Systematic review| Volume 101, ISSUE 3, P487-511, March 2020

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Exercise Interventions for Preventing and Treating Low Bone Mass in the Forearm: A Systematic Review and Meta-analysis

Published:August 26, 2019DOI:



      To examine the effectiveness of exercises for improving forearm bone mass.

      Data Sources

      MEDLINE, EMBASE, CINAHL, AMED, Web of Science, and Cochrane CENTRAL were searched from their inception until December 2018.

      Study Selection

      Eligibility included adults undertaking upper limb exercise interventions (≥12wk) to improve bone mass.

      Data Extraction

      Screening of titles, abstracts, and full texts and data extraction were undertaken independently by pairs of reviewers. Included studies were quality appraised using Cochrane risk of bias tool.

      Data Synthesis

      Exercise interventions were classified into “resistance training” of high or low intensity (HIRT/LIRT, respectively) or “impact.” Random-effects meta-analysis of the percentage change in forearm bone mass from baseline was conducted. Twenty-six studies were included in the review, of which 21 provided suitable data for meta-analysis. Methodological quality ranged from “low” to “unclear” risk of bias. Exercise generally led to increases (moderate-quality evidence) in forearm bone mass (standard mean difference [SMD], 1.27; 95% CI, 0.66-1.88; overall effect Z value=4.10; P<.001). HIRT (SMD, 1.00; 95% CI, 0.37-1.62; Z value=3.11; P=.002), and LIRT (SMD, 2.36; 95% CI, 0.37-4.36; Z value=2.33; P<.001) led to moderate increases in forearm bone mass. Improvements resulting from impact exercises (SMD, 1.12; 95% CI, −1.27 to 3.50; Z value=0.92; P=.36) were not statistically significant (low-quality evidence).


      There is moderate-quality evidence that exercise is effective for improving forearm bone mass. There is moderate-quality evidence that upper body resistance exercise (HIRT/LIRT) promotes forearm bone mass but low-quality evidence for impact exercise. Current evidence is equivocal regarding which exercise is most effective for improving forearm bone mass.


      List of abbreviations:

      BMC (bone mineral content), BMD (bone mineral density), DXA (dual-energy x-ray absorptiometry), HIRT (high-intensity resistance training), LIRT (low-intensity resistance training), 1RM (1 repetition maximum), pQCT (peripheral quantitative computed tomography), RCT (randomized controlled trial), ROI (region of interest), SMD (standardized mean difference), SPA (single photon absorptiometry)
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        • Svedbom A.
        • Hernlund E.
        • Ivergård M.
        • et al.
        Osteoporosis in the European Union: a compendium of country-specific reports.
        Arch Osteoporos. 2013; 8: 137
        • Van Staa T.P.
        • Dennison E.M.
        • Leufkens H.G.
        • Cooper C.
        Epidemiology of fractures in England and Wales.
        Bone. 2001; 29: 517-522
        • Ahmed L.A.
        • Schirmer H.
        • Bjørnerem Å.
        • et al.
        The gender- and age-specific 10-year and lifetime absolute fracture risk in Tromsø, Norway.
        Eur J Epidemiol. 2009; 24: 441-448
        • Williamson S.
        • Landeiro F.
        • McConnell T.
        • et al.
        Costs of fragility hip fractures globally: a systematic review and meta-regression analysis.
        Osteoporos Int. 2017; 28: 2791-2800
        • Borgström F.
        • Zethraeus N.
        • Johnell O.
        • et al.
        Costs and quality of life associated with osteoporosis-related fractures in Sweden.
        Osteoporos Int. 2006; 17: 637-650
        • Cummings S.R.
        • Melton L.J.
        Epidemiology and outcomes of osteoporotic fractures.
        Lancet. 2002; 359: 1761-1767
        • Moore C.M.
        • Leonardi-Bee J.
        The prevalence of pain and disability one year post fracture of the distal radius in a UK population: a cross sectional survey.
        BMC Musculoskelet Disord. 2008; 9: 129
        • Nellans K.W.
        • Kowalski E.
        • Chung K.C.
        The epidemiology of distal radius fractures.
        Hand Clin. 2012; 28: 113-125
        • Ioannidis G.
        • Flahive J.
        • Pickard L.
        • et al.
        Non-hip, non-spine fractures drive healthcare utilization following a fracture: the Global Longitudinal Study of Osteoporosis in Women (GLOW).
        Osteoporos Int. 2013; 24: 59-67
        • Ammann P.
        • Rizzoli R.
        Bone strength and its determinants.
        Osteoporos Int. 2003; 14: 13-18
        • Cummings S.R.
        • Browner W.
        • Cummings S.R.
        • et al.
        Bone density at various sites for prediction of hip fractures.
        Lancet. 1993; 341: 72-75
        • Rittweger J.
        • Simunic B.
        • Bilancio G.
        • et al.
        Bone loss in the lower leg during 35 days of bed rest is predominantly from the cortical compartment.
        Bone. 2009; 44: 612-618
        • Sugiyama T.
        • Yamaguchi A.
        • Kawai S.
        Effects of skeletal loading on bone mass and compensation mechanism in bone: a new insight into the “mechanostat” theory.
        J Bone Miner Metab. 2002; 20: 196-200
        • Paskins Z.
        • Jinks C.
        • Mahmood W.
        • et al.
        Public priorities for osteoporosis and fracture research: results from a general population survey.
        Arch Osteoporos. 2017; 12: 45
        • Raybould G.
        • Babatunde O.
        • Evans A.L.
        • Jordan J.L.
        • Paskins Z.
        Expressed information needs of patients with osteoporosis and/or fragility fractures: a systematic review.
        Arch Osteoporos. 2018; 13: 55
        • Howe T.E.
        • Shea B.
        • Dawson L.J.
        • et al.
        Exercise for preventing and treating osteoporosis in postmenopausal women.
        Cochrane Database Syst Rev. 2011; 7CD000333
        • Marques E.A.
        • Mota J.
        • Carvalho J.
        Exercise effects on bone mineral density in older adults: a meta-analysis of randomized controlled trials.
        Age. 2012; 34: 1493-1515
        • Polidoulis I.
        • Beyene J.
        • Cheung A.M.
        The effect of exercise on pQCT parameters of bone structure and strength in postmenopausal women—a systematic review and meta-analysis of randomized controlled trials.
        Osteoporos Int. 2012; 23: 39-51
        • Bérard A.
        • Bravo G.
        • Gauthier P.
        Meta-analysis of the effectiveness of physical activity for the prevention of bone loss in postmenopausal women.
        Osteoporos Int. 1997; 7: 331-337
        • Bonaiuti D.
        • Shea B.
        • Iovine R.
        • et al.
        Exercise for preventing and treating osteoporosis in postmenopausal women.
        Cochrane Database Syst Rev. 2002; 3CD000333
        • Hutton B.
        • Salanti G.
        • Caldwell D.M.
        • et al.
        The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations.
        Ann Intern Med. 2015; 162: 777
        • Higgins J.P.T.
        • Altman D.G.
        • Gotzsche P.C.
        • et al.
        The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials.
        BMJ. 2011; 343: d5928
        • International Society for Clinical Densitometry
        2015 ISCD Official Positions – Adult.
        (Available at:) (Accessed September 16, 2019)
        • Cohen J.
        Statistical power analysis for the behavioral sciences.
        Lawrence Earlbaum Associates, Hillsdale, NY1988
        • Guyatt G.H.
        • Oxman A.D.
        • Vist G.E.
        • et al.
        GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
        BMJ. 2008; 336: 924-926
        • Adami S.
        • Gatti D.
        • Braga V.
        • Bianchini D.
        • Rossini M.
        Site-specific effects of strength training on bone structure and geometry of ultradistal radius in postmenopausal women.
        J Bone Miner Res. 1999; 14: 120-124
        • Ayalon J.
        • Simkin A.
        • Leichter I.
        • Raifmann S.
        Dynamic bone loading exercises for postmenopausal women: effect on the density of the distal radius.
        Arch Phys Med Rehabil. 1987; 68: 280-283
        • Bemben D.A.
        • Fetters N.L.
        • Bemben M.G.
        • Nabavi N.
        • Koh E.T.
        Musculoskeletal responses to high- and low-intensity resistance training in early postmenopausal women.
        Med Sci Sports Exerc. 2000; 32: 1949-1957
        • Danz A.M.
        • Zittermann A.
        • Schiedermaier U.
        • Klein K.
        • Hötzel D.
        • Schönau E.
        The effect of a specific strength-development exercise on bone mineral density in perimenopausal and postmenopausal women.
        J Womens Health. 1998; 7: 701-709
        • Dornemann T.M.
        • McMurray R.G.
        • Renner J.B.
        • Anderson J.J.B.
        Effects of high-intensity resistance exercise on bone mineral density and muscle strength of 40- 50-year-old women.
        J Sports Med Phys Fitness. 1997; 3: 246-251
        • Duckham R.L.
        • Masud T.
        • Taylor R.
        • et al.
        Randomised controlled trial of the effectiveness of community group and home-based falls prevention exercise programmes on bone health in older people: the ProAct65+ bone study.
        Age Ageing. 2015; 44: 573-579
        • Duff W.R.
        • Chilibeck P.D.
        • Candow D.G.
        • et al.
        Effects of ibuprofen and resistance training on bone and muscle.
        Med Sci Sport Exerc. 2017; 49: 633-640
        • Fujimura R.
        • Ashizawa N.
        • Watanabe M.
        • et al.
        Effect of resistance exercise training on bone formation and resorption in young male subjects assessed by biomarkers of bone metabolism.
        J Bone Miner Res. 1997; 12: 656-662
        • Greenway K.G.
        • Walkley J.W.
        • Rich P.A.
        Impact exercise and bone density in premenopausal women with below average bone density for age.
        Eur J Appl Physiol. 2015; 115: 2457-2469
        • Heinonen A.
        • Sievänen H.
        • Kannus P.
        • Oja P.
        • Vuori I.
        Effects of unilateral strength training and detraining on bone mineral mass and estimated mechanical characteristics of the upper limb bones in young women.
        J Bone Miner Res. 1996; 11: 490-501
        • Heinonen A.
        • Oja P.
        • Sievanen H.
        • Pasanen M.
        • Vuori I.
        Effect of two training regimens on bone mineral density in healthy perimenopausal women: a randomized controlled trial.
        J Bone Miner Res. 1998; 13: 483-490
        • Judge J.O.
        • Kleppinger A.
        • Kenny A.
        • Smith J.-A.
        • Biskup B.
        • Marcella G.
        Home-based resistance training improves femoral bone mineral density in women on hormone therapy.
        Osteoporos Int. 2005; 16: 1096-1108
        • Karinkanta S.
        • Heinonen A.
        • Sievänen H.
        • et al.
        A multi-component exercise regimen to prevent functional decline and bone fragility in home-dwelling elderly women: randomized, controlled trial.
        Osteoporos Int. 2007; 18: 453-462
        • Kemmler W.
        • Lauber D.
        • Weineck J.
        • Hensen J.
        • Kalender W.
        • Engelke K.
        Benefits of 2 years of intense exercise on bone density, physical fitness, and blood lipids in early postmenopausal osteopenic women.
        Arch Intern Med. 2004; 164: 1084
        • Kerr D.
        • Morton A.
        • Dick I.
        • Prince R.
        Exercise effects on bone mass in postmenopausal women are site-specific and load-dependent.
        J Bone Miner Res. 1996; 11: 218-225
        • Kerr D.
        • Ackland T.
        • Maslen B.
        • Morton A.
        • Prince R.
        Resistance training over 2 years increases bone mass in calcium-replete postmenopausal women.
        J Bone Miner Res. 2001; 16: 175-181
        • Kohrt W.M.
        • Ehsani A.A.
        • Birge S.J.
        Effects of exercise involving predominantly either joint-reaction or ground-reaction forces on bone mineral density in older women.
        J. Bone Miner Res. 1997; 12: 1253-1261
        • Liu-Ambrose T.Y.L.
        • Khan K.M.
        • Eng J.J.
        • Heinonen A.
        • McKay H.A.
        Both resistance and agility training increase cortical bone density in 75- to 85-year-old women with low bone mass.
        J Clin Densitom. 2004; 7: 390-398
        • Nickols-Richardson S.M.
        • Miller L.E.
        • Wootten D.F.
        • Ramp W.K.
        • Herbert W.G.
        Concentric and eccentric isokinetic resistance training similarly increases muscular strength, fat-free soft tissue mass, and specific bone mineral measurements in young women.
        Osteoporos Int. 2007; 18: 789-796
        • Notelovitz M.
        • Martin D.
        • Tesar R.
        • et al.
        Estrogen therapy and variable-resistance weight training increase bone mineral in surgically menopausal women.
        J Bone Miner Res. 1991; 6: 583-590
        • Preisinger E.
        • Alacamlioglu Y.
        • Pils K.
        • Saradeth T.
        • Schneider B.
        Therapeutic exercise in the prevention of bone loss. A controlled trial with women after menopause.
        Am J Phys Med Rehabil. 1995; 74: 120-123
        • Prince R.L.
        • Smith M.
        • Dick I.M.
        • et al.
        Prevention of postmenopausal osteoporosis.
        N Engl J Med. 1991; 325: 1189-1195
        • Rikli R.E.
        • McManis B.G.
        Effects of exercise on bone mineral content in postmenopausal women.
        Res Q Exerc Sport. 1990; 61: 243-249
        • Stolzenberg N.
        • Belavý D.L.
        • Beller G.
        • Armbrecht G.
        • Semler J.
        • Felsenberg D.
        Bone strength and density via pQCT in post-menopausal osteopenic women after 9 months resistive exercise with whole body vibration or proprioceptive exercise.
        J Musculoskelet Neuronal Interact. 2013; 13: 66-76
        • Waltman N.L.
        • Twiss J.J.
        • Ott C.D.
        • et al.
        The effect of weight training on bone mineral density and bone turnover in postmenopausal breast cancer survivors with bone loss: a 24-month randomized controlled trial.
        Osteoporos Int. 2010; 21: 1361-1369
        • Wang M.
        • Salem G.J.
        The relations among upper-extremity loading characteristics and bone mineral density changes in young women.
        Bone. 2004; 34: 1053-1063
        • Martyn-St James M.
        • Carroll S.
        Meta-analysis of walking for preservation of bone mineral density in postmenopausal women.
        Bone. 2008; 43: 521-531
        • Martyn-St James M.
        • Carroll S.
        A meta-analysis of impact exercise on postmenopausal bone loss: the case for mixed loading exercise programmes.
        Br J Sports Med. 2009; 43: 898-908
        • Ehrlich P.J.
        • Lanyon L.E.
        Mechanical strain and bone cell function: a review.
        Osteoporos Int. 2002; 13: 688-700
        • Rubin C.T.
        • Sommerfeldt D.W.
        • Judex S.
        • Qin Y.X.
        Inhibition of osteopenia by low magnitude, high-frequency mechanical stimuli.
        Drug Discov Today. 2001; 6: 848-858
        • Wallace B.A.
        • Cumming R.G.
        Systematic review of randomized trials of the effect of exercise on bone mass in pre- and postmenopausal women.
        Calcif Tissue Int. 2000; 67: 10-18
        • Burt L.A.
        • Greene D.A.
        • Ducher G.
        • Naughton G.A.
        Skeletal adaptations associated with pre-pubertal gymnastics participation as determined by DXA and pQCT: a systematic review and meta-analysis.
        J Sci Med Sport. 2013; 16: 231-239
        • Ducher G.
        • Tournaire N.
        • Meddahi-Pellé A.
        • Benhamou C.L.
        • Courteix D.
        Short-term and long-term site-specific effects of tennis playing on trabecular and cortical bone at the distal radius.
        J Bone Miner Metab. 2006; 24: 484-490
        • Ireland A.
        • Maden-Wilkinson T.
        • McPhee J.
        • et al.
        Upper limb muscle-bone asymmetries and bone adaptation in elite youth tennis players.
        Med Sci Sports Exerc. 2013; 45: 1749-1758
        • Torvinen S.
        • Kannus P.
        • Sievänen H.
        • et al.
        Effect of 8-month vertical whole body vibration on bone, muscle performance, and body balance: a randomized controlled study.
        J Bone Miner Res. 2003; 18: 876-884
        • Kontulainen S.
        • Sievänen H.
        • Kannus P.
        • Pasanen M.
        • Vuori I.
        Effect of long-term impact-loading on mass, size, and estimated strength of humerus and radius of female racquet-sports players: a peripheral quantitative computed tomography study between young and old starters and controls.
        J Bone Miner Res. 2003; 18: 352-359
        • Nikander R.
        • Sievänen H.
        • Heinonen A.
        • Daly R.M.
        • Uusi-Rasi K.
        • Kannus P.
        Targeted exercise against osteoporosis: a systematic review and meta-analysis for optimising bone strength throughout life.
        BMC Med. 2010; 8: 47
        • Zebaze R.M.
        • Ghasem-Zadeh A.
        • Bohte A.
        • et al.
        Intracortical remodelling and porosity in the distal radius and post-mortem femurs of women: a cross-sectional study.
        Lancet. 2010; 375: 1729-1736
        • Wolff I.
        • van Croonenborg J.J.
        • Kemper H.C.G.
        • Kostense P.J.
        • Twisk J.W.R.
        The effect of exercise training programs on bone mass: a meta-analysis of published controlled trials in pre- and postmenopausal women.
        Osteoporos Int. 1999; 9: 1-12
        • Preisinger E.
        • Alacamlioglu Y.
        • Pils K.
        • et al.
        Exercise therapy for osteoporosis: results of a randomised controlled trial.
        Br J Sports Med. 1996; 30: 209-212
        • Ferretti J.L.
        • Cointry G.R.
        • Capozza R.F.
        • Capiglioni R.
        • Chiappe M.A.
        Analysis of biomechanical effects on bone and on the muscle-bone interactions in small animal models.
        J Musculoskelet Neuronal Interact. 2001; 1: 263-274
        • Guilhem G.
        • Cornu C.
        • Guével A.
        Neuromuscular and muscle-tendon system adaptations to isotonic and isokinetic eccentric exercise.
        Ann Phys Rehabil Med. 2010; 53: 319-341
        • Remaud A.
        • Cornu C.
        • Guével A.
        Neuromuscular adaptations to 8-week strength training: isotonic versus isokinetic mode.
        Eur J Appl Physiol. 2010; 108: 59-69
        • Bergquist R.
        • Iversen V.M.
        • Mork P.J.
        • Fimland M.S.
        Muscle activity in upper-body single-joint resistance exercises with elastic resistance bands vs. free weights.
        J Hum Kinet. 2018; 61: 5-13
        • Vainionpää A.
        • Korpelainen R.
        • Leppäluoto J.
        • Jämsä T.
        Effects of high-impact exercise on bone mineral density: a randomized controlled trial in premenopausal women.
        Osteoporos Int. 2005; 16: 191-197
        • Tobias J.H.
        • Gould V.
        • Brunton L.
        • et al.
        Physical activity and bone: may the force be with you.
        Front Endocrinol (Lausanne). 2014; 5: 20
        • Babatunde O.
        • Forsyth J.J.
        • Gidlow C.J.
        A meta-analysis of brief high-impact exercises for enhancing bone health in premenopausal women.
        Osteoporos Int. 2012; 23: 109-119
        • Deere K.
        • Sayers A.
        • Rittweger J.
        • Tobias J.H.
        Habitual levels of high, but not moderate or low, impact activity are positively related to hip BMD and geometry: results from a population-based study of adolescents.
        J Bone Miner Res. 2012; 27: 1887-1895
        • Turner C.H.
        Bone strength: current concepts.
        Ann N Y Acad Sci. 2006; 1068: 429-446
        • Bettis T.
        • Kim B.-J.
        • Hamrick M.W.
        Impact of muscle atrophy on bone metabolism and bone strength: implications for muscle-bone crosstalk with aging and disuse.
        Osteoporos Int. 2018; 29: 1713-1720
        • Martyn St-James M.
        • Carroll S.
        Effects of different impact exercise modalities on bone mineral density in premenopausal women: a meta-analysis.
        J Bone Miner Metab. 2010; 28: 251-267
        • Babatunde O.O.
        • Forsyth J.J.
        • Gidlow C.J.
        A meta-analysis of brief high-impact exercises for enhancing bone health in premenopausal women.
        Osteoporos Int. 2012; 23: 109-119
        • Allison S.J.
        • Folland J.P.
        • Rennie W.J.
        • Summers G.D.
        • Brooke-Wavell K.
        High impact exercise increased femoral neck bone mineral density in older men: a randomised unilateral intervention.
        Bone. 2013; 53: 321-328