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運動抗骨鬆：有氧+重訓最有效！揭密絕經後女性骨密度改善關鍵

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研究顯示，有氧運動結合阻力訓練（AE+RT）最能有效提升絕經後女性的腰椎與股骨頸骨密度。全身振動與單一有氧運動亦具成效，為預防骨質疏鬆提供具實證的運動處方。

不同類型運動對絕經後女性骨礦物質密度的影響：系統性回顧與網絡 Meta 分析

Effect of different types of exercise on bone mineral density in postmenopausal women: a systematic review and network meta-analysis

Kemmler W, Shojaa M, Kohl M, von Stengel S. Effects of Different Types of Exercise on Bone Mineral Density in Postmenopausal Women: A Systematic Review and Meta-analysis. Calcif Tissue Int. 2020;107(5):409-439. doi:10.1007/s00223-020-00744-w

https://pubmed.ncbi.nlm.nih.gov/32785775/

摘要 Abstract

絕經後女性（PMW）經歷卵巢功能的下降；雌激素的減少將加速骨質流失。運動是減輕 PMW 骨密度（BMD）流失的有效手段，但不同運動類型的相對有效性仍在研究中。我們的研究涵蓋了徹底的評估和網絡統合分析，遵循系統評價和網絡統合分析的首選報告項目（PRISMA）聲明中規定的原則。數據來源和搜索 文獻搜索數據庫包括 PubMed、Embase、Cochrane、Google Scholar、Web of Science (WOS)和 Scopus。數據搜索結合了骨密度（BMD）、絕經後女性和各種運動類型等關鍵詞。數據綜合和分析 通過使用 R 環境整合直接和間接比較來進行網絡統合分析。本網絡統合分析旨在評估和比較 PMW 中各種運動類型與骨密度，以確定最有效的類型。文獻包括 49 篇論文，涵蓋 3360 人參與八項干預。 網絡 Meta 分析根據森林圖中分配給運動干預的 p 分數，對運動干預對腰椎骨密度的影響進行了降序排名。顯示出顯著療效的運動方式為 AE + RT（有氧混合阻力運動，MD = 32.35，95% CrI [8.08;56.62]，p = 0.87）、AE（有氧運動，MD = 22.33，95% CrI [6.67;37.99]，p = 0.74）和 RT（阻力訓練，MD = 16.98，95% CrI [8.98;24.99]，p = 0.60）。同樣，根據森林圖中的 p 分數，股骨頸部位也按降序排名，對腰椎骨密度有顯著影響的運動模式為 AE + RT（MD = 140，95% CrI [40.89;239.11]，p = 0.99）、WBV（全身振動，MD = 26.07，95% CrI [2.97;49.16]，p = 0.80）和 RT（MD = 16.98，95% CrI [8.98;24.99]，p = 0.72）。運動干預顯著有效地改善了絕經後女性的骨密度，其中 AE + RT 的效果最佳。

Postmenopausal women (PMW) experience the decline of ovarian function; estrogen reduction will accelerate bone mass loss. Exercise is an effective means of mitigating bone mineral density (BMD) loss in PMW, but the relative effectiveness of different exercise types remains under investigation. Our study encompassed a thorough assessment and network meta-analysis, following the principles specified in the Preferred Reporting Items for Systematic Reviews and Network Meta-analysis (PRISMA) statement. Data sources and searches Literature search databases include PubMed, Embase, Cochrane, Google Scholar, Web of Science (WOS), and Scopus. The data search combined keywords like bone mineral density (BMD), postmenopausal women, and various exercise types. Data synthesis and analysis Perform a network meta-analysis by integrating both direct and indirect comparisons using the R environment. This network meta-analysis aimed to evaluate and compare various exercise types with bone mineral density in PMW to identify the most effective types. The literature comprised a collective of 49 papers, encompassing 3360 people across eight interventions. The Network Meta-analysis ranked the effects of exercise interventions on lumbar spine BMD in descending order, based on the p-scores assigned to them in the forest plot. The exercise modalities that showed significant efficacy were AE + RT(Aerobic Mixed Resistance Exercise, MD = 32.35, 95% CrI [8.08;56.62], p = 0.87), AE(Aerobic Exercise, MD = 22.33, 95% CrI [6.67;37.99], p = 0.74), and RT(Resistance Training, MD = 16.98, 95% CrI [8.98;24.99], p = 0.60). Similarly, the femoral neck sites were ranked in descending order based on their p-scores in the forest plot, and the exercise patterns with significant effects on lumbar spine bone mineral density were AE + RT(MD = 140, 95% CrI [40.89;239.11], p = 0.99), WBV(Whole Body Vibration, MD = 26.07, 95% CrI [2.97;49.16], p = 0.80), and RT(MD = 16.98, 95% CrI [8.98;24.99], p = 0.72). Exercise intervention significantly and effectively alleviated BMD in postmenopausal women, with AE + RT having the best effect.

引言 Introduction

在絕經後女性中，卵巢功能障礙導致雌激素合成減少，進而引發骨代謝失調、破骨細胞活性增加、骨質流失加速、骨形成不足以及骨密度下降，最終導致骨質疏鬆。在中國，絕經後骨質疏鬆的發生率在圍絕經期女性中約為 25%，在 50 歲以上女性中為 29.1%，在 65 歲以上女性中為 51.6%。由於骨密度降低而導致的骨質疏鬆性骨折，是老年患者殘疾和死亡的主要原因之一。在髖部骨折後的一年內，約 20%的患者將因各種併發症而去世，約 50%的患者將面臨殘疾和生活質量的顯著下降。此外，骨質疏鬆和骨折的醫療和護理需要大量的人力、物力和財力資源，給家庭和社會帶來沉重負擔。預測顯示，到 2025 年，全球髖部骨折的數量將上升至每年 260 萬例，並在 2050 年達到 450 萬例。 預計中國將經歷類似的模式，髖骨骨折的年發生率預計將從 2006 年的 69 萬上升至 2020 年的 164 萬，並在 2050 年進一步上升至 591 萬。2006 年，中國髖骨骨折的預期年成本約為 20.5 億美元（以 2013 年計算）。這一數字預計到 2020 年和 2050 年將分別增加到 274.8 億美元和 5819.7 億美元。因此，及時識別、干預和治療骨質疏鬆症是至關重要的。
Ovarian dysfunction in PMW (postmenopausal women) leads to decreased estrogen synthesis, resulting in bone metabolism disorders, increased osteoclast activity, accelerated bone loss, insufficient bone formation, and decreased bone density, resulting in osteoporosis1,2,3. In China, the incidence of postmenopausal osteoporosis is approximately 25% among perimenopausal women, 29.1% among women over 50, and 51.6% among those over 654. Osteoporotic fractures, resulting from diminished bone density, are one of the leading causes of disability and death in older adults patients. Within a span of one year following a hip fracture, around 20% of patients will succumb to a range of complications, and roughly 50% of patients will have disability and a notable decline in their quality of life5,6. Moreover, the medical and nursing care of osteoporosis and fractures requires a large amount of human, material, and financial resources, placing a heavy burden on families and society7. Projections indicate that the global number of hip fractures will rise to 2.6 million annually by 2025 and 4.5 million by 2050. It is expected that China will experience a comparable pattern, with the annual incidence of hip fractures projected to rise from 690,000 in 2006 to 1.64 million in 2020 and further to 5.91 million by 2050. In 2006, the anticipated yearly cost of fractures of the hip in China was around $2.05 billion (in 2013 dollars). This figure is projected to increase to $27.48 billion and $581.97 billion by 2020 and 2050, respectively8. Hence, it is imperative to promptly identify, intervene, and treat osteoporosis.

人們普遍認為，體育活動是減緩骨質流失過程的一種非常有效的方法。目前也有許多頭對頭隨機對照試驗和統合分析比較不同運動方式對 PMW 患者 BMD（骨質密度）影響的差異。例如，Li 等人的結果。 9 結果表明，6 個月的易筋經加彈性阻力訓練對 PMW 患者的脊柱、大腿、腰椎及全身的 BMD 有顯著影響； Riaz 等人 10 研究表明，8 個月的高強度混合訓練可顯著改善 PMW 的腰椎 BMD； Dutto 等人 11 證明，6 個月的高強度運動量提高了 PMW 的高強度運動結果等高強度 (LMW 的高強度有氧運動； 12 表明，有氧運動和 6 個月的 WBV 訓練對改善 PMW 的 BMD 同樣有效；在 Rahimi 等人對一組 PMW 進行的薈萃分析中。 13 ，阻力運動、負重有氧運動和綜合運動對於絕經後女性的腰椎骨礦密度沒有影響，而 WBV 則是改善絕經後女性腰椎 BMD 的有效方法。然而，在 Hejazi 等人的後續綜合分析中 14 ，有氧運動和綜合訓練顯著改善了絕經後女性的腰椎 BMD，而 WBV 訓練則沒有顯著的益處。同時，其他研究系統性地評估了身體活動對絕經後女性 BMD 的影響。然而，這些研究專注於單一介入措施的影響，例如阻力運動 15,16,17,18 、有氧運動 19,20,21,22 、太極運動 23,24,25,26 ，並且有些比較了介入措施的影響 9,27,28,29,30,31 。傳統的綜合分析將範圍限制在兩種運動介入之間的直接比較，從而提供的信息有限。某些介入之間缺乏直接對比測試進一步複雜化了最有效運動方式的確定。因此，需要更全面的證據來指導最佳介入策略，以了解各種運動治療對絕經後女性 BMD 的影響。 網絡網絡分析是一種方法，允許在單一研究中同時比較多種干預方法。它通過整合來自隨機對照試驗網絡的直接和間接數據來實現這一點。本研究使得根據不同療法的療效對其進行分類成為可能 32 。本研究的主要目的是全面分析和評估不同運動方式對絕經後女性骨密度的影響。此外，我們還旨在闡明這些影響的優勢和局限性，旨在為臨床醫療專業人員提供一個科學基礎，以便辨別和選擇最佳的運動干預。
Physical activity is widely acknowledged as a highly effective approach for mitigating the process of bone loss. At present, there are also many head-to-head randomized controlled trials and meta-analyses comparing the differences in the effects of different exercise methods on BMD (Bone Mineral Density) in PMW. For example, the results of Li et al.9 showed that 6 months of Yi Jin Jing(易筋经) plus elastic resistance exercise had significant effects on BMD of spine, thigh, lumbar vertebra and whole body of PMW; Riaz et al.10 showed that 8 months of high-intensity mixed training significantly improved lumbar spine BMD in PMW; Dutto et al.11 demonstrated that a 6-month period of high-intensity aerobic exercise yielded superior results compared to moderate-intensity resistance training in enhancing BMD in the lumbar vertebrae of PMW; The results of de Oliveira et al.12 showed that aerobic exercise and WBV training for 6 months were equally effective in improving BMD in PMW; in a meta-analysis of a cohort of PMW by Rahimi et al.13, resistance exercise, weight-bearing aerobic exercise, and combined exercise had no effect on lumbar vertebra bone mineral density in PMW, while WBV was an effective method for improving lumbar vertebra BMD in PMW. However, in a subsequent meta-analysis by Hejazi et al.14, aerobic exercise and combined training significantly improved lumbar BMD in PMW, while WBV training had no significant benefit. Concurrently, other studies have systematically evaluated the impact of physical activity on BMD in PMW. However, these studies focused on the impact of single intervention measures, such as resistance exercise15,16,17,18、aerobic exercise19,20,21,22、tai chi exercise23,24,25,26, and some compare the impact of intervention measures9,27,28,29,30,31. Conventional meta-analyses restrict their scope to direct comparisons between two exercise interventions, thereby offering a limited amount of information. The lack of head-to-head testing between certain interventions further complicates the determination of the most effective exercise modality. As a result, there is a need for more comprehensive evidence on the effects of various exercise treatments on BMD in PMW to guide optimal intervention strategies. Network meta-analysis is a method that allows for the simultaneous comparison of many intervention methods in a single study. It achieves this by incorporating both direct and indirect data from a network of randomized controlled trials. This study enables the classification of various therapies according to the efficacy of their outcomes32. The major objective of the research was to comprehensively analyze and evaluate the effects of different exercise modalities on BMD in PMW. Additionally, we sought to elucidate the strengths and limitations of these effects, aiming to furnish clinical healthcare professionals with a scientifically grounded foundation for discerning and selecting optimal exercise interventions.

方法 Methods

我們的研究涵蓋了徹底的評估和網絡元分析，遵循了系統評價和網絡元分析的首選報告項目（PRISMA）聲明中指定的原則 33 。PROSPERO 已正式記錄該協議並分配了註冊號 CRD42023472051。

Our study encompassed a thorough assessment and network meta-analysis, following the principles specified in the Preferred Reporting Items for Systematic Reviews and Network Meta-analysis (PRISMA) statement33. PROSPERO has officially recorded the protocol and assigned it the registration number CRD42023472051.

數據來源和搜索
Data sources and searches

文獻搜尋資料庫包括 PubMed、Embase、Cochrane、Google Scholar、WOS 和 Scopus。搜尋期間從開始日期到 2023 年 4 月 1 日。我們通過利用特定主題詞和不受限制的關鍵字的組合來進行搜尋。數據搜尋結合了像骨礦密度（BMD）、絕經後女性和各種運動類型的關鍵字。所採用的搜尋方法如下（以 PubMed 為例）：骨礦密度（BMD） AND（運動 OR 有氧運動 OR 抵抗運動 OR 混合運動 OR 有氧運動結合抵抗運動 OR 震動板運動 OR 太極 OR 步行 OR 衝擊運動） AND（絕經後 OR 絕經後女性），文獻的納入是手動搜尋並盡可能全面地納入。此外，搜尋已發表的系統評估文章中列出的參考文獻是獲取文章的主要方式（補充資料 2）。

Literature search databases include PubMed, Embase, Cochrane, Google Scholar, WOS, and Scopus. The search period spans from its start date to April 1, 2023. We perform the search by utilizing a blend of specific subject terms and unrestricted keywords. The data search combined keywords like bone mineral density (BMD), postmenopausal women, and various exercise types. The search approach employed was as follows (using PubMed to serve as an exemplar): Bone Mineral Density (BMD) AND (exercise OR Aerobic exercise OR Resistance exercise OR Mixed exercise OR Aerobic exercise combined with resistance exercise OR Vibrating plate exercise OR Tai Chi OR walking OR impact exercise) AND (post-menopausal OR postmenopausal), the literature for inclusion was manually searched and included as comprehensively as possible. Also, searching the references listed in published systematic evaluation articles is a primary way to access the articles (Supplementary2).

研究選擇 Study selection

納入要求是使用 PICOS（參與者、干預、比較、結果和研究設計）方法確定的 33 。(1) 研究的參與者是經歷過更年期超過一年的絕經後女性；(2) 根據內容將運動分為八種類型；運動訓練的類型在補充資料 3 中明確定義；(3) 對照組（CON）由非干預、日常活動、等待名單、健康指導或常規護理組成。此外，對於對照研究，對照組可以是與實驗組不同的八種運動中的任何一種；(4) 研究應包括感興趣的結果指標：腰椎和股骨頸部位的骨密度（BMD）；(5) 在研究設計方面，我們納入了已發表的隨機對照試驗（RCT）（個體設計、集群設計或橫斷面研究的前半部分）。 我們排除了以下研究：(1) 單次治療會對參與者的骨密度產生急性影響的研究；(2) 沒有明確描述運動類型的研究；(3) 沒有根據基線和隨訪之間的變化分數進行骨密度狀態的結果評估的研究。

The inclusion requirements were determined using the PICOS (Participants, Interventions, Comparators, Outcomes, and Study Design) methodology33. (1) The participants in the study were postmenopausal women who had experienced menopause for more than one year at the beginning of the study; (2) exercises were categorized into eight types based on content; the types of sports training are clearly defined in Supplementary 3; (3) the control group (CON) consisted of either non-intervention, regular daily activities, waiting list, health instruction, or usual care. Additionally, for head-to-head studies, the control group can be any of the eight exercises that are different from the experimental group; (4) studies should include the outcome metrics of interest: BMD at the lumbar vertebra along with femoral neck sites; and (5) in terms of study design, we included published RCTs (individual designs, cluster designs, or the first half of cross-sectional studies). We excluded studies in which (1) a single treatment session had an acute effect on participants’ BMD; (2) studies in which the type of exercise was not explicitly described; (3) no outcome assessment of BMD status was made based on change scores between baseline and follow-up.

數據抽取和質量評估
Data abstraction and quality assessment

在上述數據庫中檢索到所有相關文章後，這些文章被存檔在 EndNote X9 參考管理器中。研究人員獨立評估了搜索結果，獲取了完整文本，並收集了所納入研究的相關信息。根據 Cochrane 風險偏倚 2.0 標準（補充資料 4）對研究進行了評估和評分。所有不一致之處均由審查小組的研究人員通過共識和仲裁解決。此外，我們利用網絡元分析的證據信心（CINeMA）在線程序評估了證據的確定性。該應用程序將研究結果的信心級別分為四個類別：高、中、低和極低（補充資料 5）。

After all pertinent articles were retrieved in the aforementioned databases, they were archived in the EndNote X9 Reference Manager. The researchers conducted independent evaluation of the search results, obtained the complete text, and collected pertinent information from the studies that were included. Studies were assessed and rated according to Cochrane Risk Bias 2.0 criteria (Supplementary 4)34. All inconsistencies were addressed by consensus and arbitration among the researchers in the review team. Furthermore, we assessed the certainty of the evidence by utilizing the Confidence in Network Meta-Analyses (CINeMA) online program. This application classifies the confidence level of the findings into four categories: high, medium, low, and extremely low (Supplementary 5)35.

數據綜合和分析
Data synthesis and analysis

在 R 環境中通過整合直接和間接比較進行網絡元分析。測量數據的平均差異（MD）及其 95%置信區間（95%CI）被用作效果指標。統計分析評估了治療設計測試中的差異，通過使用 R netmeta 軟件包中的 SIDE 測試區分間接和直接證據。詳細信息請參見補充材料 6。通過對比分組研究中潛在效果修飾因子的分佈（出版年份、平均年齡、樣本大小和運動期間）來評估可轉移性假設（補充材料 7）。具有顯著可轉移性的變量和文獻質量進行了敏感性分析，詳細方法在補充材料 8 中列出。同時，創建了網絡關係圖和各種干預措施的排名圖，並根據森林圖中分配給每個干預措施的 p-score 進行評分。p-score 越大，效果越好。通過使用漏斗圖檢測出版偏倚（補充材料 9）。

Perform a network meta-analysis by integrating both direct and indirect comparisons using the R environment. Measured data were mean difference (MD) and their 95% confidence interval (95%CI) were used as effect indicators. The statistical analysis evaluated discrepancies in the treatment design tests, distinguishing between indirect and direct evidence using the SIDE tests in the R netmeta software package. For further details, refer to Supplementary 6. The transferability hypothesis was evaluated through contrasting the distribution of underlying effect modifiers (year of publication, mean age, sample size, and exercise period) in grouped studies (Supplementary 7). The variables and literature quality with significant transitivity were subjected to sensitivity analysis, with detailed methodologies outlined in Supplementary 8. Simultaneously, the network relationship chart and the ranking diagram of various interventions were created, and each intervention was rated based on the p-score assigned to it in the forest plot. The larger the p-score, the better the effect. The detection of publication bias was achieved by employing funnel plots (Supplementary9).

結果 Results

研究特徵與質量評估
Study characteristics and quality assessment

總共檢索到 5,983 項研究，經過去重後獲得了 3,834 項研究。在這些研究中，通過閱讀標題和摘要排除了 2,049 項。獲得 96 篇研究的完整文本後，排除了主題不一致、非觀察性研究、無完整文本和缺失數據的文獻，最終納入了 49 項研究，具體程序見補充資料 10。圖 1 呈現了一個全面的流程圖，說明了研究選擇的過程。

An overall of 5,983 studies were retrieved from the initial database search, and 3834 studies were obtained after deduplication. Of these, 2,049 items were excluded by reading the title and abstract. After obtaining the complete text of 96 research, literature with inconsistent themes, non-observational studies, no full text, and missing data were excluded, and finally, 49 studies were finally included, seeas described in the process described in Supplementary 10. Supplementary 10 for specific procedures. Figure 1 presents a comprehensive flow chart that illustrates the process of study selection.

圖 1 PRISMA 流程圖顯示所納入研究的選擇過程。

這 49 項研究，發表於 1993 年至 2023 年，總樣本數為 3,360。補充資料 11 包含了所納入的研究和人口特徵。所有研究參與者均為停經後女性。平均年齡為 60.83 歲，標準差為 5.87，這 49 項研究根據運動內容分為八種類型，平均年齡為 60.83 歲，標準差為 5.87。運動持續時間介於 2 至 72 個月之間，平均持續時間為 11.81 個月，標準差為 9.87。運動頻率介於每週 1 至 7 次之間，平均為 3.10 次，標準差為 1.43，而單次運動的總持續時間從 5 分鐘到 75 分鐘不等，平均為 47.24 分鐘，標準差為 19.10。

The 49 research, published from 1993 to 2023, were included , with a combined sample size of 3,360. The Supplementary 11 contains the research and demographic characteristics that have been incorporated. All study participants were postmenopausal women. The average age was 60.83 years with a standard deviation of 5.87, Tand the 49 studies were categorized into eight types according to the content of the exercises, with an average age of 60.83 years and a standard deviation of 5.87. The duration of exercise varied between 2 and 72 months, with an average duration of 11.81 months and a standard deviation of 9.87. The frequency of exercise fluctuated between 1 and 7 times per week, with an average of 3.10 and a standard deviation of 1.43, and the overall duration of a single exercise session spanned from 5 to 75 min, with an average of 47.24 min and a standard deviation of 19.10.

隨機序列生成的偏倚風險（圖 2）在 29 項研究中為低（59.2%），其中沒有研究的風險為高，而 20 項研究（40.8%）的偏倚風險則存在一些擔憂。20 項研究（40.8%）的分配隱蔽方法適當描述，風險為低，而 29 項研究（59.2%）的分配隱蔽風險則不明。在所有 49 項研究中，大多數納入的隨機對照試驗（63.3%，n = 31）在不完整結果方面顯示出低偏倚風險，並且 49 項研究（100%）在選擇性結果報告方面顯示出低偏倚風險。關於分析中納入研究的潛在偏倚的詳細信息可以在補充資料 4 中找到。

The risk of bias (Fig. 2) for randomized sequence generation was low in 29 studies (59.2%), of which no study had a high risk, and the risk of bias was some concern in 20 studies (40.8%). The method of allocation concealment was appropriately described in 20 studies (40.8%) with a low risk of bias, and the risk of bias for allocation concealment was unclear in 29 studies (59.2%). Of all 49 studies, the majority of included randomized controlled trials (63.3%, n = 31) exhibited a low risk of bias in relation to incomplete outcomes, and 49 studies (100%) shown a low risk of bias in relation to selective outcome reporting. Comprehensive details regarding the potential biases associated with the research included in the analysis can be found in Supplementary 4.

圖 2 納入研究的偏倚風險。

網絡元分析 Network meta-analysis

證據網絡  Evidence network

圖 3 顯示了針對八種不同運動方式的證據網絡，旨在干預骨質疏鬆症的結果指標。網絡關係以對照組為中心，圓圈的面積代表使用該測量的樣本大小，線段的粗細則代表比較干預措施的文獻數量。

The evidence network for eight distinct exercise modalities aimed at intervening in osteoporosis outcome indicators is depicted in Fig. 3. The network relationships are centered on the control group, with the area of the circle representing the sample size for which the measure was used and the thickness of the line segment representing the amount of included literature comparing the interventions.

圖 3 臨床症狀的網絡圖。節點的大小與隨機分配到每種類型運動的參與者數量成正比。

用一條線連接涉及直接比較的運動類型，線的粗細對應於評估比較所進行的試驗數量。AE + RT 有氧混合阻力運動，WBV 全身振動，RT 阻力訓練，TC 太極，AE 有氧運動，MIX 混合運動，IE 衝擊運動，Walking 步行運動。

Network plot of clinical symptoms. The magnitude of the nodes is directly proportional to the quantity of participants assigned randomly to each type of Exercise. A line is used to connect exercise kinds that involve direct comparisons, with the thickness of the line corresponding to the number of trials conducted to evaluate the comparison. AE + RT Aerobic Mixed Resistance Exercise, WBV Whole Body Vibration, RT Resistance Training, TC Tai Chi, AE Aerobic Exercise, MIX Mixed Exercise, IE Impact Exercise, Walking Walking Exercise.

腰椎骨密度
Bone density of lumbar vertebra

總共納入了 49 篇文章中的 46 篇，並對 2,963 名絕經後女性在腰椎骨密度（BMD）前後進行了測量。網絡 Meta 分析（表 1、2）顯示，運動類型 AE + RT（MD = 32.35，95% CrI [8.08;56.62]）、AE（MD = 22.33，95% CrI [6.67;37.99]）和 RT（MD = 16.38，95% CrI [5.03;27.73]）在提高絕經後女性的腰椎 BMD 方面顯著有效，與對照組相比。根據森林圖（圖 4）的 P-score 排名，可以看出 AE + RT 組的運動療法效果最高（P-score = 0.87），其次是 AE 運動組（P-score = 0.74）和 RT 運動組（P-score = 0.60）。聯盟表的結果顯示，各種運動類型之間沒有統計學上顯著的差異。

A total of 46 of 49 articles were included, and a total of 2,963 PMW were measured before and after lumbar vertebrae BMD. The Network Meta-analysis (Table 1, 2) revealed that exercise types AE + RT (MD = 32.35, 95% CrI [8.08;56.62]), AE (MD = 22.33, 95% CrI [6.67;37.99]), and RT (MD = 16.38, 95% CrI [5.03;27.73]) were significantly effective in enhancing BMD at the lumbar level in PMW, when compared to the control group. Based on the P-score ranking of the forest plot (Fig. 4), it can be shown that the exercise therapy effect of the AE + RT group exhibited the highest value (P-score = 0.87), followed by the AE exercise group (P-score = 0.74) and the RT exercise group (P-score = 0.60). The findings from the league table indicate that there were no statistically significant differences seen across the various types of exercise.

表 1 腰椎聯盟表。
表 2 股骨頸的聯盟表。
圖 4 森林圖顯示 8 種介入措施的療效變化。

運動類型的排名是根據 P-score 排名的概率來確定的。交叉 y 軸的治療與對照組之間沒有明顯的差異。變數「n」表示直接與對照組比較的研究數量。MD 平均差異，CI 可信區間，AE + RT 有氧混合阻力運動，WBV 全身振動，RT 阻力訓練，TC 太極，AE 有氧運動，MIX 混合運動，IE 衝擊運動，Walking 步行運動。

Forest plot change in efficacy of 8 interventions. The ranking of exercise types is determined based on the probability of P-score ranking. No substantial disparity is evident between treatments that intersect the y-axis and the control group. The variable “n” denotes the quantity of research that were directlyplaced in comparison to the control group. MD Mean Difference, CI Credible Interval, AE + RT Aerobic Mixed Resistance Exercise, WBV Whole Body Vibration, RT Resistance Training, TC Tai Chi, AE Aerobic Exercise, MIX Mixed Exercise, IE Impact Exercise, Walking Walking Exercise.

股骨頸的骨密度
Bone density of femoral neck

在 49 篇文獻中，有 37 篇被納入，並對 2679 名絕經後女性進行了股骨頸位置前後的骨密度評估。當比較 AE + RT（MD = 140, 95% CrI [40.89;239.11]）、WBV（MD = 26.07, 95% CrI [2.97;49.16]）和 RT（MD = 16.98, 95% CrI [8.98;24.99]）與對照組時，PMW 在股骨頸位置的骨密度改善上顯示出顯著效果。根據森林圖（圖 4）中 P-score 的排名，AE + RT 組的運動療法效果最佳（P-score = 0.99），其次是 WBV 運動組（P-score = 0.80），RT 運動組（P-score = 0.72）。兩兩比較的結果顯示，各種運動形式之間並未觀察到統計上顯著的差異。

37 out of 49 literature items were included, and an aggregate of 2,679 PMW were assessed for BMD before and after the femur neck position. Significant effects on BMD improvement at the femur neck position were seen in PMW when comparing exercise types of AE + RT (MD = 140, 95% CrI [40.89;239.11]), WBV (MD = 26.07, 95% CrI [2.97;49.16]), and RT (MD = 16.98, 95% CrI [8.98;24.99]) to the control group. According to the forest plot (Fig. 4) ranking of P-score, the exercise therapy effect of the AE + RT group was the best (P-score = 0.99), followed by the WBV exercise group (P-score = 0.80), RT exercise group (P-score = 0.72). The outcomes of the two-by-two comparison indicated that there were no statistically significant disparities observed across the various forms of exercise.

討論 Discussion

本研究旨在通過網絡元分析確定最佳有效運動方案，以增強絕經後女性的骨密度。該分析包括 49 項隨機對照研究的數據，涉及總共 3360 名參與者。研究結果顯示，運動干預對改善腰椎和股骨頸的骨密度有顯著影響。然而，各種運動方式的益處有所不同。AE+RT 和 RT 的結合對絕經後女性的腰椎和股骨頸的骨密度產生了顯著且有利的影響，超過了其他治療的優勢。AE+RT 和 RT 被確定為增強這兩個區域骨密度的最有效運動方式。某些運動在特定結果指標上超過了對照組。例如，AE 顯著提高了腰椎的骨密度，而 WBV 有效改善了股骨頸區域的骨密度。值得注意的是，除了上述提到的運動類型外，沒有發現其他運動類型有顯著改善。

This study aimed to determine the best efficacious exercise programs for enhancing bone density in PMW by a network meta-analysis. The analysis includes data from 49 randomized controlled studies, which involved a total of 3,360 participants. The results of the study indicated that the intervention of exercise had a significant effect on improving BMD in both the lumbar vertebra and femur neck. However, the benefits of various exercise modalities varied. The combination of AE + RT and RT had a notable and favorable impact on bone mineral density in the lumbar vertebra and femur neck of PMW, surpassing the advantages of alternative treatments. The AE + RT and RT was determined to be the most efficacious exercise modality for enhancing BMD in both areas. Certain exercises outperformed the control group on specific outcome measures. For instance, AE significantly enhanced lumbar spine BMD, whereas WBV effectively improved BMD at the femoral neck region. It is worth noting that no significant improvement was found for any other exercise types than those mentioned above.

運動對腰椎的影響
Effects of exercise on the lumbar spine

我們的結果顯示，AE + RT 被認為是增強腰椎骨密度的最佳運動類型。這一發現與先前的研究一致，表明 AE + RT 顯著減少骨質流失的速度 36 。研究一再證明，多組件運動介入（如 AE + RT）對腰椎骨密度的正面影響比單一運動計劃更為明顯 37,38,39 。另一方面，AE + RT 增加了肌肉力量和骨代謝標記，並有顯著的相關性 40 。有氧運動和抗阻運動對腰椎骨密度有不同的影響。然而，抗阻運動和有氧運動的結合被發現對於保護絕經後女性的腰椎骨密度是有效的 41 。其他研究解釋，在更微觀的層面上，多組件運動模式的成骨指數約為單一運動模式的兩倍 42 。中等強度的有氧運動有潛力通過管理在骨基質結構生成中起作用的身體微量元素來保護骨骼和軟骨。 此外，它可能透過施加抗自由基機制來防止骨吸收的過程 43 。高生物力學負荷，例如阻力訓練，可以通過激活成骨細胞和骨細胞中的離子通道來刺激成骨細胞形成新骨 44 。骨骼對阻力訓練所引起的機械壓力的適應已被證明對骨強度的幾何指標有顯著的正面影響，因此促進骨密度的增加 45,46 。在 AE + RT 訓練中整合有氧運動和阻力訓練，以最大化運動對絕經後女性骨密度的有利影響。結合慢跑與其他低衝擊活動的混合負荷運動計劃，以及將衝擊活動與高強度運動混合的阻力訓練計劃，似乎對減少絕經後髖部和脊椎的骨質流失有幫助 47 。然而，進行足夠的對照研究以建立直接證據是至關重要的。未來的研究應優先進行高質量的嚴謹隨機對照試驗。

Our results indicate that AE + RT was identified as the optimal exercise type for enhancing lumbar BMD. This finding aligns with previous studies indicating that AE + RT significantly decreases the pace at which bone is lost36. Research has consistently demonstrated that multi-component exercise interventions, like AE + RT, have a more pronounced positive effect on lumbar BMD compared to single-exercise programs37,38,39. AE + RT, on the other hand, increased muscle strength and bone turnover markers, with significant correlations40. Aerobic exercise and resistance exercise have distinct impacts on lumbar BMD. However, the combination of resistance exercise and aerobic exercise is found to be effective in preserving lumbar BMD in PMW41. Other studies explain that, at a more microscopic level, the osteogenic index of the multicomponent exercise pattern is about twice that of the single exercise pattern42. Moderate-intensity aerobic exercise has the potential to safeguard bone and cartilage through the management of body trace elements that play a role in the production of bone matrix structures. Additionally, it may prevent the process of bone resorption by exerting an anti-free radical mechanism43. High biomechanical loads such as resistance exercise can stimulate osteoblasts to form new bone by activating ion channels in osteoblasts and osteocytes44. The adaptation of bones to the mechanical pressures induced by resistance exercise has been shown to have a substantial positive impact on geometric indicators of bone strength, hence facilitating an augmentation in bone density45,46. The integration of aerobic and resistance exercise in AE + RT training to maximize the advantageous impact of exercise on bone density in PMW. Mixed-load exercise programs that combine jogging with other low-impact activities and resistance training programs that mix impact activities with high-intensity exercise seem to be useful in decreasing postmenopausal bone loss in the hip and spine47. Nevertheless, it is imperative to conduct sufficient controlled investigations in order to establish direct evidence. Future research should prioritize conducting rigorous randomized controlled trials of high quality.

我們的結果顯示，與對照組相比，三種運動類型顯著改善了絕經後女性的腰椎骨密度，其中有氧運動加抗阻訓練效果最佳，其次是有氧運動訓練和抗阻訓練，顯著高於其他運動類型。首先，有氧運動通過調節荷爾蒙水平來改善骨密度。這與先前的研究一致，顯示 18 週的中等強度有氧運動可以顯著提高年長女性的雌激素水平，進而減少骨質流失。Ettinger 等人也顯示，有氧運動增加女性的靜息雌激素水平，抑制破骨細胞，並促進降鈣素的產生，從而減少骨質流失。有氧運動促進腰椎骨密度的機制在微觀上得到了說明。此外，有氧運動通過調節骨代謝標記來改善骨密度。一項比較有氧運動、太極和步行的研究發現，有氧運動組的骨健康指標在四個月的運動干預後顯著改善。先前的綜合分析也報告指出，在絕經後女性中，有氧運動對腰椎骨密度的改善效果優於其他運動類型。 Weycker D 52 等人證明了一個包含步行、慢跑和爬樓梯的運動計劃顯著提高了全身、腰椎、股骨頸和沃德三角區的骨密度。值得注意的是，高強度的力量訓練在增加脊椎和臀部的骨量方面比低強度或中等強度的力量訓練更有效 53 。一些研究從微觀的角度解釋了中等強度的有氧運動可以通過調節體內的骨吸收和形成，有效抑制骨吸收並減少骨質流失的發生率 43,54 。眾所周知，抗阻運動、力量訓練等是對骨密度有顯著影響的運動形式 29,55,56,57 。以往的研究顯示出與本研究相同的結果：抗阻訓練在減少骨質流失和增加骨密度方面明顯優於其他運動方法，但對於最佳的訓練強度和頻率尚未達成共識 58,59 。在其他方面，抗阻運動通過增強肌肉和改善平衡能力間接維持骨量 10,60,61,62 。 從機械刺激的角度來看，在抗阻運動期間，對骨骼施加了大量的機械負荷，刺激並促進了骨骼的成骨反應 63 。研究還顯示，每週進行兩次或更多次的高速抗阻訓練能產生最大的骨骼益處，但如果訓練停止超過六個月，這些益處可能會喪失 64 。需要進一步調查以確定抗阻訓練的最有效水平和規律性。

Our results indicate that three exercise types significantly improved lumbar BMD in PMW compared with controls, with AE + RT being the best, followed by AE training and RT training, significantly higher than the rest of the exercise types. First, aerobic exercise improves bone density by regulating hormone levels. This is consistent with previous research showing48 that 18 weeks of moderate-intensity aerobic exercise can significantly increase estrogen levels in older women, which in turn reduces bone loss. Ettinger et al.49 also showed that aerobic exercise increases resting estrogen levels in women inhibits osteoclasts, and promotes calcitonin production, thereby reducing bone loss. The mechanism of aerobic exercise promoting lumbar BMD was explained microscopically. In addition, aerobic exercise improves BMD by modulating markers of bone turnover. A study comparing aerobic exercise, tai chi, and walking found that bone health indicators in the aerobic exercise group improved significantly after four months of exercise intervention50. Previous meta-analyses have also reported that aerobic exercise improves lumbar BMD better than other exercise types in PMW51. Weycker D52 et al. demonstrated that an exercise program that included walking, jogging, and stair climbing significantly increased BMD throughout the body, lumbar vertebra, femoral neck, and Ward’s triangle. Notably, high-intensity strength training is more effective at increasing bone mass in the spine and hips than low-intensity or moderate-intensity strength training53. Some studies have explained from a microscopic perspective that moderate-intensity aerobic exercise can effectively inhibit bone resorption and reduce the incidence of bone loss by regulating bone resorption and formation in the body43,54. It is well known that resistance exercise, strength training, etc., are forms of exercise that have a significant impact on BMD29,55,56,57. Previous studies have shown the same results as this study: resistance training has obvious advantages over other exercise methods in reducing bone loss and increasing BMD, but there has yet to be a consensus on the optimal intensity and frequency of training58,59. In other ways, resistance exercise maintains bone mass indirectly by strengthening muscles and improving balance ability10,60,61,62. From the mechanical stimulation point of view, during resistance exercise, a large mechanical load is applied to the bone, stimulating and promoting the osteogenic response of the bone63. Studies have also shown that high-speed resistance training twice or more per week produces the greatest skeletal benefits, but that benefits may be lost if training is stopped for more than six months64. Further investigation is required to ascertain the most effective level and regularity of resistance training.

我們的結果顯示，三種運動類型顯著改善了絕經後女性的股骨頸骨密度，其中以有氧運動加重訓練最佳，其次是全身振動和重訓，顯著高於其他運動類型。先前的研究 65 探討了全身振動及其他運動介入對絕經後女性骨密度的影響，顯示全身振動組在股骨頸和腰椎區域的骨密度有顯著提升。然而，在衝擊訓練組中，腰椎和股骨頸並未觀察到顯著效果。此外，一些動物實驗 66 也顯示在接受全身振動後，骨骼結構顯著改善，主要表現為骨密度增加和骨硬度提高，這可以從運動如何影響骨骼物理特性來解釋。這與本研究的結論一致。肌肉力量研究的綜合分析顯示，全身振動顯著改善了絕經後女性的下肢力量，改善了平衡，並在一定程度上降低了跌倒的概率和風險 67 。 此外，分析骨代謝的隨機對照試驗顯示，6 個月的全身振動訓練可以減少絕經後女性的骨質流失 65 。然而，全身振動運動方案存在高度爭議 68,69 ，主要集中在干預的持續時間、頻率和強度上。與其他干預相比，全身振動運動不需要大量的運動負荷來實現改善。然而，特定的運動參數需要持續探索，以維持其有效性和安全性。

Our results indicate that three exercise types significantly improved femoral neck BMD in PMW, with AE + RT being the best, followed by WBV and RT, significantly higher than the other exercise types. Prior research65 investigating the impact of WBV and other exercise interventions on bone mineral density in PMW has demonstrated notable enhancements in BMD specifically in the femur neck and lumbar vertebra areas among the WBV group. However, no significant effect was observed on the lumbar vertebra and femoral neck in the impact training group. In addition, some animal experiments66 also showed that bone structure was significantly improved after receiving WBV, mainly manifested by increased bone density and increased bone hardness, this is explained in terms of how motion affects the physical properties of bones. This is consistent with the conclusions of this study. Meta-analyses of muscle strength studies have shown that WBV significantly improves PMW’s lower limb strength, improves balance, and somewhat reduces the probability and risk of falls67. In addition, randomized controlled trials analyzing bone metabolism have shown that 6 months of WBV training can reduce bone loss in PMW65. However, WBV exercise regimens are highly controversial68,69, with questions focusing on duration, frequency, and intensity of intervention. Compared to other interventions, WBV exercise does not require a large exercise load to achieve improvement. However, specific exercise parameters need to be continuously explored to maintain its effectiveness and safety.

AE、RT、AE + RT 和 WBV 對於絕經後女性的腰椎或股骨頸有顯著影響，而 TC、步行、IE 和 MIX 則沒有顯著影響。太極訓練對人體骨密度的影響是一個有爭議的話題。Woo 等人 31 在絕經後女性中進行了 48 週的太極運動（每週 3 次），並與抗阻力組和對照組進行比較。太極組和抗阻力組顯示出腰椎和髖部骨密度的變化，儘管與對照組相比，這些變化在統計上並不顯著。Chan 等人 70 認為 48 週的太極運動（每週 5 次）對於維持絕經後女性的骨小梁骨和皮質骨密度有顯著影響，且太極組（與對照組相比）骨質流失較慢。Gába 等人 71 表明，進行 10 週的步行干預（每週 5 次）對於 50 歲及以上的絕經後女性的上肢和腳跟的骨密度沒有顯著影響。Kelley 等人 72 ，然而，結論指出 16 週的快走加上肌肉力量訓練顯著提高了更年期女性的 Ward 三角區骨密度，但對腰椎和其他近端股骨部位的骨密度沒有顯著影響。各種影響活動、高強度運動和抗阻訓練對骨骼計劃的影響各不相同。這些類型運動的混合已被證明能有效減少更年期期間髖部和脊椎的骨質流失。其他類型的影響運動在這個特定群體中似乎對維持骨密度的效果較低 47 。

AE, RT, AE + RT, and WBV had significant effects on the lumbar vertebra or femur neck in PMW, while TC, Walking, IE, and MIX had no significant effects. The impact of Taijiquan training on human BMD is a subject of dispute. Woo et al.31 conducted the Taiji exercise for 48 weeks (3 times/week) in PMW and compared it with the resistance group and control group. The Taiji group and the resistance group exhibited lumbar vertebra and hip BMD alterations, although these changes were not statistically significant when compared to the control group. Chan et al.70 believe that 48 weeks of Tai Chi exercise (5 times/week) has a significant effect on the maintenance of trabecular bone and cortical bone density in PMW, and the Tai Chi group (compared with the control group) has slower bone loss. Gába et al.71 demonstrated that a 10-week walking intervention, conducted 5 times per week, did not have a significant impact on bone mineral density of the upper limbs and heels in PMW aged 50 and above. Kelley et al.72, however, concluded that 16 weeks of brisk walking plus muscle strength exercise significantly increased Ward’s triangle BMD in PMW but had no significant effect on BMD at the lumbar vertebra and other proximal femur sites. The implications of a mixture of impact activity, high-intensity exercise, and resistance training on bone programs vary. A blend of these types of exercise has been shown to effectively reduce bone loss in the hip and spine during the postmenopausal era. Alternative types of impact exercise seemed to have a lower efficacy in preserving BMD in this particular group47.

研究限制 Research limitations

運動計劃、運動時間、運動頻率和運動強度是制定運動處方的四個因素。然而，所納入文獻中的隨機對照試驗未能詳細描述運動強度和運動頻率，且文獻數量需要更全面，以支持運動強度和頻率的亞組分析。本研究納入了所有能參加運動的女性。對於老年人和行動困難的女性，進行的研究較少。未來在運動模式、時間、強度、頻率和年齡方面的實驗設計應該科學且標準化，並應採用大規模、多樣本、雙盲、隨機對照試驗以進行進一步驗證。

Exercise program, exercise time, exercise frequency, and exercise intensity are the four factors in formulating an exercise prescription. However, the randomized controlled trials designed in the included literature failed to describe the exercise intensity and exercise frequency in detail, and the number of literature needed to be more comprehensive to support subgroup analysis of exercise intensity and frequency. This study included all women who could participate in sports. Few studies have been conducted on older adults and women with mobility difficulties. The design of future experiments on exercise mode, time, intensity, frequency, and age should be scientific and standardized, and large-scale, multi-sample, double-blind, randomized controlled trials should be adopted for further verification.

儘管網絡網絡分析提供了高水平的證據，但其方法學限制需要進一步討論。首先，間接比較依賴於可傳遞性假設，但未測量的混雜因素可能影響結果的可靠性。其次，納入研究中的異質性（例如運動強度、頻率和持續時間）可能導致結果的不穩定，儘管我們通過隨機效應模型和亞組分析進行了調整，但某些異質性仍無法完全消除。此外，網絡結構的不平衡（例如，WBV 和 TC 的直接比較較少）可能影響間接比較的準確性。運動參數中的數據和方法學異質性限制了劑量-反應分析的深度。儘管敏感性分析顯示對主要結論具有高度穩健性，但這些限制可能導致對某些干預效果的低估或高估。

Although the network meta-analysis provides a high level of evidence, its methodological limitations need further discussion. First, indirect comparisons rely on the transitivity assumption, but unmeasured confounding factors may affect the reliability of the results. Second, heterogeneity in the included studies (such as exercise intensity, frequency, and duration) may contribute to instability in the results, and although we adjusted for it through random effects models and subgroup analyses, some heterogeneity could not be completely eliminated. In addition, imbalances in network structure (e.g., fewer direct comparisons of WBV and TC) may affect the accuracy of indirect comparisons. Data and methodological heterogeneity in exercise parameters limited the depth of dose–response analysis. Although sensitivity analyses showed high robustness to the primary conclusions, these limitations may have led to underestimation or overestimation of the effects of certain interventions.

未來的研究應更詳細地報告運動參數，並補充高品質的隨機對照試驗，以增強網絡結構的穩健性。此外，探索個性化干預策略將有助於優化運動干預在臨床實踐中的應用。

Future studies should report motion parameters in more detail and supplement high-quality RCTs to enhance the robustness of the network structure. In addition, the exploration of individualized intervention strategies will help optimize the application of exercise intervention in clinical practice.

結論 Conclusion

總結來說，可以得出結論，參與科學合理的體育活動對於提高更年期女性的骨密度有益。此外，像是有氧運動、抗阻訓練、有氧運動加抗阻訓練和全身振動等干預措施，已被發現能在老年人中產生更顯著的骨密度變化。
In summary, it can be concluded that engaging in scientific and rational physical activity has a beneficial impact on enhancing the BMD of PMW. Moreover, interventions such as AE, RT, AE + RT, and WBV have been found to yield more substantial changes in BMD among older adults.

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