PubMed Central, : RMMJ Rambam Maimonides Medical Journal Rambam Health Care Campus 2017 July; 8(3): e0032. ISSN: 2076-9172Published online 2017 July 1. doi: 10.5041/RMMJ.10308.

Author (Year) Ref. #	Study Design	Population	Instruments and Outcomes	Results and Author’s Conclusions
Howe et al. (2011)¹⁰	Systematic review 43 RCTs; 4,320 participants met inclusion criteria	Healthy postmenopausal women (including those with previous fractures) aged 45–70 years	Number of incident fractures: vertebral and non-vertebral (hip and wrist) BMD, BMC, or calcium bone index immediately post-intervention and at follow-up BMD measured by single-photon absorptiometry, dual-photon absorptiometry, quantitative CT or DXA at baseline, immediately post-intervention, and at follow-up Serious adverse events including death Minor adverse events including falls	Most effective exercise intervention on BMD for neck or femur appears to be non-weight-bearing high-force exercise Most effective intervention for BMD at the spine was combination exercise compared with control groups For postmenopausal women: ○ Exercise slightly improves BMD ○ Exercise slightly reduces chances of fracture
Ebrahim et al. (1997)¹¹	RCT	Caucasian postmenopausal women 165 women with history of upper limb fracture in past 2 years; selected from local accident reports and emergency departments	Spinal fractures BMD at the femoral neck Lumbar spine BMD	No significant differences in clinical or spinal X-ray fracture risk or self-rated health status Promotion of brisk walking exercise by nursing staff may have a small, but clinically important, impact on BMD, but is associated with increased risk of falls
Preisinger et al. (1996)¹²	RCT	92 sedentary postmenopausal women aged 45–75 years with low back pain for at least 1 year and sedentary lifestyle for past 10 years	BMD and bone width calculated through the mean of four distal (distal forearm) and six proximal (mid-forearm) scans distal to a radio-ulnar distance of 8 mm Occurrence of bone fractures recorded by standardized questionnaire	Long-term regular exercise program designed to improve postural stability, mobility, motor control, coordination, and mechanical efficiency is effective in preventing OP and may delay bone loss
Sinaki et al. (2002)¹³	10-year follow-up study to a RCT	Postmenopausal women, aged 58–75 years	BMD, spine radiographs, back extensor strength, biochemical marker values, and level of physical activity obtained for all subjects at baseline, 2 years, and 10 years	Significant difference in BMD at 10-year follow-up Long-term effect of strong back muscles in reducing vertebral fractures in estrogen-deficient women
Nelson et al. (1994)¹⁴	RCT	40 sedentary and estrogen-deplete postmenopausal white women, aged 50–70 years	Femoral neck and lumbar spine BMD DXA for bone status, one repetition maximum for muscle strength, 24-hour urinary creatinine for muscle mass, and backward tandem walk for dynamic balance	Femoral neck BMD, lumbar spine BMD, total body BMC, muscle mass, muscle strength, and dynamic balance: Increased in strength-trained women; Decreased in controls High-intensity strength training exercises are an effective means to preserve BMD while improving muscle mass, strength, and balance in postmenopausal women Maintaining spinal BMD and improving strength and balance can significantly reduce the risk of falls and fractures
Uusi-Rasi et al. (1999)¹⁵	Cross-sectional study	117 healthy, female postmenopausal recreational gymnasts (mean age 62.1 [SD 4.7] years) and 116 sedentary controls (mean age 61.5 [4.6] years)	BMC of the distal radius, femoral neck and trochanter, measured with DXA BMC of the mid-shaft and distal tibia and trabecular density of the distal tibia, measured with peripheral quantitative CT	Recreational gymnastics was significantly associated with higher BMC and trabecular density at the tibia only Recreational gymnastics and folk dancing improve muscular strength and increase bone mass and bone size in the tibia Osteoporotic fractures are uncommon in the tibia; long-term recreational gymnastics is especially beneficial for muscular performance and body balance, which may translate to decreased propensity to fractures among elderly people
Rikkonen et al. (2010)¹⁶	15-year follow-up to population-based OP risk factor and prevention (OSTPRE) study	8,560 postmenopausal women; mean age 52.2 years at baseline	Areas of BMD at the proximal femur and lumbar spine, followed at 5-year intervals with DXA Data concerning physical activity, fractures, and falls, registered at 5-year intervals with postal enquiries	Physical activity is associated with a moderate rise in wrist fracture risk but does not increase risk of other fractures, and might significantly decrease proximal femur bone loss among postmenopausal women
Kemmler et al. (2015)¹⁷	Non-RCT 16-year follow-up analysis	105 postmenopausal osteopenic women	Clinical overall low-trauma fractures determined by questionnaires, structured interviews, and BMD at the lumbar spine and femoral neck, assessed by DXA	Clear evidence of high anti-fracture efficiency of multipurpose exercise programs
Kemmler et al. (2013)¹⁸	Systematic review and meta-analysis	Subjects 45 years and older	“Overall fractures” (i.e. cumulated number of fractures) and vertebral fractures assessed by radiographs of spine	Evidence that exercise reduces overall and, to a lesser degree, vertebral fractures in the elderly
Moayyeri (2008)³	Meta-analysis of 13 prospective cohort studies	Many different-aged cohorts, all participants at least 40, male and female	Meta-analysis of 13 prospective cohort studies with hip fracture end-point presented	Moderate-to-vigorous physical activity is associated with reduced risk of hip fracture Risk of falling generally reduced among physically active people; potential increased risk in the most active/inactive people Positive effects of physical activity on BMD are of questionable magnitude for reducing fracture risk
Lock et al. (2006)¹⁹	Systematic review and meta-analysis of RCTs	Caucasian postmenopausal women	Spinal fractures (all trials), wrist fractures, and fractures at any site (one trial) X-rays of the thoracic and lumbar spine and one of the lateral spine (two trials)	In all trials, exercise associated with a non-significantly lower risk of spinal fractures
Yoshimura (2003)²⁰	Literature review		Literature search over past 13 years to assess the relationship between exercise and the risk for low bone mass and OP-related fractures	One RCT showed back-stretching exercise reduced the risk for vertebral fractures High-impact and/or weight-bearing exercise might increase bone density in the elderly
Gregg et al. (2000)²¹	Review and synthesis of published literature		MEDLINE literature search including RCTs, case-control, and prospective cohort studies on the effects of physical activity on the incidence of falls and fracture risk	Higher levels of leisure time physical activity prevent hip fractures, and certain exercise programs may reduce risk of falls