].
Some studies show how a brisk walking or jogging can
have positive eects on hip and column BMD in women of
menopausal age []. Certainly, some low-impact activities,
such as jogging combined with stair climbing and walking,
favor minor loss of BMD in both the hip and the spine
in menopausal women. Hence, walking/jogging must reach
a sucient high level of mechanical stress determining an
important ground reaction force able to stimulate bone mass
[,,,].
In comparing dierent types of physical exercises with
controls, Howe [] found a signicant eect in BMD for
bipodalic or monopodalic static exercises and on spine and
wrist for dynamic low-impact exercises (including walking
and Tai Chi).
Regarding Tai Chi, the issue is in increasing debate; recent
literature [, , –] suggests a positive eect on attenu-
ating BMD loss at the lumbar spine and the proximal femoral
neck and on biomarkers of bone metabolism. However, in
order to be eective, this activity has to last  months as
minimum [].
In summary:
(i) Walking, as an isolated intervention, is not able to
modify the loss of BMD. However, in the context of a
health maintenance program in general it is advisable
to walk for at least 30 minutes a day.
(ii) Aerobic training and in particular the path with high
intensity and speed, interspersed with jogging, climbing
scales, and stepping, is able to limit the reduction of
BMD.
3.2. Strength and Resistance Exercises. Strength and resis-
tance training are the most studied techniques to increase
bone mass in the elderly. e rationale of these exercises lies
in the mechanical stimulus indirectly produced on the bone
[, , ]. Like weight-bearing exercises, the strength exercise
determines a joint reaction force and muscle strengthening,
producing an important clinical benet on the BMD, in the
lumbar spine and, to a greater extent, in the femoral neck [].
is type of activity is also dened as “nonimpacting” and
can be carried out with loading (liing weights) or without
loading (swimming, cycling) [].
Studies have examined the eect of strengthening the
muscles of the upper limb and lower limb, rather than sp ecic
groups such as iliopsoas and spinal extensors. From the
evidence gathered by Zehnacker et al. [] the eectiveness
of strength training in the hip and spine sites is related to
the intensity of the training; the exercise requires high loads
(-% of a maximum repetition) for - repetitions of -
 sets performed at least for  year,  times a week for -
 minutes per session. In particular some types of exercise
wouldbeabletoincreasebonemineraldensity:()weighted
squats, hack squats, leg press, hip extension, hip adduction,

BioMed Research International
T : Systematic reviews and meta-analyses on Exercise and Osteoporosis.
Authors/Title/Source Main conclusions
G´omez-Cabello A, Ara I, Gonz´alez-Ag¨uero A, Casaj´us
JA, Vicente-Rodr´ıguez G. Eects of training on bone
mass in older adults: a systematic review. Sports Med.
;;():-.[]
Walking provides a modest increase in the loads on the skeleton above gravity
and, therefore, this type of exercise has proved to be less eective in osteoporosis
prevention. Strength exercise seems to be a powerful stimulus to improve and
maintain bone mass during the ageing process. Multi-component exercise
programmes of strength, aerobic, high impact and/or weight-bearing training, as
well as whole-body vibration (WBV) alone or in combination with exercise, may
help to increase or at least prevent decline in bone mass with ageing, especially in
postmenopausal women.
Nikander R, Siev¨anen H, Heinonen A, Daly RM,
Uusi-Rasi K, Kannus P. Targeted exercise against
osteoporosis: A systematic review and meta-analysis for
optimising bone strength throughout life. BMC Med.
 Jul ;:. []
Epidemiological evidence suggests that moderate to vigorous physical activity
performed three to four times per week is associated with considerably lower
incidence of fragility fractures in both women and men. e ndings from these
studies also suggest that exercise regimens that include moderate- to
high-magnitude impacts from varying loading directions may represent the
optimal mode to enhance bone structure and strength.
Zehnacker CH, Bemis-Dougherty A. Eect of weighted
exercises on bone mineral density in post-menopausal
women. A systematic review. J Geriatr Phys er.
;():-. []
Weighted exercises can help in maintaining BMD in postmenopausal women
and increasing BMD of the spine and hip in women with osteopenia and
osteoporosis. e exercise program must be incorporated into a lifestyle change
and be lifelong due to the chronic nature of bone loss in older women.
McMahon M. What impact does aquatic therapy have
on bone density in postmenopausal women? If it has a
positive or maintenance eect, what are the programme
parameters that facilitate these outcomes? Aqualines
;():-.[]
e majority of the studies reviewed support a trend showing that exercising in
water can be useful in at least maintaining, or improving, various measures of
bone mineral density (BMD).
Howe T, Shea B, Dawson LJ, Downie F, Murray A, Ross
C, Harbour RT, Caldwell LM, Creed G. Exercise for
preventing and treating osteoporosis in
postmenopausal women. Cochrane Database Syst Rev.
 Jul ;():CD. []
e most eective type of exercise intervention on bone mineral density (BMD)
for the neck of femur appears to be non-weight bearing high force exercise such
as progressive resistance strength training for the lower limbs. e most eective
intervention for BMD at the spine was combination exercise programmes
compared with control groups. Our results suggest a relatively small statistically
signicant, but possibly important, eect of exercise on bone density compared
with control groups.
Polidoulis I, Beyene J, Cheung AM. e eect of
exercise on pQCT parameters of bone structure and
strength in postmenopausal women – a systematic
review and meta-analysis of randomized controlled
trials. Osteoporos Int. ;():-. []
We conclude that exercise in postmenopausal women may decrease bone loss by
maintaining cortical and trabecular volumetric BMD.
Martyn-St James M, Carroll S. Meta-analysis of
walking for preservation of bone mineral density in
postmenopausal women. Plos one. ;():-.
[]
We conclude that regular walking has no signicant eect on preser vation of
BMD at the spine in postmenopausal women, whilst signicant positive eects at
femoral neck are evident. However, diverse methodological and reporting
discrepancies are apparent in the published trials on which these conclusions are
based. Other forms of exercise that provide greater targeted skeletal loading may
be required to preserve bone mineral density in this population.
Ma D, Wu L, He Z. Eects of walking on the
preservation of bone mineral density in
perimenopausal and postmenopausal women: a
systematic review and meta-analysis. Menopause.
;():-. []
Walking as a singular exercise therapy has no signicant eects on BMD at the
lumbar spine, at the radius, or for the whole body in perimenopausal and
postmenopausal women, although signicant and positive eects on femoral
neck BMD in this population are evident with interventions more than  months
in duration.
Bolam KA, van Uelen JG, Taae DR. e eect of
physical exercise on bone density in middle-aged and
older men: a systematic review. Osteop Int.
;():-. []
Regular resistance training and impact-loading activities should be considered as
a strategy to prevent osteoporosis in middle-aged and older men.
Kelley GA, Kelley KS, Kohrt WM. Eects of ground and
joint reaction force exercise on lumbar spine and
femoral neck bone mineral density in postmenopausal
women: a meta-analysis of randomized controlled
trials. BMC Musculoskelet Disord. ; ;:. []
e overall ndings suggest that exercise may result in clinically relevant benets
to FN and LS BMD in postmenopausal women.
Chow TH, Lee BY, Ang ABF, Cheung VYK, Ho MMC,
Takemura S. e eect of Chinese martial arts Tai Chi
Chuan on prevention of osteoporosis: A systematic
review. J Orthop Translat. ; ;:-. []
TCC is benecial to BMD and may be a cost-eective and preventive measure of
osteoporosis. is benecial eect is better observed in long-term TCC practice.

BioMed Research International 
T  : C o n t i nu ed.
Authors/Title/Source Main conclusions
SunZ,ChenH,BergerMR,ZhangL,GuoH,HuangY.
Eects of tai chi exercise on bone health in
perimenopausal and postmenopausal women: a
systematic review and meta-analysis. Osteoporos Int.
 Oct;():-. []
Tai chi exercise may have benets on bone health in perimenopausal and
postmenopausal women, but the evidence is sometimes weak, poor, and
inconsistent.
de Kam D, Smulders E, Weerdesteyn V,
Smits-Engelsman BC. Exercise interventions to reduce
fall-related fractures and their risk fac tors in individuals
with low bone density: a systematic review of
randomized controlled trials. Osteoporos Int.
;():-. []
Exercise interventions for patients with osteoporosis should include
weight-bearing activities, balance exercise, and strengthening exercises to reduce
fall and fracture risk.
Martyn-St James M, Carroll S. A meta-analysis of
impact exercise on postmenopausal bone loss: the case
for mixed loading exercise programmes. Br J Sports
Med. ; ():-. []
Mixed loading exercise programmes combining jogging with other low-impact
loading activity and programmes mixing impact activity with high-magnitude
exercise as resistance training appear eective in reducing postmenopausal bone
loss at the hip and spine. Other forms of impact exercise appear less eective at
preserving BMD in this population. However, diverse methodological and
reporting discrepancies are evident in current published trials.
Varahra A, Rodrigues IB, MacDermid JC, Bryant D,
Birmingham T. Exercise to improve functional
outcomes in persons with osteoporosis: a systematic
review and meta-analysis. Osteoporos Int.
;():-. []
A multicomponent exercise program of high-speed training combined with
simulated functional tasks is promising to enhance functional outcomes. Due to
substantial clinical heterogeneity of the target groups and specic demands of
exercise modes, it is unclear which exercise program is optimal.
Zhao R, Zhao M, Xu Z. e eects of diering
resistance training modes on the preservation of bone
mineral density in postmenopausal women: a
meta-analysis. Osteoporos Int. ; ():-. []
Combined resistance exercise protocols appear eective in preserving femoral
neck and lumbar spine BMD in postmenopausal women, whereas
resistance-alone protocols only produced a nonsignicant positive eect.
Martyn-St James M, Carroll S. Eects of dierent
impact exercise modalities on bone mineral density in
premenopausal women: a meta-analysis. J Bone Miner
Metab. ;():-.[]
Exercise programmes that combine odd- or high-impact activity with
high-magnitude resistance training appear eective in augmenting BMD in
premenopausal women at the hip and spine. High-impact-alone protocols are
eective only on hip BMD in this group. However, diverse methodological and
reporting discrepancies are evident in published trials.
Xu J, Lombardi G, Jiao W, Ban G. Eects of Exercise
on Bone Status in Female Subjects, from Young Girls to
Postmenopausal Women: An Overview of Systematic
Reviews and Meta-Analyses. Sports Med.
;():-. []
Combined-impact exercise protocols (impact exercise with resistance training)
are the best choice to preserve/improve bone mineral density in pre- and
postmenopausal women. Whole-body vibration exercises have no benecial
eects on bone in postmenopausal or elderly women.
knee extension, and hamstring curls; () stair-climbing/step
boxes with weighted vests, power cleans with weighted
vests, and beverage boxes; () military press, latissimus pull
down, seated rowing, and rotary torso; () back extension
exercises with weighted backpack, leg press, bench press,
trunk extension, elbow exion, wrist curl, reverse wrist curl,
triceps extension, and forearm pronation and supination.
In relation to the hip, the exercise is eective on the
greater trochanter if it involves the buttocks, on the lesser
trochanter if it involves the iliopsoas, and on the Ward’s
triangle if it involves the adductors and the hip extensors,
according to the studies of Kerr et al. []. Here, the authors
concluded that there are several possible explanations for
the dierent eectiveness of site-specic exercises: various
muscle insertions, dierent weight or type of contraction, and
duration and nature of the exercise.
Similarly, Sinaki et al. [] have shown that the strength
of the back muscles in osteoporotic women is signi-
cantly reduced compared to healthy subjects; therefore,
the strengthening of these muscles can reduce the risk
of vertebral fractures with simple programs of antigravity
extension in the prone position. Aer two years of exercise,
there was a signicant reduction in the loss of BMD in the
subjects being treated. is signicant dierence, compared
to controls, was maintained eight years aer, despite the
decrement of both BMD and muscle strength.
In opposite opinion are Bemben et al. [] who investi-
gated the dose-response eects of resistance training on BMD
in elderly women and concluded that the gain in BMD at the
proximal femur and lumbar spine is independent of intensity
and frequency of isotonic exercise (with Cybex) of the
upper and lower limbs. In particular, there was no dierence
between men and women at the femur level, while in women
the eect is greater at the spine. In fact, it seems that the bone
in menopausal age can be signicantly increased by a regime
of strengthening exercises with “high-load low repetitions”
but not by a regime of resistance exercises with “low-load
high repetitions” []. e peak load exerted seems to be
therefore more important than the number of repetitions on
theincreaseinbonemassinmenopausalwomen[].Other

BioMed Research International
T : Systematic reviews and meta-analyses on Whole Body Vibration.
Authors/Title/Source Main conclusions
Slatkovska L, Alibhai SM, Beyene J, Cheung AM. Eect
of whole-body vibration on BMD: a systematic review
and meta-analysis. Osteoporos Int.
;():-.[]
We found signicant but small improvements in BMD in postmenopausal
women and children and adolescents, but not in young adults.
MaC,LiuA,SunM,ZhuH,WuH.Eectofwhole-body
vibration on reduction of bone loss and fall prevention
in postmenopausal women: a meta-analysis and
systematic review. J Orthop Surg Res. ; ;:. []
Low-magnitude whole-body vibration therapy can provide a signicant
improvement in reducing bone loss in the lumbar spine in postmenopausal
women.
Merriman H, Jackson K. e eects of whole-body
vibration training in aging adults: a systematic review. J
Geriatr Phys er. ;():-. []
Some but not all of the studies in this review reported similar improvements in
muscle performance, balance, and functional mobility with WBV as compared to
traditional exercise programs. Bone studies consistently showed that WBV
improved bone density in the hip and tibia but not in the lumbar spine.
Oliveira LC, Oliveira RG, Pires-Oliveira DA. Eects of
whole body vibration on bone mineral density in
postmenopausal women: a systematic review and
meta-analysis. Osteoporos Int. ;():-. []
Despite WBV presenting potential to act as a coadjutant in the prevention or
treatment of osteoporosis, especially for BMD of the lumbar spine, the ideal
intervention is not yet clear. Our subgroup analyses helped to demonstrate the
various factors which appear to inuence the eects of WBV on BMD,
contributing to clinical practice and the denition of protocols for future
interventions.
Fratini A, Bonci T, Bull AM. Whole Body Vibration
Treatments in Postmenopausal Women Can Improve
Bone Mineral Density: Results of a Stimulus Focussed
Meta-Analysis. PLoS One. ;():e. []
Whole body vibration treatments in elderly women can reduce BMD decline.
However, many factors (e.g., amplitude, frequency and subject posture) aect the
capacity of the vibrations to propagate to the target site; the adequate level of
stimulation required to produce these eects has not yet been dened.
Lau RW, Liao LR, Yu F, Teo T, Chung RC, Pang MY. e
eects of whole body vibration therapy on bone
mineral density and leg muscle strength in older adults:
a systematic review and meta-analysis. Clin Rehab.
;():-.[]
Whole body vibration is benecial for enhancing leg muscle strength among
older adults. However, the review suggests that whole body vibration has no
overall treatment eect on bone mineral density in older women.
JepsenDB,omsenK,HansenS,JørgensenNR,
Masud T, Ryg J. Eect of whole-body vibration exercise
in preventing falls and fractures: a systematic review
and meta-analysis. BMJ Open. ; ;():e.
[]
Whole body vibration reduces fall rate but seems to have no overall eect on
BMD or microarchitecture.
considerations that must be taken into account [] are that
women require a greater intensity of exercise to obtain certain
results on bone mass. Hence, it is always important to per-
form a balanced agonists and antagonists training taking into
account that the speed of execution during the movements
is pertinent in obtaining greater osteogenic stimulation. e
eectiveness of progressive resistance training is conrmed
also in the review of Cheung and Giangregorio [] who
considered this exercise the best one in postmenopausal
women to improve both spine and hip BMD. is would not
be the case of older adults, in which physical activity and
exercise only have minimal eects on BMD, while strength
training should be suggested. However, in clinical practice, in
osteoporotic individuals with high risk of vertebral fracture,
the use of resistance machines should be well thought out,
since this technique oen requires forward bending and
twisting of the trunk to perform the exercise or to adjust
the equipment and to ensure the proper setting. ey can be
utilized only if is used and adjusted with the proper form [].
In summary:
(i) Strength training determines an increase in specic site
bone density, in particular at the neck of the femur and
at the lumbar spine, which is maintained in the short to
medium term. At least 3 sessions a week for a year are
recommended.
(ii) Progressive resistance training for the lower limbs is
themosteectivetypeofexerciseinterventiononbone
mineral density (BMD) for the neck of femur.
3.3. Multicomponent Training. e multicomponent training
consists of a combination of dierent exercises (aerobics,
strengthening, progressive resistance, balancing, and danc-
ing) and it is aimed at increasing or preserving bone mass.
is implies that the same interventions are provided to all
people, dierently from multifactorial training, customized
on the individual characteristics [].
e association of several types of exercise is advised
to the patients aected by osteoporosis with the goal to
counter the reduction of bone mass [–, , –].
e combination of multiple types of exercise would have
a signicant eect on BMD at three sites: femoral neck
and greater trochanter, but the maximum benet would be
achieved at the spine level [].
However, diverse methodological and reporting discrep-
ancies with respect to the proposed mix of exercises, the
characteristics of patients with or without fractures, and the

BioMed Research International 
outcome measures seem relevant in determining the result of
the exercise program. e revision of Gomez-Cabello et al. []
reports substantially two studies [, ] that demonstrate a
signicant improvement in BMD at the level of the lumbar
spine, the neck of the femur, and the greater trochanter,
following programs including muscle strengthening and
impact exercises. e meta-analysis conducted by Nikander
et al. [] reports in postmenopausal women dierent results
about the eects of the exercise. While resistance training
seems to have a good eect on lumbar BMD, the association
of this type of exercise with so-called “low-moderate” impact
exercises such as jogging, walking, and stair climbing is much
more eective in preserving BMD at both lumbar and femoral
level [].
It is interesting to note from this review how the most
challenging high impact exercise programs, such as jumping,
are only eective when they are associated with other low-
impact exercises. Bolan at al. [] report in their systematic
review a positive osteogenic eect of resistance training alone
or associated with high impact weight-bearing activities and
recall that the intensity and increment of the type of load
are two fundamental elements of exercise to avoid adaptation
phenomena and produce an improvement on bone mass
rather than just decreasing the loss.
Giangregorio et al. [] stressed the importance for
individuals with osteoporosis and osteoporotic vertebral
fracture to engage in a multicomponent exercise program
with resistance training combined with balance training. In
particular, it is stated that such individuals should not engage
in aerobic training to the exclusion of resistance or balance
training.
Xu et al. [] quantied the frequency with which a
multicomponent training must be carried out in order to be
eective. ey suggest that each session should be between 
and  min,  or more times per week for at least  months.
Also, in the review of studies analyzed by Marquez et al.
[, ], the combination of non-high-impact weight-bearing
exercises for muscle strengthening, resistance, aerobic, and
balance exercises determined an increase in BMD at the
lumbar spine and femoral neck in elderly subjects. According
to this group, a multicomponent exercise program with
moderate-high impact (marching on the spot, stepping at
/ b/m, on a bench of  cm, and heel drops on a rigid
surface) was able to determine an increase in BMD in the
femoral neck in a population of elderly women who had never
performed exercise programs before.
In summary:
(i) Combined exercise and group exercise programs,
including weight-bearing activities, balance training,
jogging, low-impact loading, high magnitude exercise,
muscle strength, and simulated functional tasks, are
advised to determine BMD increasing or at least
to preserve it. However the combination of exercise
should be tailored on the patient’s clinical features.
No agreement exists on the best protocol in terms of
duration, frequency, and the type of exercises to be
combined. e most relevant eect was detected at the
spine.
3.4. Training with Vibrating Platforms. e vibration of the
entire body is a physiotherapy intervention based on the
use of a high frequency mechanical stimulus generated
by a vibrating platform (Whole Body Vibration or WBV)
that activates the mechanoreceptors of the bone favoring
osteogenesis. e results of the studies included in two
systematic reviews [, ] conclude that the treatment with
aWBVseemstobemoreeectivethansimplewalkingand
of similar ecacy to strength training to improve bone mass
at specic sites (femoral neck and spine) in postmenopausal
women.
To obtain these results, Dionello et al. [] report an
average duration of the training from  to  months with
one or two weekly sessions lasting from  to  minutes,
with vertical or horizontal vibratory energy, at a variable
frequencyfromHztoHzwithamplitudefrom.
mm to  mm. e positive eect of WBV in improving
BMD in dierent sites is supported also by other reviews
[–] and conrmed by Oliveira et al. [] concluding that,
despite WBV presenting potential to act as a coadjutant in the
prevention or treatment of osteoporosis, especially for BMD
of the lumbar spine, the ideal intervention is not yet clear.
Fratini et al. [] also claim that whole body vibration
produces signicant BMD improvements on the hip and
spine when compared to no intervention, while treatment
associated with exercise training resulted in negligible out-
comes when compared to exercise training or to placebo. e
authors specify that the most osteogenic eect is obtained
with side-alternating platforms, due to the similarity of the
stimulus with gait, mechanical oscillations of magnitude
higher than  g, and/or frequency lower than  Hz, while
exercising on the platform does not provide further improve-
ment of BMD. us, it is better if the subject during the treat-
ment assumes static postures, such as full-standing or hack
squat. However, many factors (e.g., amplitude, frequency,
and subject posture) aect the capacity of the vibrations to
propagate to the target site; the adequate level of stimulation
required to produce these eects has not yet been dened.
Conversely, a previous systematic review [ ] showed that
while the use of vibration platforms can improve muscle
strength in the lower limbs of elderly patients, it does
not seem to induce signicant changes in bone mineral
density in women. Similarly, while the analysis performed
by Cheung and Giangregorio [] on  systematic reviews
shows only a modest clinical improvement of BMD at the hip
in postmenopausal women, the review of Jepsen et al. []
reports only a reduction in fall rate, but not in BMD.
In summary:
(i) Training with vibrating platforms is reported to have
eect on enhancing muscle strength, improving bal-
ance, and reducing the risk of fall in osteoporotic
patients, while controversial ndings on improvement
of BMD in dierent sites were reported.
4. Conclusions
Although several exercise recommendations for individuals
with osteoporosis have been proposed, reviews are oen

BioMed Research International
inconclusive, for the methodological variability emerging
from the studies.
However, results from the Cochrane review [] suggest a
relatively small, statistically signicant, but possibly impor-
tant eect of exercise on bone density in postmenopausal
women compared with control groups. e exercise types
most eective on BMD for the neck of femur, which should
be considered in clinical practice, appear to be the progres-
sive resistance strength training for the lower limbs. e
most eective intervention for BMD at the spine has been
suggested to be the multicomponent training exercise pro-
gramme. Weight-bearing aerobic exercise and training with
vibrating platforms may have also an impact in improving
BMD. ese evidences are relevant not only because they
support the possibility to increase BMD in postmenopausal
women, but also because they conrm the possibility to
prevent further bone loss in osteoporotic patients, thus
limiting the risk of fractures. Key considerations for future
research lines emerge from this review: () the need for
studies to evaluate the eects of the longer-term exercise; ()
the need for studies on male patients; () the need for studies
that use evaluation criteria of the outcome that are more
sensitive to changes in the bone structure; () inclusion of
parameters such as diet or drugs as a covariate in the analysis
of the eects of the exercise; () the need to stratify studies on
theeectsofexerciseonBMDbasedonage;and()theneed
to understand the eects of deconditioning.
Conflicts of Interest
e authors declare that they have no conicts of interest.
Acknowledgments
isstudywassupportedbytheErasmusProject“ACTLIFE-
Physical activity the tool to improve the quality of life in
osteoporosis people,” Grant Agreement n.  –  / 
–.
References
[] A. G´omez-Cabello,I.Ara,A.Gonz´alez-Ag¨uero,J.A.Casaj´us,
and G. Vicente-Rodr´ıguez, “Eects of training on bone mass in
older adults: a systematic review,” Sports Medicine,vol.,no.
, pp. –, .
[] D. Bonaiuti, G. Arioli, G. Diana et al., “SIMFER rehabilitation
treatment guidelines in postmenopausal and senile osteoporo-
sis,” European Journal of Physical and Rehabilitation Medicine,
vol. , no. , pp. –, .
[]D.Bonaiuti,B.Shea,R.Iovineetal.,“Exerciseforprevent-
ing and treating osteoporosis in postmenopausal women.,”
Cochrane Database of Systematic Reviews (Online),no.,p.
CD, .
[] M.E.Nelson,W.J.Rejeski,S.N.Blairetal.,“Physicalactivity
and public health in older adults: recommendation from the
American College of Sports Medicine and the American Heart
Association,” Circulation, vol. , no. , pp. –, .
[] W.M.Kohrt,S.A.Bloomeld,K.D.Little, M.E.Nelson,and
V. R. Yingling, “Physical activity and bone health,” Medicine &
Science in Sports & Exercise,vol.,no.,pp.–,.
[] R. Nikander, H. Siev¨anen, A. Heinonen, R. M. Daly, K. Uusi-
Rasi, and P. Kannus, “Targeted exercise against osteoporosis:
a systematic review and meta-analysis for optimising bone
strength throughout life,” BMC Medicine,vol.,article,.
[] T. Mori, C. J. Crandall, and D. A. Ganz, “Cost-eectiveness
of combined oral bisphosphonate therapy and falls prevention
exercise for fracture prevention in the USA,” Osteoporosis
International, vol. , no. , pp. –, .
[] A. Guadalupe-Grau, T. Fuentes, B. Guerra, and J. A. L. Calbet,
“Exercise and bone mass in adults,” Sports Medicine,vol.,no.
, pp. –, .
[] M. R. Hingorjo, S. Zehra, S. Saleem, and M. A. Qureshi, “Serum
Interleukin- and its relationshipwith adiposity Indices before
and aer short-term endurance exercise,” Pakistan Journal of
Medical Sciences,vol.,no.,.
[] B. Morseth, N. Emaus, and L. Jørgensen, “Physical activity and
bone: e importance of the various mechanical stimuli for
bone mineral density. A review,” Norsk epidemiologi,vol.,no.
, pp. –, .
[] C. H. Zehnacker and A. Bemis-Dougherty, “Eect of weighted
exercises on bone mineral density in post menopausal women
a systematic review,” Journal of Geriatric Physical erapy,vol.
, no. , pp. –, .
[] L. Langsetmo, C. L. Hitchcock, E. J. Kingwell et al., “Phys-
ical activity, body mass index and bone mineral density-
associations in a prospective population-based cohort of
women and men: e Canadian Multicentre Osteoporosis
Study (CaMos),” Bone,vol.,no.,pp.–,.
[]M.Rossini,S.Adami,F.Bertoldoetal.,“Guidelinesfor
the diagnosis, prevention and management of osteoporosis,”
Reumatismo,vol.,no.,pp.–,.
[] M. McMahon, “What impact does aquatic therapy have on
bone density in postmenopausal women? If it has a positive
or maintenance eect, what are the programme parameters
that facilitate these outcomes?” Aqualines: e Journal of the
Hydrotherapy Association of Chartered Physiotherapists,vol.,
no.,pp.–,.
[] T. E. Howe, B. Shea, L. J. Dawson et al., “Exercise for pre-
venting and treating osteoporosis in postmenopausal women,”
Cochrane Database of Systematic Reviews,vol.,no.,pp.–
, .
[]I.Polidoulis,J.Beyene,andA.M.Cheung,“eeectof
exercise on pQCT parameters of bone structure and strength
in postmenopausal women - A systematic review and meta-
analysis of randomized controlled trials,” Osteoporosis Interna-
tional,vol.,no.,pp.–,.
[] M. Martyn-St James and S. Carroll, “Meta-analysis of walking
for preservation of bone mineral density in postmenopausal
women,” Bone,vol.,no.,pp.–,.
[] D. Ma, L. Wu, and Z. He, “Eects of walking on the preser-
vation of bone mineral density in perimenopausal and post-
menopausal women: a systematic review and meta-analysis,”
Menopause,vol.,no.,pp.–,.
[] K. A. Bolam, J. G. Z. van Uelen, and D. R. Taae, “e eect
of physical exercise on bone density in middle-aged and older
men: a systematic review,” Osteoporosis International,vol.,no.
, pp. –, .
[] G. A. Kelley, K. S. Kelley, and W. M. Kohrt, “Eects of ground
and joint reaction force exercise on lumbar spine and femoral

BioMed Research International 
neck bone mineral density in postmenopausal women: A meta-
analysis of randomized controlled trials,” BMC Musculoskeletal
Disorders,vol.,.
[] T.H.Chow,B.Y.Lee,A.B.F.Ang,V.Y.K.Cheung,M.M.C.
Ho, and S. Takemura, “e eect of Chinese martial arts Tai
Chi Chuan on prevention of osteoporosis: A systematic review,”
Journal of Orthopaedic Translation,vol.,pp.–,.
[] Z.Sun,H.Chen,M.R.Berger,L.Zhang,H.Guo,andY.Huang,
“Eects of tai chi exercise on bone health in perimenopausal
and postmenopausal women: a systematic review and meta-
analysis,” Osteoporosis International,vol.,no.,pp.–
, .
[] D. de Kam, E. Smulders, V. Weerdesteyn, and B. C. M.
Smits-Engelsman, “Exercise interventions toreduce fall-related
fractures and their risk factors in individuals with low bone
density: a systematic review of randomized controlled trials,”
Osteoporosis International, vol. , no. , pp. –, .
[] M. Martyn-St James and S. Carroll, “A meta-analysis of impact
exercise on postmenopausal bone loss: the case for mixed load-
ing exercise programmes,” British Journal of Sports Medicine,
vol. , no. , pp. –, .
[] A. Varahra, I. B. Rodrigues, J. C. MacDermid, D. Bryant,
and T. Birmingham, “Exercise to improve functional outcomes
in persons with osteoporosis: a systematic review and meta-
analysis,” Osteoporosis International,vol.,no.,pp.–,
.
[] A. J. Serra, “Dierent land-based exercise training programs
to improve bone health in postmenopausal women,” Medical
Science and Technology,vol.,pp.–,.
[] M. M.-S. James and S. Carroll, “Eects of dierent impact
exercise modalities on bone mineral density in premenopausal
women: A meta-analysis,” Journal of Bone and Mineral
Metabolism,vol.,no.,pp.–,.
[] J.Xu,G.Lombardi,W.Jiao,andG.Ban,“EectsofExercise
on Bone Status in Female Subjects, from Young Girls to
Postmenopausal Women: An Overview of Systematic Reviews
and Meta-Analyses,” Sports Medicine,vol.,no.,pp.–
, .
[] L. Slatkovska,S. M.H. Alibhai,J.Beyene,andA.M.Cheung,
“Eect of whole-body vibration on BMD: a systematic review
and meta-an alysis,” Osteoporosis International,vol.,no.,pp.
–, .
[] C.Ma,A.Liu,M.Sun,H.Zhu,andH.Wu,“Eectofwhole-
bodyvibrationonreductionofbonelossandfallprevention
in postmenopausal women: a meta-analysis and systematic
review,” Journal of Orthopaedic Surgery and Research, vol. , no.
, .
[] H. Merriman and K. Jackson, “e eects of whole-body
vibration training in aging adults: A systematic review,” Journal
of Geriatric Physical erapy,vol.,no.,pp.–,.
[] L.C.Oliveira,R.G.Oliveira,andD.A.Pires-Oliveira,“Eects
of whole body vibration on bone mineral density in post-
menopausal women: a systematic review and meta-analysis,”
Osteoporosis International,vol.,no.,pp.–,.
[] A. Fratini, T. Bonci, A. M. Bull, and A. Nazarian, “Whole body
vibration treatments in postmenopausal women can improve
bone mineral density: Results of a stimulus focussed meta-
analysis,” PLoS ONE, vol. , no. , .
[]R.W.K.Lau,L.-R.Liao,F.Yu,T.Teo,R.C.K.Chung,and
M. Y. C. Pang, “ e eects of whole body vibration therapy on
bone mineral density and leg muscle strength in older adults:
A systematic review and meta-analysis,” Clinical Rehabilitation,
vol. , no. , pp. –, .
[] D. B. Jepsen, K. omsen, S. Hansen, N. R. Jørgensen, T.
Masud, and J. Ryg, “Eect of whole-body vibration exercise in
preventing falls and fractures: a systematic review and meta-
analysis,” BMJ Open,vol.,no.,.
[]G.Ban,A.Colombini,G.Lombardi,andA.Lubkowska,
“Metabolic markers in sports medicine,” Advances in Clinical
Chemistry,vol.,pp.–,.
[] A. Andreoli, M. Celi, S. L. Volpe, R. Sorge, and U. Tarantino,
“Long-term eect of exercise on bone mineral density and
body composition in post-menopausal ex-elite athletes: A
retrospective study,” European Journal of Clinical Nutrition,vol.
, no. , pp. –, .
[] J. F. Bean, A. Vora, and W. R. Frontera, “Benets of exercise
for community-dwelling older adults,” Archives of Physical
Medicine and Rehabilitation,vol.,no.,pp.S–S,.
[] P.R.Ebeling,R. M.Daly,D.A.Kerr,andM.G. Kimlin,“An
evidence-informed strategy to prevent osteoporosis in australia
an outline of the building healthy bones throughout life white
paper,” Medical Journal of Australia, vol. , supplement , no.
, pp. -, .
[

]J.Multanen,M.T.Nieminen,A.H¨akkinen et al., “Eects of
high-impact training on bone and articular cartilage: -month
randomized controlled quantitative MRI study,” Journal of Bone
and Mineral Research, vol. , no. , pp. –, .
[] A. M. Cheung and L. Giangregorio, “Mechanical stimuli and
bone health: What is the evidence?” Current Opinion in
Rheumatology,vol.,no.,pp.–,.
[] N. B. Watts, R. A. Adler, and J. P. Bilezikian, “Osteoporosis
in men: an endocrine society clinical practice guideline,” e
Journal of Clinical Endocrinology & Metabolism,vol.,no.,
pp. –, .
[] R. M. Daly, “Exercise and nutritional approaches to prevent frail
bones, falls and fractures: an update,” Climacteric,vol.,no.,
pp. –, .
[] L. Zou, C. Wang, K. Chen et al., “e Eect of Taichi Practice
on Attenuating Bone Mineral Density Loss: A Systematic
Review and Meta-Analysis of Randomized Controlled Trials,”
International Journal of Environmental Research and Public
Health,vol.,no.,p.,.
[] M. S. Lee, M. H. Pittler, B.-C. Shin, and E. Ernst, “Tai Chi for
osteoporosis: a systematic review,” Osteoporosis International,
vol.,no.,pp.–,.
[] H. Blake and H. Hawley, “Eects of tai chi exercise on physical
and psychological health of older people,” Current Aging Sci-
ence,vol.,no.,pp.–,.
[] D. Kerr, A. Morton, I. Dick, and R. Prince, “Exercise eects on
bone mass in postmenopausal women are site-specic and load-
dependent,” Journal of Bone and Mineral Research, vol. , no. ,
pp.–,.
[] M. Sinaki, E. Itoi, H. W. Wahner et al., “Stronger back muscles
reduce the incidence of vertebral fractures: A prospective 
year follow-up of postmenopausal women,” Bone,vol.,no.
,pp.–,.
[] D. A. Bemben and M. G. Bemben, “Dose-response eect of 
weeks of resistance training on bone mineral density in older
adults,” Osteoporosis International, vol. , no. , pp. –,
.
[] V.P.Nicholson,M.R.McKean,G.J.Slater,A.Kerr,andB.J.
Burkett, “Low-Load Very High-Repetition Resistance Training

 BioMed Research International
Attenuates Bone Loss at the Lumbar Spine in Active Post-
menopausal Women,” Calcied Tissue International,vol.,no.
, article no. , pp. –, .
[] L. M. Giangregorio, A. Papaioannou, N. J. MacIntyre et al., “Too
Fit to Fracture: Exercise recommendations for individuals with
osteoporosis or osteoporotic vertebral fracture,” Osteoporosis
International,vol.,no.,pp.–,.
[] S. Hopewell, O. Adedire, B. J. Copsey et al., “Multifactorial
and multiple component interventions for preventing falls in
older people living in the community,” Cochrane Database of
Systematic Reviews,vol.,no.,.
[] B.R.Beck,R.M.Daly,M.A.F.Singh,andD.R.Taae,“Exercise
and Sports Science Australia (ESSA) position statement on
exercise prescription for the prevention and management of
osteoporosis,” Journal of Science and Medicine in Sport,vol.,
no.,pp.–,.
[] A. Harding and B. Beck, “Exercise, osteoporosis, and bone
geometry,” Sports,vol.,no.,p.,.
[] N. M. Schmitt, J. Schmitt, and M. D¨oren, “e role of physical
activity in the prevention of osteoporosis in postmenopausal
women-An update,” Maturitas,vol.,no.,pp.–,.
[] R. Zhao, M. Zhao, andZ. Xu, “e eects of diering resistance
training modes on the preservation of bone mineral density in
postmenopausal women:a meta-analysis,” Osteoporosis Interna-
tional,vol.,no.,pp.–,.
[] W. Kemmler, S. Von Stengel, K. Engelke, L. H¨aberle, and W.
A. Kalender, “Exercise eects on bone mineral density, falls,
coronary r isk factors, and h ealth care costs in older women: e
randomized controlled senior tness and prevention (SEFIP)
study,” JAMA Internal Medicine ,vol.,no.,pp.–,.
[]S.Kukuljan,C.A.Nowson,S.L.Bassetal.,“Eectsofa
multi-component exercise program and calcium-vitamin-D
-fortied milk on bone mineral density in older men: A
randomised controlled trial,” Osteoporosis International,vol.,
no.,pp.–,.
[] E. A. Marques, J. Mota, L. Machado et al., “Multicomponent
training prog ram with weig ht-bearing exercis es elicits favorabl e
bone density, muscle strength, and balance adaptations in older
women,” Calcied Tissue International,vol.,no.,pp.–,
.
[] E. A. Marques, J. Mota, and J. Carvalho, “Exercise eects
on bone mineral density in older adults: a meta-analysis of
randomized controlled trials,” AGE,vol.,no.,pp.–,
.
[]C.F.Dionello,D.S´a-Caputo, H. V. F. S. Pereira et al.,
“Eects of whole body vibration exercises on bone mineral
density of women with postmenopausal osteoporosis without
medications: Novel ndings and literature review,” Journal of
Musculoskeletal and Neuronal Interactions,vol.,no.,pp.–
, .