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Table 2 Description of included studies comparing two or more forms of physical activity

From: Evidence on physical activity and osteoporosis prevention for people aged 65+ years: a systematic review to inform the WHO guidelines on physical activity and sedentary behaviour

Reference
PEDro score
Study design
Allocated/Analysed
Participants (n, age mean (SD), % women, setting, health status) Intervention
Primary exercise type according to ProFANEa
Relevant comparison Outcomes Follow up (mo) Results
dArmamento-Villareal 2020
7/10 [87]
RCT
160/141
Setting: Community; United States
Health status: Obese older adults
A. Aerobic exercise
n= 40 (randomised); 35 (analysed)
Age: 70 (4)
Female: 65%
B. Resistance exercise
n= 40 (randomised); 35 (analysed)
Age: 70 (5)
Female: 63%
C. Combination
n= 40 (randomised); 35 (analysed) 40
Age: 70 (5)
Female: 60%
D. Control
[control group not relevant for this review question]
A. Aerobic exercise
Frequency: 3 times/week
Intensity: ~65% of peak heart rate, gradually increased to 70% to 85%.
Session duration: ~60 min
Delivered by: Exercise physiologists
Duration of the intervention (wks): 26
Primary exercise type: Endurance
B. Resistance exercise: nine upper-body and lower-body exercises using weightlifting machines
Frequency: 3 times/week
Intensity: 1 to 2 sets of 8 to 12 reps at 65% of the 1 RM and increased progressively to 2 to 3 sets at ~85% of the 1-RM.
Session duration: ~60 min
Delivered by: Exercise physiologists
Duration of the intervention (wks): 26
Primary exercise type: Resistance
C. Combination: Aerobic and resistance exercise training sessions
Frequency: 3 times/week
Intensity:
Aerobic exercise: ~65% of their peak heart rate, gradually increased to 70% to 85%.
Resistance exercise: 1 to 2 sets of 8 to 12 reps at 65% of the 1 RM and increased progressively to 2 to 3 sets at ~85% of the 1-RM
Session duration: 75 to 90 min
Delivered by: Exercise physiologists
Duration of the intervention (wks): 26
Primary exercise type: Multiple (endurance plus resistance)
A vs B
A vs C
B vs C
1. Total hip BMD
2. Femoral neck BMD
3. Trochanter BMD
4. Intertrochanter BMD
5. Lumbar spine BMD
6. Whole body BMD
7. One-third radius BMD
6 Change score (mean ± SD)
1. Total hip BMD
A. Aerobic: -0.027 ± 0.004¥
B. Resistance: -0.006 ± 0.004
C. Combination: -0.012 ± 0.004
2. Femoral neck BMD
A. Aerobic: -0.020 ± 0.003¥
B. Resistance: -0.003 ± 0.003
C. Combination: -0.008 ± 0.003
3. Trochanter BMD
A. Aerobic: -0.035 ± 0.007¥
B. Resistance: -0.006 ± 0.007
C. Combination: -0.016 ± 0.007
4. Intertrochanter
A. Aerobic: -0.035 ± 0.007¥
B. Resistance: -0.006 ± 0.007
C. Combination: -0.016 ± 0.007
5. Lumbar spine BMD
A. Aerobic: 0.002 ± 0.006
B. Resistance: 0.008 ± 0.006
C. Combination: 0.008 ± 0.005
6. Whole body BMD
A. Aerobic: -0.003 ± 0.005
B. Resistance: 0.005 ± 0.005
C. Combination: 0.002 ± 0.005
7. One-third radius BMD
A. Aerobic: -0.001 ± 0.001
B. Resistance: -0.0020 ± 0.001
C. Combination: -0.001 ± 0.002
Ashe 2013 [77] RCT
155/135
Setting: Community; Canada
Health status: Healthy
A. Balance and tone (BT)
n= 49 (randomised); 42 (analysed)
Age: 69.9 (3.1)
B. Once a week resistance training (RT1)
n= 54 (randomised); 47 (analysed)
Age: 69.4 (3.0)
C. Twice a week resistance training (RT2)
n= 52 (randomised); 46 (analysed)
Age: 69.2 (3.0)
Female: 100%
A. BT: Group-based supervised intervention consisting of balance and tone training with the use of body weight.
Frequency: 2 times/week
Intensity: NR
Session duration: NR
Primary exercise type: Balance and functional
B. RT1: Low-frequency, group-based supervised resistance training for upper and lower body with the use of resistance equipment.
Frequency: 1 time/week
Intensity: 2 sets of 8 RM
Session duration: NR
Primary exercise type: Resistance
C. RT2: High-frequency, group-based supervised resistance training for upper and lower body with the use of resistance equipment.
Frequency: 2 times/week
Intensity: 2 sets of 8 RM
Session duration: NR
Primary exercise type: Resistance
Duration of the interventions (wks): 52
Delivered by: Certified fitness instructors
A vs B
A vs C
1. Tibial volumetric cortical density (CovBMD)
2. Total area (ToA) midtibia
3. Tibial bone strength
12 Adjusted mean difference (95% CI)
1. Tibial CovBMD
B – A
0.76 (-5.32 to 6.85)
C – A
-2.09 (-8.22 to 4.05)
2. Total area (ToA) midtibia
B – A
0.10 (-2.72 to 2.92)
C – A
-0.49 (-3.34 to 2.35)
3. Tibial bone strength
B – A
23.32 (-248.86 to 295.5)
C – A
-91.56 (-366.5 to 183.28)
bBlumenthal 1991
6/10 [44]
RCT
101/85
Setting: NR
Health status: Healthy
A. Aerobic Training
n= 33 (randomised)
B. Yoga and flexibility
n= 34 (randomised)
C. Control: Not relevant for this comparison.
Age: (whole sample) 67 (min-max: 60-83)
Female: NR
A. Aerobic training: Endurance training involving bicycle ergometry, brisk walking/jogging, and arm ergometry.
Frequency: 3 times/week
Intensity: 70% heart rate reserve
Session duration: 60 min
Delivered by: NR
Duration of intervention (wks): 16
Primary exercise type: Endurance training
B. Yoga: Supervised non-aerobic yoga programme.
Frequency: at least 2 times/week
Intensity: NR
Session duration: 60 min
Delivered by: NR
Duration of intervention (wks): 16
Primary exercise type: Balance and function
A vs B 1. Distal radius BMD 14 1. Distal radius BMD: no between-group differences.
Quantitative estimates not reported for between-group comparisons.
dChan 2018
7 /10 [92]
RCT
110/54
Setting: Community; Taiwan
Health Status: Increased risk for falls and fracture
A. Integrated care (IC)
n= 55 (randomised); 31 (analysed)
Age: 74.6 (7.4)
Female: 69%
B. Lower extremity exercise (LEE)
n= 55 (randomised); 23 (analysed)
Age: 73.08 (6.57)
Female: 69%
Both groups: 1-hour educational course related to osteoporosis, sarcopenia and 1-hour exercise intervention including warm up, brisk walking and gentle stretching. Subjects encouraged to conduct exercise at least 3 times per week.
A. Integrated care (IC): Basic intervention, 15-minute warm-up exercise, 30-minute resistance exercise and 10-minute balance exercise
Frequency: 1 time/week
Intensity: Resistance training using rubber band and bottled water (0.6–1 L) as weight for upper and lower limbs.
Delivered by: NR
Session duration: 55 min
Duration of the intervention (wks): 12
Primary exercise type: Multiple (resistance plus balance and functional)
B. Lower extremity exercise (LEE): Basic intervention and machine based lower extremity resistance exercise
Frequency: 2 times/week
Intensity: 60-80% of 1 RM
Delivered by: NR
Session duration: 30 min
Duration of the intervention (wks): 12
Primary exercise type: Resistance
A vs B 1. Lumbar spine BMD
2. Hip BMD
3 Change score (% change)
1. Lumbar spine BMD
A. IC: 1.26%
B. LEE: 2.08%
2. Hip BMD
A. IC: -1.73%
B. LEE: -0.88%
bHelge 2014
5/10 [50]
RCT
27/23
Setting: Community; Denmark
Health status: Healthy
A. Football group
n= 9 (randomised); 9 (analysed)
Age: 68.0 (4.0)
B. Resistance training
n= 9 (randomised); 8 (analysed)
Age: 69.1 (3.1)
C. Control: Not relevant for this comparison.
Female: 0%
A. Football group: Supervised progressive football training
Frequency: 1.7 (0.3) times/week (range: 1.2-2.2)
Intensity: 82% of maximum heart rate (range 64 to 90%)
Session duration: 45 to 60 min
Delivered by: NR
Duration of the intervention (wks): 52
Primary exercise type: Balance and function (football)
B. Resistance training: Progressive resistance training for core and upper and lower body
Frequency: 1.9 (0.2) times/week (range: 1.4-2.2)
Intensity: Started from 3 sets of 16-20 RM to 4 sets of 8 RM
Session duration: 45 to 60 min
Delivered by: NR
Duration of the intervention (wks): 52
Primary exercise type: Resistance (seated)
A vs B 1. Whole body BMD
2. Right femoral neck BMD
3. Left femoral neck BMD
4. Right femoral shaft BMD
5. Left femoral shaft BMD
6. Total right proximal femur
7. Total left proximal femur
12 Final score (mean ± SD)
1. Whole body BMD
A. Football: 1.211 ± 0.036
B. Resistance: 1.225 ± 0.024
2. Right femoral neck BMD
A. Football: 0.921 ± 0.034
B. Resistance: 1.000 ± 0.042
3. Left femoral neck BMD
A. Football: 0.939 ± 0.034
B. Resistance: 1.006 ± 0.036
4. Right femoral shaft BMD
A. Football: 1.156 ± 0.042
B. Resistance: 1.229 ± 0.056
5. Left femoral shaft BMD
A. Football: 1.143 ± 0.043
B. Resistance: 1.229 ± 0.057
6. Total right proximal femur
A. Football: 0.982 ± 0.031
B. Resistance: 1.066 ± 0.048
7. Total left proximal femur
A. Football: 0.989 ± 0.031
B. Resistance: 1.069 ± 0.048
bKarinkanta 2007c
7/10 [53]
RCT
149/144
Setting: Community; Finland
Health Status: Healthy and excluded participants with osteoporosis
A. Balance-jumping training
n= 37 (randomised); 35 (analysed)
Age: 72.9 (2.3)
B. Resistance training
n= 37 (randomised); 37 (analysed)
Age: 72.7 (2.5)
C. Combined Balance-jumping and resistance training
n= 38 (randomised); 36 (analysed)
Age: 72.9 (2.2)
D. Control: Not relevant for this comparison
Female: 100%
A. Balance-jumping training: Balance training including static and dynamic balance exercise, agility training, impact exercises and changes of direction exercise.
Intensity: NR
Primary exercise type: Balance and function including bone loading (jumps)
B. Resistance training: Tailored progressive resistance training programme for large muscle groups.
Intensity: Initially 2 sets of 10-15 reps at intensity 50-60% of 1RM, progressed to 3 sets of 8-10 reps at 75-80% of 1RM. Rate of perceived exertion: above 18 out of 20
Primary exercise type: Resistance
C. Combined Balance-jumping and resistance training: A combination of A & B on alternate weeks.
Primary exercise type: Multiple (balance and function plus resistance)
For all exercise groups:
Frequency: 3 times/week
Session duration: 50 min
Delivered by: Exercise leaders
Duration of the intervention (wks): 52
A vs B
A vs C
B vs C
1. Femoral neck BMC
2. Distal tibia trabecular density (mg/cm3)
12 Final score (mean ± SD)
1. Femoral neck BMC
A. Balance: 2.73 ± 0.40
B. Resistance: 2.71 ± 0.33
C. Combined: 2.65 ± 0.29
2. Distal tibia trabecular density (mg/cm3)
A. Balance: 224 ± 34
B. Resistance: 219 ± 26
C. Combined: 215 ± 39
ebKarinkanta 2009c
5/10 [98]
RCT
149/126
Setting: Community; Finland
Health Status: healthy and excluded participants with osteoporosis
A. Balance jumping training group
n= 37 (randomised); 33 (analysed)
Age: 72.9 (2.3)
B. Resistance training group
n= 37 (randomised); 34 (analysed)
Age: 72.7 (2.5)
C. Combined resistance and balance jumping training group
n= 38 (randomised); 32 (analysed)
Age: 72.9 (2.2)
D. Non-training control group
n= 27 (randomised); 27(analysed)
Age: 72.0 (2.1)
Female: 100%
A. Balance-jumping training: Balance training including static and dynamic balance exercise, agility training, impact exercises and changes of direction exercise.
Intensity: NR
Primary exercise type: Balance and function including bone loading (jumps)
B. Resistance training: Tailored progressive resistance training programme for large muscle groups.
Intensity: Initially 2 sets of 10-15 reps at intensity 50-60% of 1RM, progressed to 3 sets of 8-10 reps at 75-80% of 1RM. Rate of perceived exertion: above 18 out of 20
Primary exercise type: Resistance
C. Combined Balance-jumping and resistance training: A combination of A & B on alternate weeks.
Primary exercise type: Multiple (balance and function plus resistance)
For all exercise groups:
Frequency: 3 times/week
Session duration: 50 min
Delivered by: Exercise leaders
Duration of the intervention (wks): 52
A vs D
B vs D
C vs D
1. Femoral neck section moduls (Z) (mm3)
2. Tibia midshaft desnity-weighted polar section modulus (BSI) (mm3)
12 Mean change score (95% CI) reported on a graph
Quantitative data was only reported between-group differences with control group as a reference. Additional results were reported in a graph.
bKohrt 1997
3/10 [55]
Quasi-randomised trial
39/30
Setting: NR; United States
Health Status: Healthy
A. Ground reaction forces training
n= 14 (randomised); 12 (analysed)
Age: 66.0 (1.0)
B. Joint reaction forces training
n= 13 (randomised); 9 (analysed)
Age: 65.0 (1.0)
C. Control: Not relevant for this comparison
Female: 100%
A. Ground reaction forces training: Individualised exercise training focusing on activities that involved ground-reaction forces, such as walking, jogging and/or stair climbing.
Frequency: 3 to 5 times/week
Intensity: 60-70% to 80-85% maximum heart rate
Session duration: 30 to 45 min
Delivered by: NR
Duration of the intervention (wks): 36
Primary exercise type: Multiple (balance and function plus endurance plus flexibility)
B. Joint reaction forces training: Individualised exercise training including activities that involved joint-reaction forces, such as weightlifting and rowing.
Frequency: 3 to 5 sessions/week
Intensity: Weightlifting: 2-3 sets of 8-12 reps; Rowing: 60-70% to 80-85% of maximum heart rate
Session duration: NR for the total session duration; however; rowing took 15 to 20 min
Delivered by: NR
Duration of the intervention (wks): 36
Primary exercise type: Multiple (resistance plus endurance plus flexibility)
A vs B 1. Whole body BMD
2. Lumbar spine (L2-L4) BMD
3. Femoral neck BMD
4. Trochanter BMD
5. Ward’s BMD
6. Ultra distal wrist BMD
7. One-third distal wrist BMD
12 Quantitative estimates not reported (chance scores are provided in a graph)
1. Whole body BMD
Positive effect towards “A”
2. Lumbar spine (L2-L4) BMD
Positive effect towards “A”
3. Femoral neck BMD
Positive effect towards “A”
4. Trochanter BMD
Positive effect towards “A”
5. Ward’s BMD
Positive effect towards “A”
6. Ultra distal wrist BMD
Positive effect towards “B”
7. One-third distal wrist BMD
Positive effect towards “B”
bRikli 1990
1/10 [67]
Quasi-randomised trial
37/31
Setting: Local retirement community; United States
Health Status: Healthy
A. General exercise
n= 13 (randomised); 10 (analysed)
Age: 72.2 (5.57)
B. General exercise + weight
n= 13 (randomised); 10 (analysed)
Age: 71.6 (5.66)
C. Control: Not relevant for this comparison
Female: 100%
A. General exercise: Group-based aerobic exercise training for large muscle groups.
Frequency: 3 times/week
Intensity: 60-70% maximum heart rate
Session duration: 30 to 50 min
Delivered by: NR
Duration of the intervention (wks): 40
Primary exercise type: Endurance
B. General exercise + weight: Group-based aerobic exercise training plus upper body progressive resistance training. The resistance training was performed without supervision.
Frequency: 3 times/week
Intensity: 60-70% maximum heart rate for aerobic activities
Session duration: 50 to 70 min
Delivered by: Assistants
Duration of the intervention (wks): 40
Primary exercise type: Multiple (resistance plus endurance)
A vs B 1. Distal radius BMC/BW
2. Distal radius BMC
10 Change score (%)
1. Distal radius BMC/BW
A. General exercise: 0.921
B. General exercise and weight: 1.734
2. Distal radius BMC
A. General exercise: 1.023
B. General exercise and weight: 1.743
Statistical test not performed between the two intervention groups
Shen 2007
6/10 [69]
RCT
28/24
Setting: Local senior living campus; United States
Health Status: Healthy
A. Tai chi
n= 14 (randomised); 12 (analysed)
Age: 78.8 (1.3)
Female: 79%
B. Resistance exercise
n= 14 (randomised); 12 (analysed)
Age: 79.4 (2.2)
Female: 71%
A. Tai chi: 24-form simplified Yang style Tai Chi.
Frequency: 3 times/week
Intensity: NR
Session duration: 40 min
Delivered by: Experienced Tai Chi instructor
Duration of the intervention (wks): 24
Primary exercise type: 3D (Tai Chi)
B. Resistance exercise: Low-intensity resistance training for lower and upper extremities using equipment and dumbbells.
Frequency: 3 times/week
Intensity: 1 set of 10-12 reps at 50% of the 1RM
Session duration: 40 min
Delivered by: Certified fitness trainer
Duration of the intervention (wks): 24
Primary exercise type: Resistance
A vs B 1. Bone specific alkaline phosphatase (BAP), concentration change (%)
2. Pyridinoline (PYD), concentration change (%)
3. Parathyroid hormone (PTH), concentration change (%)
6 1. BAP
No between-group difference (positive effect towards Tai chi)
2. PYD
No between-group difference (positive effect towards Resistance training)
3. PTHP
No between-group difference (positive effect towards Resistance training)
Quantitative results not provided. Results reported in a graph
bWoo 2007
6/10 [75]
RCT
180/176
Setting: Community; Hong Kong
Heath status: Healthy
A. Tai Chi
n=60 (randomised); 58 (randomised)
Age: 68.2 years
B. Resistance training
n= 60 (randomised); 59 (randomised)
Age: 68.7 years
C. No Treatment: Not relevant for this comparison
Female: 50%
A. Tai Chi: 24-forms of Tai Chi using Yang style
Frequency: 3 times/week
Intensity: NR
Session duration: NR
Delivered by: NR
Duration of the intervention (wks): 52
Primary exercise type: 3D (Tai Chi)
B. Resistance training: Resistance training with the use of medium strength TheraBand
Frequency: 3 times/week
Intensity: 30 times with medium strength TheraBand
Session duration: NR
Delivered by: NR
Duration of the intervention (wks): 52
Primary exercise type: Resistance
A vs B 1. Total hip BMD
2. Total spine BMD
12 Change score (mean % change ± SE)
Men
1. Total hip BMD
A. Tai Chi: -0.48 ± 0.37
B. Resistance: -1.20 ± 0.38
2. Total spine BMD
A. Tai Chi: 1.35 ± 0.40
B. Resistance: 1.27 ± 0.42
Women
1. Total hip BMD
A. Tai Chi: 0.07 ± 0.64
B. Resistance: 0.09 ± 0.62
2. Total spine BMD
A. Tai Chi: 0.10 ± 0.50
B. Resistance: 1.98 ± 0.48
  1. BMC bone mineral content (g), BMD bone mineral density (g/cm2), BMI body mass index (kg/m2), BW bone width, NR not reported, RCT randomised controlled trial. When data was available for more than one time-point, we extracted the post-intervention and follow-up data. Mean estimates were extracted in the following hierarchical order: mean difference, change score and final score
  2. aExercise is a physical activity that is planned, structured and repetitive and aims to improve or maintain physical fitness. There is a wide range of possible types of exercise, and exercise programmes often include one or more types of exercise. We categorised exercise based on a modification of the Prevention of Falls Network Europe (ProFaNE) taxonomy that classifies exercise type as: i) gait, balance, and functional training; ii) strength/ resistance (including power); iii) flexibility; iv) three- dimensional (3D) exercise (e.g., Tai Chi, Qigong, dance); v) general physical activity; vi) endurance; and vii) other kind of exercises. The taxonomy allows for more than one type of exercise to be delivered within a programme. We also considered whether the exercise explicitly included bone loading eg hopping or heel drops
  3. bIndicates studies also included in the exercise vs control comparison (Table 1), but only the results for exercise comparisons are presented here
  4. cindicates articles reporting results from the same study
  5. dindicates studies that were found in the expanded search for individual studies conducted in March 2020 in PubMed
  6. eindicates studies that were found in the updated search for systematic reviews conducted in July 2020 in PubMed, Embase, CINAHL, SPORTDiscus
  7. ¥ indicates statistically significant between-group differences at p < 0.05.