Consensus statement

Strong, steady and straight: UK consensus statement

Br J Sports Med: first published as 10.1136/bjsports-2021-104634 on 16 May 2022. Downloaded from http://bjsm.bmj.com/ on May 22, 2022 by guest. Protected by copyright.
on physical activity and exercise for osteoporosis
Katherine Brooke-­Wavell  ‍ ‍,1 Dawn A Skelton  ‍ ‍,2 Karen L Barker  ‍ ‍,3
Emma M Clark  ‍ ‍,4,5 Sarah De Biase,6,7 Susanne Arnold  ‍ ‍,7,8 Zoe Paskins  ‍ ‍,9
Katie R Robinson,10 Rachel M Lewis,5 Jonathan H Tobias  ‍ ‍,4,5 Kate A Ward  ‍ ‍,11
Julie Whitney  ‍ ‍,12 Sarah Leyland13

► Additional supplemental ABSTRACT Current approaches to reduce fracture incidence

material is published online Exercise and physical activity can improve bone strength include identifying people with significant fracture
only. To view, please visit the
journal online (http://d​ x.​doi.​ and the risk of falls, which may offer benefits in the risk and prescribing pharmaceutical treatment,
org/1​ 0.​1136/​bjsports-​2021-​ prevention and management of osteoporosis. However, using education and support to promote adher-
104634). uncertainty about the types of exercise that are safe and ence to medication, and developing falls prevention
effective instigates lack of confidence in people with strategies especially for those who are older and
For numbered affiliations see
end of article.
osteoporosis and health professionals. Existing guidelines frailer.8 9 Additional preventive strategies include
leave some questions unresolved. This consensus healthy eating with adequate calcium and vitamin
Correspondence to statement aimed to determine the physical activity and D, not smoking or consuming excessive alcohol and
Dr Katherine Brooke-­Wavell, exercise needed to optimise bone strength, reduce fall being physically active in adolescence and young
National Centre for Sport and and fracture risk, improve posture and manage vertebral adulthood to maximise peak bone mass.8 9
Exercise Medicine, School of fracture symptoms, while minimising potential risks in Epidemiological and intervention studies provide
Sport, Exercise and Health
people with osteoporosis. The scope of this statement evidence of a strong relationship between phys-
Sciences, Loughborough
University, Loughborough LE11 was developed following stakeholder consultation. ical activity, exercise and bone health, with regular
3TU, UK; Meta-­analyses were reviewed and where evidence was exercisers having a lower incidence of fracture.10
k​ .​s.f​ .​brooke-​wavell@​lboro.​ac.​uk lacking, individual studies or expert opinion were used Exercise can both increase bone mineral density
to develop recommendations. A multidisciplinary expert (BMD) and reduce falls risk. However, there is still
KB-­W and DAS are joint first group reviewed evidence to make recommendations,
authors. uncertainty about whether increasing volume and
by consensus when evidence was not available. Key intensity of exercise, especially in later life or when
Accepted 28 March 2022 recommendations are that people with osteoporosis bone strength is compromised, will improve bone
should undertake (1) resistance and impact exercise strength, and importantly, what type or intensity of
to maximise bone strength; (2) activities to improve exercise intervention is most beneficial.
strength and balance to reduce falls; (3) spinal extension Osteoporotic fractures may be precipitated by
exercise to improve posture and potentially reduce risk a fall or with loading during activity. People with
of falls and vertebral fractures. For safety, we recommend osteoporosis and health professionals are thus
avoiding postures involving a high degree of spinal concerned that physical activity could increase
flexion during exercise or daily life. People with vertebral
fracture risk, although evidence to support these
fracture or multiple low trauma fractures should usually
concerns is limited. Uncertainty persists about
exercise only up to an impact equivalent to brisk walking.
what is appropriate and safe in people with, or at
Those at risk of falls should start with targeted strength
risk of, osteoporosis, and may be accompanied by
and balance training. Vertebral fracture symptoms may
concerns about liability. As a result, people signifi-
benefit from exercise to reduce pain, improve mobility
cantly reduce activity levels, limiting both function
and quality of life, ideally with specialist advice to
and enjoyment.11 This may have important adverse
encourage return to normal activities. Everyone with
implications for their bone health, falls and future
osteoporosis may benefit from guidance on adapting
fracture risk.
postures and movements. There is little evidence that
physical activity is associated with significant harm, and For the vast majority of adults and older adults,
the benefits, in general, outweigh the risks. taking part in activities that promote muscle and
bone strength is safe and will help to maintain or
improve function, irrespective of age or health.12–14
Providing authoritative and effective guidance may
© Author(s) (or their BACKGROUND prompt an increase in physical activity and exercise.
employer(s)) 2022. Re-­use It is estimated that 137  million women and This will have wider beneficial effects on physical,
permitted under CC BY-­NC. No 21 million men have high osteoporotic fracture risk social and psychological health14 15 alongside phys-
commercial re-­use. See rights
globally, with this prevalence expected to double in ical literacy, including physical competence, knowl-
and permissions. Published
by BMJ. the next 40 years.1 Fractures of the hip and spine edge and understanding, to engage in physical
can lead to loss of independence, disability and activities for life.16
To cite: Brooke-­Wavell K,
reduced life expectancy.2 Vertebral fractures are There is no UK guidance on exercise and oste-
Skelton DA, Barker KL, et al.
Br J Sports Med Epub ahead associated with long-­term pain and other physical oporosis. Although there is international guidance
of print: [please include Day and psychological symptoms,3–5 whereas hip frac- on safe and effective exercise and physical activity
Month Year]. doi:10.1136/ tures are associated with increased morbidity and for bone health, from the USA,17 Australia13 and
bjsports-2021-104634 mortality.6 7 Canada,18 some key questions remain unanswered.

Brooke-­Wavell K, et al. Br J Sports Med 2022;0:1–10. doi:10.1136/bjsports-2021-104634    1

 Consensus statement
These include the appropriate intensity of exercise interventions provided ‘free text’ responses about what they felt were the key

Br J Sports Med: first published as 10.1136/bjsports-2021-104634 on 16 May 2022. Downloaded from http://bjsm.bmj.com/ on May 22, 2022 by guest. Protected by copyright.
for those with diagnosed osteoporosis, whether there are real issues and uncertainties about exercise and osteoporosis (online
harms from any particular types of exercises or activities, and supplemental appendix II). These were entered into a spread-
whether or how to modify physical activity for specific ‘fracture sheet and structured according to categories and themes.
risk’ groups.
Refining scope through exercise expert consultation
OBJECTIVE A UK Expert Exercise Steering Group (EESG) consisting of 12
The objective of this consensus statement is to provide guidance clinical and academic experts developed the consensus statement
on the role of exercise and physical activity in the prevention (online supplemental appendix III). This group included four
and management of osteoporosis. physiotherapists, three rheumatologists, three academics and an
The specific aims are to: osteoporosis specialist nurse; all but one of whom were female.
► Clarify the role of physical activity and exercise for opti- Nine were clinically active with mean (SD) 18 (13) years of clin-
mising bone strength and reducing falls and fracture risk. ical experience, and ten were research active with 18 (11) years
► Clarify the role of physical activity and exercise in managing research experience. A wider UK Exercise Expert Working group
the pain and symptoms of vertebral fracture. (EEWG) consisted of a further 16 experts: nine physiotherapists,
► Review any safety issues of exercise for those with osteopo- two patient representatives, two patient advocates, an exercise
rosis, to address fears of causing fractures (particularly in instructor, nurse and physiologist; 13 female and 3 male (online
the spine) while engaging in exercise or day-­to-­day physical supplemental appendix III). Experts were selected to provide
activities. relevant clinical, research expertise and/or lived experience,
► Promote confidence and a positive approach so that people often through contacts of the Royal Osteoporosis Society clinical
with osteoporosis do more rather than less exercise and and scientific advisory committees, or professional bodies (such
physical activity. as the Chartered Society of Physiotherapists).
► Ensure consistent advice for people with osteoporosis so The scope was refined by the EESG by teleconference and
that people can exercise safely and effectively. email, and evidence synthesised. The scope and evidence were
The target population is people with osteoporosis, who have then reviewed in a full day, face-­to-­face meeting of the EESG and
bone mineral density measured by dual X-­ray absorptiometry EEWG in London in September 2017. A summary was circu-
in the osteoporotic range or a significant fracture risk based on lated, with all members invited to comment.
a fracture risk assessment score, with or without fragility frac-
ture. Separate consideration is made for those with vertebral or Literature search strategy
multiple low trauma fractures and for those who are living with The EESG identified several international osteoporosis and falls
frailty and are unsteady or experiencing falls. Physical activity prevention guidance documents, meta-­analyses and systematic
includes any activity, whatever the purpose, that increases reviews. These have synthesised the published evidence, agreed
energy expenditure, while exercise is structured physical activity key principles and reported evidence12 20–46 and consensus-­based
performed to enhance or maintain performance or health. guidance.12 13 17 18 The EESG agreed a pragmatic approach to
This document updates the principles underpinning previous review and update existing literature reviews and that a further
guidance on exercise and physical activity and distils current systematic review of all the scientific and clinical evidence was
research evidence for people with osteoporosis.19 This guidance not indicated. We thus repeated the searches conducted in
is developed for clinicians, including physiotherapists and exer- previous systematic reviews of exercise and BMD43; falls47 and
cise practitioners, as well as policy makers, and is designed to outcomes after vertebral fracture.44
inform clinical practice and policy. Limited literature was available on the adverse events and
safety issues associated with physical activity and exercise for
METHODS adults with osteoporosis and osteopenia so a systematic review
Developing scope through stakeholder consultation was undertaken that has been published separately.48
To determine the scope and content for the consensus state-
ment, stakeholder consultations were undertaken in 2017. Formulation of recommendations
First, face-­
to-­
face stakeholder discussion groups were held. Reviews of literature were circulated to the EESG and EEWG.
Two groups consisted of people with osteoporosis; both were It was agreed that, as there was inevitably limited evidence to
recruited through the Royal Osteoporosis Society database of answer some of the core questions, the statement would need to
members in two UK areas of differing socioeconomic status base some recommendations for best practice on agreed princi-
(Camerton and Stoke-­ on-­
Trent). A further stakeholder group ples. It would also aim to provide some ‘standard responses’ to
in Camerton involved exercise and health professionals, again common questions to aid meaningful discussion between practi-
recruited through local Royal Osteoporosis Society contacts and tioners and the people they are treating or working with. Where
professional members. Discussions were facilitated by ZP, using appropriate, key statements or standard responses were agreed
a discussion guide (online supplemental appendix I), to explore using discussion and modifying wording as needed to reach
perceptions of the importance and role of exercise, identify consensus across the EESG and EEWG, which was confirmed
areas of uncertainty and to seek views on the provisional content by email after each draft. Recommendations were made in
framework for the consensus document. The discussions were each section based on either the evidence reviewed (marked E)
audio-­recorded, written field notes taken and a summary of the or expert consensus (marked C) where limited or no research
main discussion themes produced. evidence was available and unanimous agreement across the
Second, an online/telephone survey was distributed to EESG and EEWG was achieved.
people affected by osteoporosis and interested health profes- The EESG then developed the draft statement and presented
sionals recruited through Royal Osteoporosis Society members, it for review by the EEWG at a second face-­to-­face meeting in
healthcare professionals and social media channels. Participants London in March 2018. This involved more detailed discussion

2 Brooke-­Wavell K, et al. Br J Sports Med 2022;0:1–10. doi:10.1136/bjsports-2021-104634

 Consensus statement
of the wording. Final changes were approved by email with each in increasing bone strength, and what exercise is safe and appro-

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member of EESG and EEWG providing confirmation that they priate for those with, or at risk of, vertebral fractures. Given
agreed with the final principles and recommendations. that the majority of fractures result from a fall, the EESG added
exercise for falls prevention as a further theme. User consulta-
Consultation strategy tion in stakeholder discussion groups (as described above) was
The draft statement was endorsed by the Royal Osteoporosis undertaken to identify acceptable terminology for these themes,
Society clinical and scientific committee. It was disseminated to resulting in the following:
stakeholders, including partnership organisations (online supple- ► Strong: physical activity and exercise to benefit bone
mental appendix IV). Public consultation was sought (through the strength;
Royal Osteoporosis Society website) from September to October ► Steady: physical activity and exercise to prevent falls;
2018. Feedback was collated on a spreadsheet according to the ► Straight: physical activity and exercise to reduce risk of
strong, straight and steady themes. Any changes were initially vertebral fracture, improve posture and manage symptoms
reviewed by the editorial group (DAS, SL, EMC, KB-­W) before after vertebral fracture.
being circulated for discussion/agreement by expert groups. An Under each theme recommendations were specified for:
online meeting of the EESG was then held in October 2018 to ► All people with osteoporosis. People with osteoporosis
review all changes. were defined here as someone with BMD in the osteopo-
rosis range (a dual energy X ray absorptiometry (DXA) bone
density scan measurement T-­score  <−2.5) or a significant
RESULTS fracture risk (based on fracture risk assessment) with or
Outcome of stakeholder consultation without fragility fractures (including vertebral).
Stakeholder meetings for those with, or at risk of, osteoporosis were ► People with vertebral fractures or multiple low trauma frac-
attended by 27 people (25 postmenopausal women with osteo- tures (the latter group may be at more significant risk of
porosis with two of their spouses). The professionals’ stakeholder vertebral fracture during exercise).
meeting was attended by 13 health or exercise professionals (four ► People living with frailty and unsteadiness or those experi-
physiotherapists, three osteoporosis specialist nurses, three Pilates encing falls.
instructors and three health professionals with osteoporosis). Interventions of interest included exercise or other physical
The stakeholder group discussions identified that people with activity. Outcomes included BMD or other proxies of bone
osteoporosis viewed exercise and physical activity as very important strength, falls, fracture incidence, spinal curvature/posture
with wide-­ranging benefits on health and well-­being, and areas of and pain related to vertebral fracture. Recommendations were
frustration, about being given no, conflicting or negative ‘don’t do’ intended to be applicable for community, primary and secondary
exercise advice by health professionals. Areas of uncertainty, for care settings.
both non-­professionals and professionals alike included what exer-
cise was ‘best’ and safe to improve specific and general bone and
muscle strength, dependent on ability. People with osteoporosis Literature search
wanted more specific information about exercise regimens to guide The updated searches from previous systematic reviews of exer-
safe functional activity, and professionals wanted more information cise and BMD,43 falls47 and outcomes after vertebral fracture44
about how to tailor advice, dependent on patient characteristics. yielded 35, 19 and 3 new trials, respectively.
A total of 880 stakeholders participated in the online survey.
Of those who provided demographic information, >70% were Safety of exercise in people with osteoporosis or fragility
aged between 56 and 75 years; 772 (94%) described their ethnic fractures
origin as ‘white’ and 782 (96%) said they were female. Most Information from three sources was reported: observational and
respondents were people with osteoporosis: 521 (61%) diag- case studies reporting circumstances of osteoporotic fracture;
nosed from a bone density scan; 83 (10%) reported one spinal reports of exercise interventions in people with osteoporosis;
fracture and 114 (13%) reported more than one spinal fracture; adverse event reporting from exercise interventions to increase
148 (17%) had other fragility fractures; 44 (5%) said they were bone strength and to reduce falls risk.
less mobile and unaccustomed to regular exercise. One hundred A few case studies described instances of vertebral fractures
and thirty-­nine respondents (16%) were health professionals. during horse riding or during a golfing mid-­ swing stroke.48
Of the respondents who provided specific queries, 44% However, the majority of observational or non-­ randomised
wanted to know what exercise was effective for strengthening studies in people with osteoporosis did not report adverse
bones (including specific questions on type, intensity and dura- events, apart from muscle soreness and joint discomfort.44 48
tion, or site-­specific exercise) and 38% wanted to know about There were some reports of vertebral fractures associated with
the role of exercise in prevention or management of vertebral end-­range, sustained, repeated or loaded flexion exercises,
fractures. Over a third had questions about the safety of specific including sit-­ups49 and some yoga positions involving extreme
exercises, such as Pilates or yoga positions. Questions about spinal flexion.50 One study reported fractures associated with
equipment, including vibration platforms, were asked. There rolling from prone to supine and dropping a weight on a foot.51
was substantial uncertainty about what exercise was effective or In exercise interventions designed to increase BMD, many
safe, from both health professionals and those with osteoporosis. studies did not report whether there were adverse events. Of
The preferred format for receiving information was leaflets 62 trials, 11 reported fractures48 over the course of the studies
(90%) online video clips (59%) and DVDs (36%). but rarely due to the intervention itself. Overall, 5.8% of inter-
vention group participants sustained fractures compared with
Outcome of refining scope through exercise expert 9.6% of control group participants.48 In particular, there was
consultation no evidence of symptomatic vertebral fracture in association
The EESG consideration of scope concluded that two key themes with impact exercise or moderate to high-­ intensity muscle-­
arose from stakeholder consultations: what exercise is effective strengthening exercise.48 Closely supervised high-­ intensity

Brooke-­Wavell K, et al. Br J Sports Med 2022;0:1–10. doi:10.1136/bjsports-2021-104634 3

 Consensus statement
resistance and impact training in osteoporotic men and women

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was associated with few adverse effects and no vertebral frac-
Box 1  Recommendations for exercise to promote bone
tures.52 53 In a further study of strength, balance and daily strength
moderate to vigorous physical activity in people with osteo-
porosis, adverse events (both falls and fractures) did not differ For all people with osteoporosis
► Muscle-­strengthening physical activity and exercise is
significantly between the control and the intervention groups.54
These trials demonstrate that exercise can be conducted even in recommended on two or three days of the week to maintain
those who already have osteoporosis. bone strength. [E]
► For maximum benefit, muscle strengthening should include
In studies on exercise for fall prevention, only 27 out of 108
trials reported adverse events and only one study reported a progressive muscle resistance training. In practice, this is the
(pelvic stress) fracture.21 There is some evidence that brisk maximum that can be lifted 8–12 times (building up to three
walking increased fracture risk in a population already at risk sets for each exercise). Lower intensity exercise ensuring
of falls and fracture, who may therefore require strength and good technique is recommended before increasing intensity
balance exercise to improve stability before embarking on brisk levels. [E]
► All muscle groups should be targeted, including back muscles
walking or fatiguing exercise.47
Overall, there is little evidence of harm, including fractures, to promote bone strength in the spine. [C]
► Daily physical activity is recommended as a minimum, spread
occurring while exercising. Furthermore, cases that were iden-
tified comprised a mixture of people with and without osteo- across the day and avoiding prolonged periods of sitting. [C]
porosis (as defined by DXA). Exercise is therefore unlikely to In addition:
cause a fracture (and specifically a vertebral fracture) and does For people with osteoporosis who do not have vertebral fractures
not need to be adapted for those with osteoporosis according to or multiple low-­trauma fractures
fracture risk or low BMD (including osteoporosis or osteopenia ► Moderate impact exercise is recommended on most days
determined by DXA). to promote bone strength (eg, stamping, jogging, low-­level
jumping, hopping) to include at least 50 impacts per session
(jogs, hops etc). [C]
Strong: physical activity and exercise to promote bone ► Brief bursts of moderate impact physical activity should be
strength and prevent fractures considered: about 50 impacts (eg, 5 sets of 10) with reduced
Research evidence underlying recommendations is summarised impact in between (eg, walk-­jog). [C]
in online supplemental appendix V. This evidence was consid- For people with osteoporosis who have vertebral fractures or
ered alongside previous guidance12 13 17 and EESG consensus to multiple low trauma fractures
agree recommendations (Box 1). ► Impact exercise on most days at a level up to brisk walking is
The combination of impact and progressive resistance training recommended, aiming for 150 minutes over the week (20 min
best promotes bone strength43 as reflected in other national per day). This a precautionary measure because of theoretical
guidance.12 13 17 18 (unproved) risks of further vertebral fracture in this group. [C]
Resistance exercise is ideally supervised to ensure good tech- ► Individualised advice from a physiotherapist is recommended
nique and minimise injury risk,13 18 with interventions starting for both impact and progressive resistance training to ensure
with lower loads while correct technique is attained. For consis- correct technique, at least at the start of a new programme of
tent gains, resistance exercise should be progressive—that is, exercise or activity. [C]
loads gradually increased.55 The ultimate intensity recommended For people with osteoporosis who are frail and/or less able to
previously was 8–12 repetitions maximum (RM)18—that is, the exercise
maximum weight that could be lifted 8–12 times or 8 repetitions ► Physical activity and exercise to help maintain bone strength
at 80–85% 1 RM13—that is, 80–85% of the maximum load that should be adapted according to individual ability. [C]
could be lifted just once. Both recommend increasing to two to ► Strength and balance exercise to prevent falls will be needed
three sets. EESG consensus was that recommending an 8–12 for confidence and stability before physical activity levels are
RM was easier to implement outside a formal laboratory setting, increased. In practice, falls prevention may be a priority. [C]
although supervised progressive resistance training at higher
intensity is likely to have greatest effects on BMD.
Resistance exercises involving major muscle groups should be should also be encouraged, such as circuit training, rowing,
used to load skeletal sites at risk of osteoporotic fracture, such Pilates or yoga, stair climbing, sit to stands, heavy housework
as the spine, proximal femur and forearm. This may be achieved or gardening and carrying shopping, although repeated or end-­
through one exercise each for legs, arms, chest, shoulders and range flexion should be avoided in these activities (figure 1).
back using exercise bands, weights or body weight,18 or eight Weightbearing or impact activity includes running, jumping,
exercises targeting major muscle groups of the hip and spine, aerobics, some forms of dancing and many ball games and sport.
including weighted lunges, hip abduction/adduction, knee exten- As it does not necessarily require specialist facilities or equip-
sion/flexion, plantar–dorsiflexion, back extension, reverse chest ment, this can be more accessible for many people than resis-
fly, and abdominal exercises13 (while avoiding loaded spinal tance exercise. Previous guidance recommends aerobic exercise
flexion). The latter recommendation could be replaced by fewer for 30 min per day, 5 days a week,18 to comply with recommen-
compound movements, such as squats and dead lifts. Such activi- dations for other health outcomes, but this may not necessarily
ties should be performed on two or three days of the week. While include exercise with sufficient gravitational loading to increase
evidence relates to progressive resistance training, performed bone strength. Australian recommendations are more specific
usually in a formal exercise setting or using specialist equipment, in suggesting impact exercise on 4–7 days per week, with each
such activities are undertaken by only a small proportion of the session including 50 jumps: 3–5 sets of 10–20 repetitions with
population.56 To enable activity, EESG consensus was that other 1–2 min rest between sets.13 They recommended high inten-
sports or leisure activities that might promote muscle strength sity (>4 times body weight (BW)), which may be encountered

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 Consensus statement

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Figure 1  Summary of exercise recommendations (from Royal Osteoporosis Society).63 Most research evidence is based on formal exercise. The
suggested sports and activities include some with research evidence and some that may safely help engagement in activity and improve quality of life
based on expert consensus.

in gymnastics or drop jumps) for those without osteopo- such an exercise programme. Learning best possible posture and
rosis, and 2–4 BW for those at moderate risk of osteoporosis. correct technique is recommended as part of any progressive
Because of the lack of evidence of greater benefit of the high muscle resistance training. Balance and muscle strength training
versus moderate intensity, EESG consensus was to recommend will be important for those at risk of falling before increasing to
moderate impact exercise, such as jumps, skipping, hopping, activities such as brisk walking.
running, higher impact forms of dance such as Scottish dancing Some sports and leisure activities involve an inherent risk of
or Zumba, or ball sports (figure 1) but not very high impact injurious impact, falling and fracture, such as contact sports,
exercise such as landing from height. Consistent with Australian horse riding and skiing.48 However, for those who practice these
guidance,13 the recommended volume and frequency was ~50 regularly, the benefits provided by the activity, including enjoy-
moderate impacts interspersed with rest pauses, on most days. ment and benefits to muscle and bone strength, are likely to
People with vertebral fractures or multiple low trauma frac- outweigh the risks unless people have had multiple fragility frac-
tures, will have greater general bone fragility and a higher risk of
tures or painful spinal fractures. People with osteoporosis may
further fracture. The expert group consensus was more cautious
need some reassurance to continue with activities they enjoy.
about moderate impact exercise in these people. A discussion
about personal preferences and concerns is recommended to
aid decisions about amending or excluding specific leisure or
Steady: exercise and physical activity to prevent falls
sports activities. An individualised progressive tailoring of inten-
Research evidence is summarised in online supplemental
sity of both impact and muscle-­strengthening exercise, under
appendix V and recommendations in Box 2. Substantial evidence
supervision, would often be appropriate. Gradually increasing
suggests that targeted strength and balance training can prevent
impact up to ‘moderate’ could be appropriate depending on the
number of vertebral fractures and symptoms experienced; other falls.21 Such specific exercise may be accessed by referral to a
medical conditions, level of fitness or previous experience of falls service for those who have experienced falls or are limiting
moderate impact activity before the vertebral fracture need to activity though fear of falling.
be considered. Strength and balance training is recommended that is individ-
When starting an impact or muscle-­strengthening programme, ualised, supervised by a health or exercise professional, highly
factors including general fitness, previous exercise and comor- challenging and conducted for 3 hours per week over at least
bidities should be considered in everyone. Building up gradu- 4 months, in line with previously published evidence.21 The
ally, employing good technique, and monitoring both progress consensus opinion was that following such exercise, weight-
and any adverse effects, is the best approach. Urinary inconti- bearing activities such as brisk walking could be introduced.
nence may be a barrier to impact exercise so addressing stress For people who are not eligible for a falls service, the consensus
incontinence may be a necessary step to being able to implement was that activities that improve balance and muscle strength,

Brooke-­Wavell K, et al. Br J Sports Med 2022;0:1–10. doi:10.1136/bjsports-2021-104634 5

 Consensus statement

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Box 2  Recommendations for exercise to reduce falls Box 3  Recommendations to reduce risk of vertebral
fracture, improve posture and manage symptoms of
For all people with osteoporosis (particularly those aged vertebral fracture
65 or who have poor balance)
► Physical activity or exercise to improve balance and muscle For all people with osteoporosis
strength is recommended. [E] ► A positive and reassuring approach is recommended to
► Balance and muscle strength exercise (including activities reduce fear, enhance confidence and control - ‘how to’ rather
such as Tai Chi, dance, yoga and Pilates) are recommended than ‘don’t do’, especially as most people with osteoporosis
at least twice a week to reduce the risk of falls especially in are unlikely to experience a vertebral fracture during these
older age. [C] activities. [C]
► Exercises to improve muscle strength in the back are
For people with osteoporosis who are already having falls
recommended to improve posture and support the spine. Aim
► People who fall repeatedly or have started to avoid activity as
for exercises repeated 3–5 times and held for 3–5 s at least
a result of concern about falling, should be referred to a local
twice a week. [C]
falls service. [C]
► Safe techniques for day-­to-­day moving and lifting are: [C]
► Exercise interventions to prevent falls should be tailored to
‘Think straight’—a straight upper back (and keeping the neck
suit the individual to ensure that they challenge balance
in line with the spine) is the key principle for all movements
without increasing falls risk. [E]
that involve bending and lifting.
► Specific and highly challenging balance and muscle-­
However, recognising the natural curves in the back, flexibility
strengthening exercises, supervised by a trained health or
and function remain important and should be encouraged.
exercise professional, are recommended. [E]
Safe lifting techniques are recommended rather than
► Highly challenging balance and muscle strength training for
instructions such as ‘don’t lift’ or ‘only lift up to a specific
3 hours a week over at least 4 months is recommended—this
weight’.
could be around 25 min/day or 3×1 hour sessions a week. [E]
The ‘hip hinge’ is a simple technique for safe bending that
► The Otago or Falls Management Exercise (FaME) programmes
facilitates this and can be practised and integrated into all
are recommended. [E]
day-­to-­day movements.
► Gradual progression from strength and balance exercises
Always move in a smooth, controlled way within a
to higher impact exercise (such as brisk walking) is
comfortable range. Rotation (twisting) movements should be
recommended for the frailer older adult to prevent an
safe if performed smoothly and comfortably.
increase in falls risk. [C]
Engage abdominal muscles during movements.
► Exercise to strengthen back muscles and improve posture
► Movements or exercise that involve sustained, repeated or
should be considered to reduce falls risk. [C]
end-­range flexion should be modified or avoided. [C]
► Advice about reducing falls risk should be communicated in a
► Any exercise that causes the back to curve excessively
positive way to be relevant and effective. [E]
especially with an added load should be modified or avoided.
[C]
► People who are experienced, demonstrate flexibility in the
such as Tai Chi, dance, yoga or Pilates could be conducted, at spine and can manage the moves comfortably and smoothly,
least twice a week in line with physical activity guidance. should be advised that they can continue with these activities
As kyphosis may increase fall risk, consensus was that exercise as long as they are fit enough to manage them with ease. As
to strengthen back muscle (particularly of spinal extensors) and a precaution, alternatives to exercises such as the ‘roll down
improve posture should also be recommended to reduce falls ‘and ‘curl up’ in Pilates should be considered. [C]
risk. ► Correct form and technique is important [C]
How professionals communicate the benefits of falls preven- For people with osteoporosis with vertebral fracture
tion exercise is important. Most people do not perceive them- ► Prompt moving and lifting advice is recommended soon
selves as fallers or as frail. People need to be motivated to take after painful vertebral fractures to reduce fear and maintain
part in falls prevention exercise using appropriate language, such mobility and function. [C]
as ‘maintaining independence’ and ‘reducing the risk of frac- ► A referral to a physiotherapist will be helpful although some
tures’ rather than ‘fall prevention’. Emphasising the importance advice will also be important as soon as possible after a
of balance to feel confident and be able to enjoy other activities painful fracture. [C]
may also be useful.57 ► Daily exercises to strengthen back muscles (with a focus on
endurance by exercising at low intensity), reduce muscle
spasm, relieve pain, improve flexibility, and promote best
Straight: modifying physical activity and exercise to reduce possible posture are recommended with a referral to a
risk of vertebral fracture, improve posture and manage physiotherapist for tailored advice. Aim for repeated exercise
symptoms after vertebral fracture 3–5 times and held for 3–5 s. [C]
Given the limited evidence about how to reduce risk of vertebral ► Maintaining physical activity and exercise is recommended to
fracture during activity, and the role of exercise in improving address pain and improve well-­being. [C]
kyphosis and managing vertebral fracture (online supplemental ► Professionals should explain how exercise interventions may
appendix V), recommendations (Box 3) are consensus rather help with back pain as people are fearful that exercise will
than evidence based and take into account previous consensus make pain worse. [C]
statements.
Continued
The risks of exercise were found to be relatively low6 and the
benefits of exercise to health and well-­being are substantial,12–14

6 Brooke-­Wavell K, et al. Br J Sports Med 2022;0:1–10. doi:10.1136/bjsports-2021-104634

 Consensus statement
DISCUSSION

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Box 3  Continued
Health professionals and people with osteoporosis had substan-
tial uncertainty about the efficacy and safety of exercise for those
► Yoga and Pilates and similar exercise programmes should be
with osteoporosis. However, evidence synthesis confirmed that
considered to help with posture and pain through teaching
physical activity and exercise have multiple potential benefits for
form, alignment and muscle strength and relaxation. [C]
those with osteoporosis: it may modestly benefit bone strength;
Classes should, if possible, by led by an instructor who has
improve muscle strength and balance and hence reduce falls
been trained to work with older individuals or those with
risk and reduce kyphosis, which may benefit pain, self-­esteem
osteoporosis and can amend exercises according to ability
and risk of falls and fractures. Physical activity has a range of
and range of movement.
► Breathing and pelvic floor exercises are recommended to
other health benefits. We conducted an updated and more thor-
help with other symptoms that may be exacerbated by severe ough analysis of adverse events (particularly fractures) reported
spinal kyphosis. [C] during exercise: harms have not been consistently reported, and
► Hydrotherapy should be considered to help improve quality although a small number of fractures have been reported during
of life. [C] exercise, the benefits outweigh the risks. The level of evidence
for people who have existing fractures is lower unfortunately;
there is inconsistent evidence that exercise could benefit pain,
physical function and quality of life. Many of our recommen-
so it is recommended that the emphasis is on being able to dations for this group are thus based on consensus rather than
continue rather than prohibit exercise. evidence.
As reduced kyphosis may benefit pain, falls and vertebral frac- We recommend several overarching principles. Physical
ture risk, exercises to improve posture (particularly by increasing activity and exercise have an important role in promoting
the strength of spinal extensors) are recommended. Exercise bone strength, reducing falls risk and managing vertebral frac-
can improve back extensor strength and posture, to counter ture symptoms, so they should be part of a broad approach
the expected neuromuscular changes linked to weaker, less that includes other lifestyle changes, combined with pharma-
fatigue-­resistant, muscles, combined with deficits due to spinal ceutical treatment where appropriate. People with osteopo-
pathology that exacerbate back muscle weakness and postural rosis should be encouraged to do more rather than less. This
deformity in people with osteoporosis.58 Improvements in back requires professionals to adopt a positive and encouraging
extensor muscle function are likely to underpin the improve- approach, focusing on ‘how to’ messages rather than ‘don’t
ments observed in standing balance.59 Different trials have do’. Although specific types or exercise may be most effective,
used varying frequency and intensity of exercise. Overall, the even a minimal level of activity should provide some benefit.
consensus from the trials is that the initial dose and progression The evidence indicates that physical activity and exercise is
needs to be tailored to the individual to provide safe but incre- not associated with significant harm, including vertebral frac-
mental challenge and that the higher the dose and the longer ture; in general, the benefits of physical activity outweigh the
the duration of the intervention the greater change observed, risks. Professionals should avoid restricting physical activity or
particularly in people over 70 years old.60 exercise unnecessarily according to BMD or fracture thresh-
Avoiding activities that may provide excessive spinal load or olds as this may discourage exercise or activities that promote
flexion is a pragmatic approach to limit potential triggers of bone and other health benefits. Finally, people with painful
vertebral fracture, and more detailed strategies are supplied in vertebral fractures need clear and prompt guidance on how to
previous guidance.18 adapt movements involved with day-­to-­day living, including
People with pain following vertebral fracture may benefit how exercises can help with posture and pain. Anyone with
from exercise to improve symptoms as well as helping to osteoporosis may benefit from guidance on amending some
maintain usual activity. While such exercise should be deliv- postures and movements to care for their back. Supporting
ered with expert advice, it is important that those with limited resources were produced.62–64
access to physiotherapy still have opportunity to benefit,
so yoga or Pilates classes with an instructor with an under-
standing of appropriate exercise and movement for patients Bone strength
with vertebral fracture may be an alternative. Hydrotherapy A combination of high load resistance exercise or weight-
improved quality of life61 so may be appropriate for improving bearing exercise with impact appears the most effective for
vertebral fracture symptoms as those affected may find water-­ bone strength. Moderate impact exercise may be more effective
based exercise more comfortable, although it may not benefit but lower impact (equivalent to brisk walking) was advised in
bone strength. those with vertebral fractures or multiple low trauma fractures.
Several recent reviews confirmed the efficacy of resistance exer-
cise65–67; one reported no benefit but was selective in the studies
Responses to consultation included.68 Consistent with previous guidance, we recom-
A total of 155 comments were received. Minor changes were mend that resistance exercise should progress to high intensity.
made in response to this feedback. In 2020/2021, the final Although some recent meta-­analyses did not detect greater bene-
updated statement was again reviewed and updated by the EESG fits from high than lower load resistance exercise,66 67 69 some
to confirm that recommendations were still consistent with more of the interventions classified as high intensity were of more
recent evidence. moderate loading, and substantial heterogeneity meant that it
To support implementation, a range of resources were devel- was not possible to detect significant differences according to
oped, which are available on the Royal Osteoporosis Society intensity.66 67 One recent meta-­ analysis confirmed that high-­
website: infographics and quick guide for health professionals62 63 intensity training was more effective than moderate intensity at
as well as fact sheets and videos for the public.64 the lumbar spine.70

Brooke-­Wavell K, et al. Br J Sports Med 2022;0:1–10. doi:10.1136/bjsports-2021-104634 7

 Consensus statement
Falls risk some types of exercise available in the community that seemed

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A high proportion of fractures result from falls, and we recom- likely to provide the necessary training stimulus (figure 1),
mend strength and balance training to reduce fall incidence, although the type and intensity of such exercise may be much
based on a large body of evidence. Exercise is effective in more variable. Even if such exercise is less effective it may at
preventing fall-­related injuries in people with osteoporosis,71 least postpone inactivity-­related decline.
and in the broader population, participants randomised to exer- This statement provides updated evidence consideration and
cise interventions had 26% fewer injurious falls, and 16% fewer application to the UK setting. Limitations to the process include
fractures, than those randomised to control groups.72 This high- that the stakeholder groups were predominantly white and
lights that although health practitioners and people with oste- female, although advice and access to exercise is needed for all
oporosis may be concerned about vertebral fractures sustained populations. Furthermore, we have no health economic evalua-
during exercise that can directly be attributed to the exercise, it tion. Limitations to the strength of recommendations arise due
is important to balance this concern with the injuries prevented to limited evidence available in some areas, including lack of
by exercise despite it being much harder to directly attribute an studies with fracture as primary outcome, inconsistent reporting
injury to not exercising. of adverse effects of exercise and limited number of interventions
in men, ethnic minority groups and people with osteoporosis
Vertebral fracture prevention and management (although recent findings from LIFTMOR studies suggest that
We follow previous guidance in recommending safe lifting principles developed in theoretical studies and broader popula-
strategies and in particular avoiding loaded flexion or end of tions apply to those with osteoporosis). A further limitation is
range movements, both during everyday life and exercise such as that many individual trials have small sample sizes, and so we are
Pilates or yoga. We also recommend exercise to strengthen spine reliant on meta-­analyses of data pooled from multiple studies.
muscles, that may reduce pain and reduce kyphosis which may This may cause problems with exercise interventions: heteroge-
further reduce risks of falls and fractures. neity may arise through different types of exercise interventions,
Our recommendations for people with vertebral fracture are intensity, frequency and volume of exercise or population char-
to undertake strength and balance training, although keep impact acteristics, such as age, health status and habitual activity. Even
exercise to an intensity no more than brisk walking unless under within one exercise mode, such as resistance training, differences
instruction with personalised advice. Exercises to strengthen in exercise intensity, or velocity of contraction, could affect effi-
the spine muscles should be conducted and symptoms may also cacy. Furthermore, selection of studies for meta-­ analyses has
benefit from pelvic floor exercise or hydrotherapy. Given the differed in search strategies, inclusion and exclusion criteria and
limited evidence, these recommendations are consensus based. classifications of exercise, sometimes producing conflicting find-
An updated Cochrane review on exercise after vertebral frac- ings. We have not formally rated the quality of the reviews in our
ture found that evidence was still sparse and findings variable; analysis. Given the highly localised effects of exercise on bone,
no further studies had reported adverse events.45 Recent find- the efficacy at specific skeletal sites may vary depending on the
ings continue to be mixed; a home-­based exercise intervention precise exercises used. Finally, most studies focused on BMD,
produced only modest improvements in physical function and but localised adaptations in bone mean that such changes may
no change in quality of life, pain or kyphosis in women with not parallel changes in bone strength.
vertebral fracture; authors ascribed this to poor adherence to
home-­based exercise.73 A shorter resistance and balance training
intervention improved strength, balance and fear of falling, Implementation
which may reduce falls risk and increasing confidence to remain This consensus statement provides clear consistent advice for
active.74 There is thus no later evidence that would affect the people living with osteoporosis and health professionals working
recommendations and the level of evidence about exercise in with them about the evidence for, and safety of, exercise (see
those with vertebral fracture is still low. online supplemental appendix VI for further UK-­specific guid-
ance), supported by resources.62–64 To ensure effective imple-
mentation of the strong, steady and straight exercise approaches,
Exercise and pharmaceutical treatment the factors that act as both facilitators and barriers to implemen-
The level of evidence and magnitude of benefit from exercise is tation need consideration. These include appropriate and timely
substantially lower than that for osteoporosis medication,8 with identification and management of people living with osteopo-
much less funding to exercise studies. Thus, exercise should be rosis by primary and secondary care providers; provision of exer-
viewed as an adjunct rather than an alternative to pharmaceu- cise interventions that conform to evidence-­based requirements
tical treatment where this is indicated. However, people with and the complexity of providing multiple exercise programmes
osteoporosis are keen to contribute to management of their oste- for different long-­ term conditions in the context of limited
oporosis with lifestyle approaches/exercise, and inactivity will resources; and uptake and adherence to exercise interventions
increase the risk of falls and many other health conditions, so (short-­term and long-­term). Osteoporosis exercise programmes,
it is important to consider exercise even when pharmaceutical like other exercise programmes for older people and those with
treatment is used. long-­term conditions, need to be more than a prescribed set of
exercises. They need to consider education and physical literacy,
Strengths and limitations support and goal setting, motivation strategies, behaviour
The evidence reviewed was primarily composed of targeted change techniques and take into consideration needs and pref-
exercise interventions, often conducted in a laboratory or clinic. erences.75 76 For effective implementation of the strong, steady
Although such well-­ controlled interventions are informative and straight exercise approaches an infrastructure for measuring
about the parameters of exercise that are effective, they may and monitoring quality assurance and improvement is needed,
be less available to many people with osteoporosis (although a to ensure ongoing fidelity (the right populations targeted by the
fall prevention exercise programme should be available to those right professionals, dose, frequency, intensity, challenge, resis-
at risk of falls). We took the pragmatic decision to recommend tance, etc.). We need to demonstrate impact to justify investment

8 Brooke-­Wavell K, et al. Br J Sports Med 2022;0:1–10. doi:10.1136/bjsports-2021-104634

 Consensus statement
in osteoporosis programmes. This is increasingly important as terminology, drug names and drug dosages), and is not responsible for any error

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the impact of COVID-­19 and increased prevention and rehabili- and/or omissions arising from translation and adaptation or otherwise.
tation needs have the potential to jeopardise the offer of exercise Open access  This is an open access article distributed in accordance with the
for osteoporosis. Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-­commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
CONCLUSIONS is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Key recommendations are that people with osteoporosis should
ORCID iDs
undertake resistance and impact exercise to maximise bone Katherine Brooke-­Wavell http://orcid.org/0000-0002-3708-4346
strength; should take part in activities to improve strength and Dawn A Skelton http://orcid.org/0000-0001-6223-9840
balance to reduce falls and undertake spinal extension exercise Karen L Barker http://orcid.org/0000-0001-9363-0383
to improve posture, and potentially reduce pain levels caused by Emma M Clark http://orcid.org/0000-0001-8332-9052
vertebral fractures, risk of falls and vertebral fracture. Although Susanne Arnold http://orcid.org/0000-0001-8152-7610
Zoe Paskins http://orcid.org/0000-0002-7783-2986
we recommend avoiding postures involving a high degree of Jonathan H Tobias http://orcid.org/0000-0002-7475-3932
spinal flexion (especially weighted) during exercise or daily life, Kate A Ward http://orcid.org/0000-0001-7034-6750
and that people with vertebral fracture or multiple low trauma Julie Whitney http://orcid.org/0000-0002-4109-9970
fractures should only exercise up to an impact equivalent to brisk
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