Does adding exercise or physical activity to pharmacological osteoporosis therapy in patients with increased fracture risk improve bone mineral density and lower fracture risk? A systematic review and meta-analysis.

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• It is estimated that 30% of women and 20% of men over the age of 50 years worldwide will experience osteopenic fractures during their lifetime.
• While the evidence certainty is low, the mean effect sizes typically favoured additional exercise to pharmacological treatments for osteopenia and osteoporosis.
• This systematic review and meta-analysis suggest favourable changes in BMD and BTM after 12 months in patients with osteopenia and osteoporosis.

Introduction

A systematic review and meta-analysis were conducted to investigate whether exercise (EX) plus pharmacological therapy (PT) had an additive effect over PT alone on bone mineral density (BMD), bone turnover markers (BTM), fracture healing, and fractures in patients with osteopenia or osteoporosis.

Method

Five randomised controlled trials (RCT) were included in the review of 530 male and female participants with a mean age of 46 to 81 years. The participant groups consisted of chronic spinal cord injuries with low bone mass, postmenopausal osteoporotic women, postmenopausal breast cancer survivors, women with osteoporosis or osteopenia, and patients with type 2 diabetic osteoporosis.

Results

The meta-analysis reported the following when evaluating the effect of EX + PT compared to PT alone:

• Hip aBMD increased at 12 months (SMD [95%CI]: 0.18 [− 1.71; 2.06]; (p=0.72); and at the end of the intervention (0.55 [− 7.08; 8.18]; (p = 0.53); I2 = 79%.
• Femoral neck aBMD decreased at 12 months (− 0.03 [− 1.80; 1.75]; (p = 0.95;) and increased at the end of the intervention (0.13; [− 7.34; 7.60]; (p = 0.86) ); I2 = 80%.
• Tibia BMD increased at 12 months (0.25 [− 4.85; 5.34]; (p = 0.65); I2 = 57%.
• Lumbar spine aBMD increased at 12 months (0.20 [− 1.15; 1.55]; (p = 0.67) and at the end of the intervention (0.85 [− 5.02; 6.73]; (p = 0.32); I2 = 90%.
• No significant results were found for the healing of fractures.

Conclusion

This systematic review and meta-analysis found changes in BMD and BTM that favoured exercise in addition to pharmacological therapy in osteopenia and osteoporosis patients.

• Clinical practice guidelines worldwide recommend exercise in combination with pharmacological therapy as part of the treatment for osteopenia and osteoporosis.
• Although the certainty of the evidence is low, and the heterogeneity is high, it seems logical to prescribe both exercise and pharmacological therapy to patients with osteopenia and osteoporosis.

• This review included five RCTs, therefore more high-quality targeted RCTs are required to examine the additive effect of exercise with pharmacological therapy.
• Additionally, primary RCTs are needed to evaluate the frequency and duration of different forms of exercise and physical activity to the added effect of pharmacological therapy.
• Besides exercise and pharmacological therapies, BTM also depends on various other factors such as nutrition and genetic predisposition. These factors also require further investigation in the future.