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ArthroplastyMeta-analysis

Effect of exercise on bone health in middle aged and older adults: hierarchical network meta-analysis of randomised trials

BMJ · 9 Sept 2026

Rigour86/100
Clinical54/100
Impact†54/100

† Impact is the editorial-priority score. All scores are out of 100. Clinical is a stored clinical-importance score from the earlier method; it has not been recalculated.

Why it matters

Gives clinicians a starting point for prescribing specific exercise types and doses to preserve bone density and reduce fracture risk in aging patients, an issue relevant to orthopaedic, primary care, and rehabilitation counselling.

The evidence

This network meta-analysis pooled 124 randomised trials (18,429 adults ≥40 years) comparing different exercise types against no-exercise controls for bone mineral density (BMD) and fracture risk. Brisk walking/jogging and combined aerobic-resistance training produced the largest, though modest, BMD gains (e.g., lumbar spine mean difference 0.013 g/cm², 95% CrI 0.006 to 0.021), while mixed aerobic exercise (odds ratio 0.29) and mind-body exercise (odds ratio 0.58) were associated with lower fracture risk; effects generally plateaued above roughly 600-900 METs-min/week of activity.

lumbar spine bone mineral density: Mean difference 0.013 (95% CI 0.006 to 0.021; other). The interval favours the first group; the size of the benefit needs clinical interpretation.

Why this rigour score?

Meta-analysis of RCTsDesign starting point: 60.8

86/ 100

Raised the score

  • Prospectively registered+5.1
  • Pools randomised trials+5.1

Lowered the score

    No negative adjustments recorded.

    Methods at a glance

    Recorded assessment
    • Comprehensive literature searchMet
    • Risk of bias assessedMet
    • Bias considered in synthesisMet
    • Publication bias assessedMet
    • Study exclusions justifiedMet
    • Prospective registrationMet

    Not reported does not mean not done. Checks have different weights; this is not a count of boxes ticked.

    See the full score breakdown
    Study design starting point
    60.8
    0% loss to follow-up
    +1.7
    Prospectively registered
    +5.1
    Pools randomised trials
    +5.1
    Comprehensive literature search
    +3.4
    Risk of bias assessed in the included studies
    +3.4
    Risk of bias carried into the synthesis
    +2.5
    Excluded studies listed and justified
    +1.7
    Publication bias assessed
    +2.5
    Final rigour score rounded
    86 / 100

    Study design sets the starting point and a ceiling of 96. Recorded methods then adjust the score. Points are shown to one decimal place; the final score uses unrounded values.

    Checklist from the stored appraisal. “Not met” describes the recorded criterion; it does not always produce a deduction. This overview supports reading the full study.

    For journal club

    1.For a patient with osteopenia who dislikes high-impact activity, would substituting mind-body exercise (like tai chi) provide comparable fracture-risk reduction to more traditional aerobic programmes?

    2.Given that BMD benefits plateaued around 600-900 METs-min/week, how should clinicians balance recommending 'more is better' exercise advice against fall risk in older, frailer patients?

    Original publication title

    Effect of exercise on bone health in middle aged and older adults: hierarchical network meta-analysis of randomised trials

    Read original paper