OBJECTIVE: Osteoporosis clinical practice guidelines recommend exercise to prevent fractures, but the efficacy of exercise depends on the exercise types, the population studied, or the outcomes of interest. The purpose of this systematic review was to assess the effects of progressive resistance training (PRT) on health-related outcomes in people at risk of fracture. METHODS: Multiple databases were searched to October 2019. Eligible articles were randomized controlled trials (RCTs) of PRT interventions in men and women >= 50 years with low bone mineral density (BMD) or fracture history. Descriptive information and mean difference (MD) and standard deviation (SD) were directly extracted for included trials. Fifty-three studies were included. RESULTS: PRT does not increase the total number of falls (incidence rate ratio (IRR) 1.05; 95% CI 0.91 to 1.21; 7 studies), whereas the effects on risk of falls are uncertain (relative risk (RR) 1.23; 95% CI 1.00 to 1.51; 5 studies). PRT improved performance on the Timed "Up and Go" test (MD -0.89 seconds; 95%CI -1.01 to -0.78; 13 studies) and health-related quality of life (standardized mean difference (SMD) 0.32; 95%CI 0.22 to 0.42; 20 studies). PRT may increase femoral neck (MD 0.02 g/cm2; 95% CI 0.01 to 0.03; 521 participants, 5 studies) but not lumbar spine BMD (MD 0.02 g/cm2; 95%CI -0.01 to 0.05; 4 studies), whereas the effects on total hip BMD are uncertain (MD 0.00 g/cm2; 95% CI 0.00 to 0.01; 435 participants, 4 studies). PRT reduced pain (SMD -0.26; 95%CI -0.37 to -0.16; 17 studies). Sensitivity analyses including PRT-only studies confirmed these findings. CONCLUSION: Individuals at risk of fractures should be encouraged to perform PRT, as it may improve femoral neck BMD, health-related quality of life, and physical functioning. PRT also reduced pain; however, whether PRT increases or decreases the risk of falls, the number of people experiencing a fall, or the risk of fall-related injuries is uncertain.

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