Bone Fractures In Postmenopausal Women Research Articles

Association between Postmenopausal Osteoporosis and IL-6、TNF-α: A Systematic Review and A Meta-analysis.

Postmenopausal osteoporosis (PMOP) greatly increases the risk of bone fracture in postmenopausal women, seriously affects the quality of life of patients, and is an important global public health problem. Persistent chronic systemic inflammation may be involved in the change process of PMOP, and many cytokines, such as TNF-alpha and Interleukin-6, play an important role in the inflammatory response. Therefore, This study takes commonly representative inflammatory factors as indicators to better determine their role in PMOP patients by means of databases from multiple studies for use in Meta-analysis. Systematic review of studies on the relationship between PMOP and markers of inflammation: interleukin-6 (IL-6) and tumour necrosis factor-α (TNF-α). Each effect size was expressed with a 95% confidence interval (CI), and I2 quantified the heterogeneity. The final results were aggregated and evaluated using random or fixed effects models. Twenty-one original studies were identified. There were twenty studies involving IL-6 and eleven involving TNF-α. Overall, The levels of IL-6[MD=23.93, 95%CI (19.65, 28.21)] and TNF-α[MD=2.9, 95%CI (2.37, 3.44)] were increased in PMOP patients compared with postmenopausal women without osteoporosis; The levels of IL-6[MD=42.4, 95%CI (38.62, 46.19)] and TNF-α[MD=0.40, 95%CI (0.36, 0.44)] were significantly higher than those of premenopausal healthy women. The levels of inflammatory cytokines IL-6 and TNF-α were significantly increased in PMOP patients compared with controls, suggesting that persistent chronic inflammatory reaction exists in PMOP patients, which may be an important cause of aggravated osteoporosis in postmenopausal women. Therefore, the level of IL-6 and TNF-α indexes may be of great significance for the early prevention, diagnosis, treatment and prognosis assessment of PMOP.

DANCR Mediates the Rescuing Effects of Sesamin on Postmenopausal Osteoporosis Treatment via Orchestrating Osteogenesis and Osteoclastogenesis.

As one of the leading causes of bone fracture in postmenopausal women and in older men, osteoporosis worldwide is attracting more attention in recent decades. Osteoporosis is a common disease mainly resulting from an imbalance of bone formation and bone resorption. Pharmaceutically active compounds that both activate osteogenesis, while repressing osteoclastogenesis hold the potential of being therapeutic medications for osteoporosis treatment. In the present study, sesamin, a bioactive ingredient derived from the seed of Sesamum Indicum, was screened out from a bioactive compound library and shown to exhibit dual-regulating functions on these two processes. Sesamin was demonstrated to promote osteogenesis by upregulating Wnt/β-catenin, while repressing osteoclastogenesis via downregulating NF-κB signaling . Furthermore, DANCR was found to be the key regulator in sesamin-mediated bone formation and resorption . In an ovariectomy (OVX)-induced osteoporotic mouse model, sesamin could rescue OVX-induced bone loss and impairment. The increased serum level of DANCR caused by OVX was also downregulated upon sesamin treatment. In conclusion, our results demonstrate that sesamin plays a dual-functional role in both osteogenesis activation and osteoclastogenesis de-activation in a DANCR-dependent manner, suggesting that it may be a possible medication candidate for osteoporotic patients with elevated DNACR expression levels.

Incidence of fractures in women in the post-menopause: a cohort study in primary care in southern Brazil.

Few studies are evaluating the incidence of fractures in Latin America and Brazil. This study aimed to estimate the incidence of bone fractures in postmenopausal women seen in primary care and evaluate the FRAX algorithm's performance in these women. A cohort study was carried out in the municipality of Santa Maria, Southern Brazil. Postmenopausal women aged 55years and over who attended primary health care were included. The recruitment period was from March 1 to August 31, 2013, and the participants were followed for 5years. The fracture risk was calculated using the FRAX algorithm. The reported incident fractures were confirmed by imaging studies or surgical reports. Of the 1057 women recruited for the study, 854 were followed. They contributed to 2732 person/year. The mean follow-up time was 3.2years (SD 1.05). The incidences of total fractures, major fractures, and hip fractures were 22.3, 15.0, and 3.3 per 1000 person/year. The most frequent fracture sites were the wrist, shoulder, and ribs. The fracture predictors were rheumatoid arthritis, previous fracture, and the use of glucocorticoids. The discriminatory capacity of incident fractures calculated by FRAX without the inclusion of BMD was AUC 0.730 (95% CI 0.570, 0.890) for hip fracture and AUC 0.691 (95% CI 0.598, 0.784) for major fractures. The FRAX algorithm showed an adequate discriminatory capacity to identify incident fractures in primary care in our study. The incidence of fractures found in our study appears to be lower than that reported in North America and Europe.

Beneficial effect of pristimerin against the development of osteoporosis in ovariectomy-induced osteoporosis rats by the RANKL/TRAF6/NF-κB pathway.

Osteoporosis is a major cause of bone fracture in post-menopausal women. We evaluated the effects of pristimerin treatment on ovariectomy-induced osteoporosis, and its possible molecular mechanism. Rats were ovariectomised and biochemical markers of bone formation were determined from serum samples. The microarchitectures of bone tissues were analyzed via micro-CT scans and Western blotting assays. The cytotoxic effects of pristimerin, the differentiation of osteoclasts, and bone reabsorption were evaluated in vitro using RAW 264.7 cells. Treatment with pristimerin attenuated changes in markers of bone formation and reabsorption such as creatine kinase (CK), alkaline phosphatase (ALP), tartrate-resistant acid phosphatase (TRAP), collagen type I fragments (CTX), bone Gla-protein (BGP), and osteocalcin (OC) in the serum of ovariectomised rats. It also appeared to restore the microarchitecture of bone tissue. The expression levels of TNF receptor-associated factor 6 (TRAF-6), nuclear factor κ light chain enhancer of activated B cells (NF-κB p65), and receptor activator of nuclear factor-κB ligand (RANKL) protein were significantly lower, while those of Akt and PI3K were significantly higher, in the bone tissues of the pristimerin-treated group than in negative controls. Pristimerin had no cytotoxic effect on RAW 264.7 cells and reduced the differentiation of osteoclasts, bone reabsorption, and translocation of p65 in RANKL-stimulated RAW 264.7 cells in vitro. Pristimerin reduces the effects of osteoporosis by restoring the altered RANKL/TRAF-6/NF-κB pathway in ovariectomised rats.

Association between glycosylated hemoglobin A1c and bone biochemical markers in type 2 diabetic postmenopausal women: a cross-sectional study

Backgroundtype 2 diabetes mellitus (T2DM) is a complicated disease that can affect bone health, but the change in bone biochemical markers caused by T2DM was controversial, so the aim of this study was to investigate whether there was a discrepancy in the levels of bone biochemical markers between postmenopausal women with T2DM and non-diabetic women and to explore the relationship between the level of glycosylated hemoglobin A1c (HbA1c) and bone biochemical markers in these subjects.MethodsA total of 237 type 2 diabetic postmenopausal women visiting the First Affiliated Hospital of Anhui Medical University from January 2017 to October 2018 and 93 healthy postmenopausal women were retrospectively enrolled. The differences in the levels of bone biochemical markers between patients and controls were analyzed by one-way ANOVA or chi-square test. The relationship between HbA1c and bone biochemical markers was analyzed by multivariate regression, forest plot and fitted curve.ResultsBone formation markers including N-MID osteocalcin and procollagen type 1 amino-terminal pro-peptide (PINP) were decreased in postmenopausal women with T2DM compared to controls (17.42 ± 9.50 vs 23.67 ± 7.58, p < 0.001; 48.47 ± 27.27 vs 65.86 ± 21.06, p < 0.001, respectively), but the bone resorption markers β-crossLaps (β-CTX) was no difference between the two groups (0.57 ± 0.28 vs 0.55 ± 0.21, p = 0.868). Multivariate regression showed that HbA1c was inversely associated with N-MID osteocalcin and PINP after adjusting for age, BMI, menopause’s years, diabetic duration, TC, TG, HDL-c, LDL-c, creatinine, UA and eGFR. The adjusted coefficients for N-MID osteocalcin and PINP per 1% HbA1c decrease were − 0.71 (− 1.19, − 0.22) and − 1.79 (− 3.30, − 0.28), respectively. A segmentation effect was seen in the fitted curve between HbA1c and β-CTX with an inflection point at 7.4% of HbA1c, the highest quartile of β-CTX (> = 0.74 ng/ml) showed a significantly negative with HbA1c. No significant association was seen between HbA1c and other biochemical markers.ConclusionsOur study found that bone formation was inhibited in postmenopausal women with T2DM, but bone resorption was not affected, and poor glycemic control was related to lower levels of bone formation, may increase the risk of bone fracture in postmenopausal women with T2DM.

Glabridin and glycyrrhizic acid show no beneficial effect on the chemical composition and mechanical properties of bones in ovariectomized rats, when administered in moderate dose.

One of the major causes of osteoporosis and bone fracture in postmenopausal women is estrogen deficiency. To prevent the fractures, and avoid the side effects of hormone replacement therapy, phytoestrogens including the isoflavonoids are used. In the presented study two constituents occurring in the licorice root-the isoflavane glabridin and triterpenoid saponin glycyrrhizic acid were examined on the skeletal system of ovariectomized rats. The female Wistar rats were divided into five groups: control group, ovariectomized group as well as three ovariectomized groups treated with estradiol (0.2mg/kg), glabridin (5mg/kg) or glycyrrhizic acid (15mg/kg). All substances were administered orally for 4 weeks. The estradiol served as a positive control. The mechanical properties of femoral diaphysis, tibial metaphysis and femoral neck were assessed using bending and compression tests. Moreover the chemical composition of the femur, tibia and L-4 vertebra - content of water, organic substances and minerals - was determined. Ovariectomy induced unfavorable changes in the skeletal system of the rats. Administration of glabridin and glycyrrhizic acid to the ovariectomized rats did not improve analyzed parameters of the bones. Obtained results indicate, that the tested substances revealed no beneficial effect on the mechanical properties and chemical composition of the tested bones, thus they cannot be used as the osteoporosis protective agents.

The Role of Estrogen Receptor in Bone Cells

Estrogen is an essential regulator of the skeleton homeostasis during both childhood and adulthood. As a matter of fact, estrogens and selective estrogen receptor modulators are considered essential treatment tools by clinicians to prevent bone fractures in postmenopausal women. All these observations promote a great interest in discovering the mechanisms by which estrogens protect bone. Over the past years, research performed from several groups has established that the osteoprotective effects of estrogens are due to both direct actions on bone cells and indirect effects mediated through bone marrow cells. Experiments performed in humans and animals, in which estrogen receptor deletion was specifically carried out in different bone cells, have allowed unraveling some aspects of the estrogen actions on bone through these cells. This review highlights the current knowledge about the role of estrogens in the RANKL/OPG system, as well as their role in different bone cells and bone marrow cells.

Strontium ranelate stimulates the activity of bone-specific alkaline phosphatase: interaction with Zn2+ and Mg2+

Strontium ranelate (SR) is an orally administered and bone-targeting anti-osteoporotic agent that increases osteoblast-mediated bone formation while decreasing osteoclastic bone resorption, and thus reduces the risk of vertebral and femoral bone fractures in postmenopausal women with osteoporosis. Osteoblastic alkaline phosphatase (ALP) is a key enzyme involved in the process of bone formation and osteoid mineralization. In this study we investigated the direct effect of strontium (SR and SrCl2) on the activity of ALP obtained from UMR106 osteosarcoma cells, as well as its possible interactions with the divalent cations Zn(2+) and Mg(2+). In the presence of Mg(2+), both SR and SrCl2 (0.05-0.5 mM) significantly increased ALP activity (15-66 % above basal), and this was dose-dependent in the case of SR. The stimulatory effect of strontium disappeared in the absence of Mg(2+). The cofactor Zn(2+) also increased ALP activity (an effect that reached a plateau at 2 mM), and co-incubation of 2 mM Zn(2+) with 0.05-0.5 mM SR showed an additive effect on ALP activity stimulation. SR induced a dose-dependent decrease in the Km of ALP (and thus an increase in affinity for its substrate) with a maximal effect at 0.1 mM. Co-incubation with 2 mM Zn(2+) further decreased Km in all cases. These direct effects of SR on osteoblastic ALP activity could be indicating an alternative mechanism by which this compound may regulate bone matrix mineralization.

Limitaciones de los fármacos dependientes de insulina para el tratamiento de la diabetes mellitus tipo 2

In this study, we review the efficacy and safety limitations of insulin-dependent oral antidiabetic agents. In terms of efficiency, the main drawback of metformin, sulfonylureas, gliptins and –to a lesser extent–glitazones is durability. No drug per se is able to maintain stable blood glucose control for years.Metformin, sulfonylureas and gliptins have demonstrated safety. Experience with the first two drug groups is more extensive. The main adverse effect of metformin is gastrointestinal discomfort. Major concerns related to the use of sulfonylureas are hypoglycemia and weight gain. The use of pioglitazone has been associated with an increased risk of bladder cancer, edema, heart failure, weight gain, and distal bone fractures in postmenopausal women. The most common adverse reactions associated with glucagon-like peptide-1 agonists are gastrointestinal discomfort that sometimes leads to treatment discontinuation.

Virus clearance reduces bone fracture in postmenopausal women with osteoporosis and chronic liver disease caused by hepatitis C virus

Osteoporosis is often present in postmenopausal women. The aim of this retrospective cohort study was to assess the cumulative incidence and predictive factors for bone fracture after cessation of interferon (IFN) in postmenopausal women with osteoporosis and chronic liver disease caused by hepatitis C virus (HCV). A total of 420 postmenopausal women treated with IFN monotherapy were enrolled. The mean observation period was 7.2 years. The primary goal was the development of bone fracture. Evaluation was carried out by using the Kaplan-Meier method and the Cox proportional hazards analysis. Thirty-one out of 420 patients sustained bone fracture. The cumulative development rate of bone fracture was 3.6% at 5th year, 9.2% at 10th year, and 17.4% at 15th year. Multivariate Cox proportional hazards analysis showed that bone fracture after cessation of IFN therapy occurred when histological staging of the liver was advanced (hazard ratio (HR): 2.54; 95% confidence interval (CI) = 1.21-5.31; P = 0.013), serum albumin level was < 3.5g/dl (HR: 2.25; 95% CI = 1.10-4.59; P = 0.026), and virus clearance was not achieved (HR: 3.65; 95% CI = 1.11-12.05; P = 0.033). The results indicate that virus clearance causes a reduction of two-thirds in the risk of bone fracture after cessation of IFN therapy in postmenopausal women with osteoporosis and chronic liver disease caused by HCV. J. Med. Virol. 82:390-395, 2010. (c) 2010 Wiley-Liss, Inc.

Bone fractures among postmenopausal patients with endocrine-responsive early breast cancer treated with 5 years of letrozole or tamoxifen in the BIG 1-98 trial

BackgroundTo compare the incidence and timing of bone fractures in postmenopausal women treated with 5 years of adjuvant tamoxifen or letrozole for endocrine-responsive early breast cancer in the Breast International Group (BIG) 1-98 trial. MethodsWe evaluated 4895 patients allocated to 5 years of letrozole or tamoxifen in the BIG 1-98 trial who received at least some study medication (median follow-up 60.3 months). Bone fracture information (grade, cause, site) was collected every 6 months during trial treatment. ResultsThe incidence of bone fractures was higher among patients treated with letrozole [228 of 2448 women (9.3%)] versus tamoxifen [160 of 2447 women (6.5%)]. The wrist was the most common site of fracture in both treatment groups. Statistically significant risk factors for bone fractures during treatment included age, smoking history, osteoporosis at baseline, previous bone fracture, and previous hormone replacement therapy. ConclusionsConsistent with other trials comparing aromatase inhibitors to tamoxifen, letrozole was associated with an increase in bone fractures. Benefits of superior disease control associated with letrozole and lower incidence of fracture with tamoxifen should be considered with the risk profile for individual patients.

Once-yearly zoledronic acid in the prevention of osteoporotic bone fractures in postmenopausal women.

Zoledronic acid is a nitrogen-containing, third-generation bisphosphonate that has recently been approved for the treatment of postmenopausal osteoporosis as an annual intravenous infusion. Zoledronic acid is an antiresorptive agent which has a high affinity for mineralized bone and especially for sites of high bone turnover. Zoledronic acid is excreted by the kidney without further metabolism. Zoledronic acid administered as a 5 mg intravenous infusion annually increases bone mineral density in the lumbar spine and femoral neck by 6.7% and 5.1% respectively and reduces the incidence of new vertebral and hip fractures by 70% and 41% respectively in postmenopausal women with osteoporosis. Most common side effects are post-dose fever, flu-like symptoms, myalgia, arthralgia, and headache which usually occur in the first 3 days after infusion and are self-limited. Rare adverse effects include renal dysfunction, hypocalcemia, atrial fibrillation, and osteonecrosis of the jaw.

Prolonged‐efficacy of bisphosphonate in postmenopausal women with osteoporosis and chronic liver disease

Osteoporosis is present often in postmenopausal women. The aim of this retrospective cohort study is to assess the cumulative appearance incidence and predictive factors for bone fracture in postmenopausal women with osteoporosis and chronic liver disease. The patients were 80 postmenopausal women with osteoporosis and chronic liver disease due to hepatitis virus B or C. These patients were given cyclic etidronate therapy within 3 months after diagnosis of osteoporosis (etidronate-group). Another 400 postmenopausal women with osteoporosis and chronic liver disease were selected as controls (control group). Patients in control group were matched 1:5 with etidronate-group for age. Patients in control group were not given any drugs after diagnosis of postmenopausal osteoporosis. The mean observation period was 8.1 years. Four patients in the etidronate-group and 46 in control group developed bone fracture. The 10th year cumulative appearance rates of bone fracture were 4.9% in etidronate-group and 13.8% in control group. Cox regression model showed that the appearance rate of bone fracture decreased with statistical significance in the following cases: (1) patients <65 years (P<0.001), (2) patients with serum albumin level of >or=3.5 g/dl (P=0.003), and (3) patients treated with etidronate (P=0.020). The cumulative survival rate after bone fracture was 82.2% at the second year, and 57.6% at the fifth year. The present study suggests that a serum albumin level of >or=3.5 g/dl and cyclic etidronate treatment reduce the appearance of bone fracture.

Hormonal replacement therapy (HRT) in postmenopause: a reappraisal

Hormone replacement therapy (HRT) is the most effective treatment currently available for vasomotor and urogenital symptoms and decreased libido. Because harmful effects were evidenced in some clinical trials, health authorities now consider that risk-benefit considerations do not favour the use of HRT for prevention of cardiovascular diseases and bone fractures in postmenopausal women. However, experimental and clinical studies indicate that adverse effects of HRT may largely depend on the estrogen and progesterone/progestin formulation, dosage, mode of administration, patient's age, associated diseases, and duration of treatment. All estrogen formulations and modes of administration have similar beneficial effects on vasomotor and urogenital symptoms and on bone structure. But cardiovascular and invasive breast cancer risks are higher with oral estrogen than with transdermal estradiol, and also higher with many progestin compounds than with micronized progesterone. The combination of transdermal estradiol + micronized progesterone appears to be effective and relatively safe if elementary precautions are taken, and seems to be presently the best choice for HRT in most postmenopausal women. In the author's — heterodox — opinion, HRT may also be a good therapeutic choice to prevent bone loss, since alternative medications, including raloxifene and bisphosphonates, may have dramatic harmful effects in some patients. It might also have beneficial effects on the development of coronary disease in young postmenopausal women. HRT requires careful adjustment to each individual patient and continuous monitoring of clinical evolution. In the future, this adjustment could benefit from genetic screening to maximize in each individual the ratio between positive and adverse effects.

Comparison of Weekly Treatment of Postmenopausal Osteoporosis with Alendronate Versus Risedronate Over Two Years

Alendronate and risedronate are bisphosphonate drugs that are widely used to lower the risk of bone fractures in postmenopausal women who have osteoporosis. Both these agents-but particularly alendronate-significantly increased bone mineral density (BMD) and lowered markers of bone turnover in the FACT (Fosamax Actonel Comparison Trial), a randomized, double-blind, multicenter study enrolling 1053 women, postmenopausal for at least 6 months, who initially had low values of BMD and were followed up after 12 months of treatment. Once-weekly doses of alendronate and risedronate were 70 and 35 mg, respectively. A one-year extension of the FACT now has been completed in 833 of the original participants. Changes in BMD were assessed at the trochanter, total hip, femoral neck, and lumbar spine. Similar proportions of women in the two treatment groups took part in the extended study, and their demographic characteristics were similar. BMD increased significantly more at all sites in alendronate-treated women, and the differences increased over time. In addition, significantly more women treated with alendronate maintained or gained BMD at each measurement site, and fewer of them had lower BMD values after 2 years. Both drugs significantly reduced bone resorption as reflected by decreases in urinary N-telopeptide of type 1 human collagen (corrected for creatinine) and serum C-telopeptide. Both drugs lowered serum levels of two markers of bone formation, bone-specific alkaline phosphatase and N-terminal propeptide of type 1 procollagen. There were no significant group differences in rates of total clinical adverse events, serious events, or withdrawal because of side effects after 2 years of treatment. Levels of upper gastrointestinal side effects such as dyspepsia, nausea, and reflux that prompted withdrawal from the study were similarly frequent in the two treatment groups. One risedronate-treated patient developed a bleeding duodenal ulcer during the extension period and died. Patients in the two groups were at similar risk of clinical fractures.

Effects of estrogen and selective estrogen receptor modulators on osteoporosis

Evidence indicates that estrogen and raloxifene hydrochloride, a selective estrogen receptor modulator, prevent bone loss and reduce the risk of bone fractures in postmenopausal women. However, recent reports indicate that the health risks associated with the use of estrogen, which include breast cancer and coronary heart disease (CHD), exceed the benefits. In contrast, raloxifene is associated with a lower incidence of breast cancer and is not associated with CHD. Therefore, the use of raloxifene is preferable for the prevention and treatment of osteoporosis in postmenopausal patients.

Optimal Calcium Intake

IT HAS BEEN a decade since the 1984 Consensus Development Conference on Osteoporosis first suggested that increased intake of calcium might help prevent osteoporosis. Osteoporosis affects more than 25 million people in the United States and is the major underlying cause of bone fractures in postmenopausal women and the elderly. Previous surveys have revealed that the US population experiences more than 1.5 million fractures annually at a cost in excess of $10 billion per year to the health care system. Two important factors that influence the occurrence of osteoporosis are optimal peak bone mass attained in the first two to three decades of life and the rate at which bone is lost in later years. Adequate calcium intake is critical to achieving optimal peak bone mass and modifies the rate of bone loss associated with aging. A number of publications have addressed the possible role of calcium intake in the

Tamoxifen and breast cancer???from palliation to prevention

Tamoxifen, a synthetic antiestrogen, has been used in the treatment of all stages of breast cancer. The National Surgical Adjuvant Breast and Bowel Project (NSABP) is now in the process of evaluating the role of tamoxifen in the prevention of breast cancer (NSABP P-1 trial). Beneficial effects of tamoxifen in reducing coronary artery disease and preventing bone fractures in postmenopausal women will also be examined. Adjuvant therapy trials conducted during the 1980s provided extensive data on the biologic and possibly toxic effects of tamoxifen. These trials laid the groundwork to support the benefits and risks of the present preventional trial. The NSABP P-1 trial population of 16,000 participants will consist of women > or = 60 years of age and women 35-39 years old who are at increased risk for developing breast cancer. Nursing will play an important role in educating the public and counseling possible trial participants. Nurses monitoring the progress of this trial may witness the use of tamoxifen therapy come full cycle--from a palliative agent used in advanced breast cancer to a therapeutic agent that prevents the development of breast cancer.

The Role of Exercise in Prevention of Osteoporosis

Summary Osteoporosis is currently the major cause of bone fractures in post-menopausal women and older people and is associated with a high personal and medical cost. Peak bone mass is achieved in the fourth decade followed by a gradual loss of bone which is less in men than women. Superimposed on this gradual age-related loss is an accelerated period of bone loss following the menopause in women. Preventive strategies against the development of osteoporosis include maximising bone mass early in life and slowing the age-related loss. It is now well established that mechanical force through gravity or muscle pull is a major factor in maintaining or increasing bone mass and strength, the improvements being specific to the bone being loaded. Conversely, physical inactivity and weightlessness are associated with loss of bone mass. Many athletes have a greater bone mass than their age-matched sedentary controls. Correlates have been also found between indices of physical activity, fitness and muscle and bone mass in relatively sedentary men and women over a wide age range. Controlled prospective trials of exercise intervention have demonstrated that physical exercise can prevent or reverse loss of bone in pre- and post-menopausal women. Additional desirable effects of increased exercise are improvements in muscle strength, cardiovascular fitness and general well-being. The combined effect of these should be to decrease the incidence of falls and therefore protect against further fractures. Further long-term studies are now required to determine the most effective form of exercise, the optimum duration and frequency and the effect that this has on fracture incidence.