Examining how resistance training affects bone strength in older adults with rheumatic diseases: a systematic review

Abstract

Background

Rheumatic diseases significantly impact global healthcare through disability, lost productivity, and reduced quality of life, making them an important focus for researchers. As physiological changes associated with aging decrease bone mineral density, rheumatic diseases further elevate fracture risk in older adults. Resistance training has been shown to counteract age-related declines through increases in muscle, strength, and bone mineral density, demonstrating its potential for mitigating bone mineral density loss. This systematic review examines the effectiveness of resistance training interventions in maintaining or improving bone mineral density in older adults with rheumatic diseases, an issue of relevance given impaired skeletal integrity linked to these diseases.

Methods

Articles were included if written in English, published after December 31, 1999, and in peer-reviewed journals with full-text, examined adults aged 65 years and above with diagnosed rheumatic disease, and used prospective longitudinal resistance training interventions on bone mineral density outcomes. Through the Web of Science Core Collection, SPORTDiscus (EBSCOhost), PubMed, ScienceDirect, and Wiley Online Library databases, the search yielded 17 eligible studies, of which 12 were deemed high-quality using the PEDro scale.

Results

Results were organized into four themes: (1) Resistance training alone on bone mineral density, (2) Combining resistance training with supplement intake, (3) Pairing resistance training with other exercises, and (4) How resistance training influences balance and fall risk. While most studies showed that resistance training positively impacts bone health, interpretations are limited as supplements or additional exercises were often combined with resistance training.

Conclusion

Resistance training interventions appear to be well tolerated in older individuals and generally have a positive impact on bone health. Nevertheless, we propose that future research should focus more on longitudinal resistance training-only interventions to isolate the specific effects of resistance training on bone mineral density, in addition to prioritizing high-quality randomized controlled trials to strengthen the evidence base.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-025-00531-w.

Background

Rheumatic diseases (RDs) like osteoporosis, rheumatoid arthritis, polymyalgia rheumatica, and osteosarcopenia are of growing concern among older adults due to physiological changes associated with aging. Advanced age is accompanied by decreases in bone mineral density (BMD) resulting from natural bone loss that outstrips bone formation [1]. Low BMD significantly increases the risk of fractures, a major public health problem linked to morbidity, disability, and high economic costs [2].

On the other hand, resistance training (RT) has been shown to effectively counteract age-related decline through increases in muscle mass, strength, power and BMD [3]. RT enhances bone strength and improves balance in older populations [3]. Inactivity, obesity, nutritional deficiencies, and hereditary factors can accelerate BMD reduction and RD progression.

While RT has emerged as a promising approach to mitigate the symptoms derived from RD and ameliorate the functional decline [4], uncertainty remains regarding its effects on BMD. As such, evaluation of RT interventions for RD patients is necessary given the impaired skeletal integrity associated with these diseases [5].

Current evidence suggests that RT can enhance BMD in older adults; however, its effects are less clear in populations with RDs. While several studies have demonstrated modest improvements in BMD following RT interventions, others report inconsistent or negligible effects, especially when comparing different skeletal sites like the lumbar spine and femoral neck [6]. In addition, variations in RT protocols, such as intensity, frequency, and duration, have contributed to a lack of consensus regarding the optimal approach for individuals with compromised bone health due to RD. Given that older individuals with RD appear to face a heightened risk of reduced quality of life and functional decline [5], a focused systematic review on the effects of RT on lumbar spine BMD in this specific population is needed to inform clinical guidelines and optimize intervention strategies. As such, this systematic review examines existing literature to assess the impact of RT on BMD in older adults with RDs. By synthesizing current evidence, we aim to determine the effectiveness of RT in maintaining or improving BMD in this population. Although not the primary focus of this review, potential improvements in quality of life and reductions in fall risk associated with RT should also be considered in the broader context of its benefits.

Methods

Eligibility criteria

Prior to starting the search process, this systematic review was registered in PROSPERO baseline records (registration number CRD42023399446). A review protocol was not prepared. The articles required in this review needed to meet certain requirements. During registration in PROSPERO, our inclusion criteria differed slightly from our final inclusion criteria stated below. This initially included adults being aged 55 years and above and not specifying that interventions should have lasted a minimum of 12 weeks. As such, based on expert opinion, the final inclusion criteria of our systematic review were as follows: (1) Articles written in English; (2) Articles published after December 31, 1999; (3) Articles published in peer-reviewed journals and written in full-text; (4) Adults aged 65 years and above and with any form of diagnosed RD; (5) Longitudinal RT intervention on BMD outcomes that lasted a minimum of 12 weeks; (6) Interventions that examined BMD in the lumbar spine; and (7) Studies that were prospective in nature. Given the Studies that combined RT interventions with other exercise modalities, such as with aerobic exercises were also included.

Articles were excluded if the intervention examined BMD in the femoral neck due to measurement sensitivity as lumbar spine BMD is more sensitive to bone density changes than the femoral neck and is a more robust indicator of bone health. The lumbar spine is also a common site for early bone loss compared to the femoral neck and is more consistently reported in literature, which reduces the heterogeneity of outcome measures and study methodologies in the articles identified in the review. Articles were also excluded if the control group in the intervention included resistance training. Review papers, systematic reviews, meta-analyses, abstracts, supplements, reports, and/or opinion articles were also excluded.

Information sources and search strategies

This search took place between February 19, 2023, and March 30, 2023. A systematic search of five different scientific databases was performed during this time by the primary author. The gathering of articles was performed through a computer assisted electronical database search including the databases as listed: Web of Science Core Collection, SPORTDiscus (EBSCOhost), PubMed, ScienceDirect, and Wiley Online Library. The databases were available to the author through institutional access. Each study was assessed and examined for relevance by reviewing the title and abstract by the primary author. See Table A1 for a comprehensive list of search queries used for each database. These search queries collectively identified 4,447 total records that required screening.

Selection and data collection process

Of the 4,447 records identified, 3,255 were removed before screening due to relevancy. Thirty-two articles were removed due to duplication. A total of 1,160 records were screened and 882 records were additionally excluded after review of abstract and title. Of the 278 records that were assessed for eligibility by the primary and corresponding authors collectively, a further 262 articles were excluded due to not meeting the inclusion criteria, as detailed in Fig. 1. The 16 remaining records were further assessed for eligibility by reading the full text, abstracts, and criteria independently by all authors. A consensus was reached as all records were found to meet the inclusion criteria. The final step included independent review of the references of each of the 16 articles by each author which resulted in an additional 716 articles scanned. The reference search resulted in an additional article that is relevant to this systematic review. In total, 17 articles were included in this review. See Fig. 1 for the flow of information diagram, in accordance with the updated 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Fig. 1.

Flow of information through the different phases of a systematic review, according to the 2020 PRISMA guidelines

Quality appraisal and data items

The PEDro scale was used to evaluate the methodological quality of the studies included in the review [7]. The PEDro scale is an 11- item “Yes/No” scale of which 10 are scored. The unscored option (the item on eligibility criteria) is related to external validity and thus it is not used to calculate the PEDro score. Studies with scores between 0 and 3 points are considered “low” quality, those with scores between 4 and 5 points are “moderate” quality, and those with scores between 6 and 10 points are considered “high” quality. The PEDro scale criteria is depicted in Fig. 2. Importantly, the PEDro scale can be used to support decision-making about therapy for all disciplines [8].

Fig. 2.

PEDro Scale Checklist

Results

Study selection

There were 17 articles that met the inclusion criteria for this systematic review that examined the effect of RT on BMD for older adults with RDs.

Study characteristics

From these 17 articles, one article was a case report, one article was a non-randomized controlled trial (RCT), and 15 articles were RCTs. The 17 studies took place across six countries (Brazil, Germany, Sweden, Australia, Switzerland, and the USA). The total number of participants across all studies was 2,631. The average length of intervention betweeen the 17 studies was approximately 13 months. All studies included some sort of RT (e.g., strength, power training, elastic bands) and all included older adults with RDs as their population. Eight of these studies also incorporated some forms of supplement into the research, such as creatine, omega-3, or whey protein. The main type of RT intervention that was predominantly examined was largely characterized by high resistance training bouts along with a combination of free weight or body weight exercises.

Quality appraisal

The quality of the studies based on the PEDro scale are as follows: One study [9] was “low quality.” Four studies [10–13] were “moderate quality,” and the remaining articles [14–24] were deemed “high quality.” See Fig. 2 for a complete breakdown of the study’s scores based on the scale’s criteria.

Thematic areas

Out of the 17 articles, four articles mentioned the effects of sole RT interventions without a combination of supplements or other exercises on BMD. Five studies explicitly combined RT intervention with supplements intake. Five studies explicitly combined RT with other exercise modalities. Three articles explicitly discussed RT intervention with either supplements or other exercise modes in combination with balance and risks of falls (see Table A2). This systematic review identified key themes from the 17 articles that are presented below.

Does RT help improve BMD?

Four articles mentioned the effects of sole RT interventions without a combination of supplements or other exercises on BMD. Those articles are analyzed and discussed in the following section.

Vincent and Braith [13] examined the effect of RT on bone turnover on older adults. This investigation specifically examined the effect of high (80% of one-rep max [1 RM]) or low (30% of 1 RM) intensity RT on BMD and biochemical markers of bone turnover in adults. The study consisted of 62 participants of both men and women with an average age of 68.4 years. The results imply that BMD can be increased via high-intensity RT regardless of health status. Muscular strength significantly increased in both training groups, ranging from 10.8 to 25.3% and from 14.6 to 27.6% for the low intensity groups and high intensity groups, respectively.

In addition, Gerdhem and colleagues [11] estimated the effect of various variables, such as physical activity, muscle strength, muscle mass, and weight, on bone mass in elderly women. The study consisted of 1004 women all aged 75 years old. The results of the study reported an increase in BMD of 1.01 g/cm² for total body and 0.99 g/cm² at the spine. It was concluded that current levels of physical activity impacts BMD variability in older adults.

Furthermore, in a study conducted by Beavers and colleagues [15], the authors assessed the effects of dietary-induced weight loss (D) and weight loss plus exercise (D þ E) compared to exercise alone (E) on BMD in adults with RDs. Data came from 454 participants over 18 months. The study found no change in the spine BMD, which was determined by a DXA scan (bone density test). It was concluded that exercise intervention did not help with weight loss or improve BMD.

Moreover, a study by Watson and colleagues [24] assessed the effect of a 12-week intervention of RT on BMD. The purpose of the study was to determine the efficacy and monitor parameters of risk for fracture in postmenopausal women with RDs. A total of 101 women aged 65 years and older participated in the trial. RT results were better on the lumbar spine and femoral neck BMD in comparison to the control group. RT was shown to be a useful intervention that prompted an increase in BMD. The authors concluded that RT twice a week can improve BMD. It was stated that: “twice-weekly high-intensity resistance and impact training (HiRIT) exercise intervention was efficacious and superior to previous programs for enhancing bone at clinically relevant sites, as well as stature and functional performance of relevance to falls in postmenopausal women with low to very low bone mass” [p. 20; 24].

Two out of four articles above discussed the positive effect of RT on BMD, where they concluded that RT helps improve BMD and muscle strength in older adults with RDs. In contrast, Vincent and Braith [13] showed no significant change in BMD, although their study focus was on biochemical markers of bone turnover. The other study that reported no positive effect was Beavers et al. [15]. They found no change in the spine BMD. Based on this evidence, RT appears to help with BMD, but to a certain extent; sole RT interventions may not be enough to notice a change in BMD numbers.

What are the effects of RT intervention with supplements intake?

In the next section, there was a total of five articles from this systematic review that explicitly combined RT intervention with supplements intake (see Table A2).

Pinto and colleagues [12] evaluated the combination of RT with creatine. In the 12-week study, participants were assigned to either the placebo plus RT group or the creatine supplementation plus RT group. The primary outcomes of the study were strength and lean mass, which were measured using a DXA scan and ten-repetition maximal tests (10 RM). The study reported an increase in lean mass in older men (+ 3.3 kg) three months post to creatine supplementation (0.3 g/kg of body weight/day for the first 5 days and 0.07 g/kg of body weight/day until completion of the final test period) associated with RT, when compared with the placebo group. There was no significant change in body strength and BMD. It was concluded that: “12-week trial of low-dosage creatine supplementation with RT resulted in an increase in lean mass among elderly participants” [p. 420; 12].

In another study, Cornish and colleagues [16] examined the effects of RT in combination with omega-3 on BMD on 23 men aged 65 years or older. The participants were randomized to an omega-3 supplementation group (n = 11) or placebo group (n = 12). The objectives of their study were to assess the effect of supplementation with omega-3 and RT on body composition, muscle power, functional ability as well as inflammatory cytokines. These RT bouts were done for three days a week for 12 weeks total. At 12 weeks, they found an increase of 1.1% in lumbar BMD compared to baseline, in addition to reporting a substantial main effect of change in percent body fat (− 2.5%) and lean tissue mass (+ 1.1%) from baseline to the post-test. They concluded that supplementation with omega-3 does not increase these parameters or affect inflammatory biomarkers, and RT is an efficient method for improving muscular composition, skeletal muscle strength, and function. In summary, it was stated that 12 weeks of supplementation with omega-3 combined with RT did not have any greater effect than placebo and RT on body composition, muscle power, and functional ability in older men [25]. It was also stated that RT helped enhance parameters in both groups: “although our intervention did not result in any statistically significant improvement in muscle mass or strength with Omega-3 vs. placebo supplementation, we did demonstrate the efficacy of using resistance training to enhance these parameters in both groups combined” [p. 93; 25].

Moreover, another intervention examined the effect of RT with vitamin D intake on BMD for older adults with RDs [21]. The authors noted that a combination of RT with vitamin D intake as an intervention enhances physical fitness, promotes health, and increases musculoskeletal performance through several training modalities. This intervention was an 18-month study with a two-group design. Forty-three men aged 72 years or older were randomly assigned to either an active HI-RT group (HI-RT) or an inactive control group (CG). Their study resulted in an improved Z-score for participants with RDs in comparison to the beginning of the trial. It was stated that: “HI-RT in combination with protein supplementation is a favorable intervention strategy to reduce the risks, progression, and burden of sarcopenia. The high changes in muscle mass and sarcopenia Z-score can be achieved in an inexpensive, time-efficient, and safe manner. The high compliance and lack of injuries in our cohort proved that HI-RT is indeed feasible for the elderly” [p. 2183; 21].

In addition, Kemmler et al. [25] argued that RT should be combined with supplements. When comparing participants in [19] and [25], it was unclear if the same participants were used in both studies given the age overlap. In [25], 43 men aged 73 to 91 years with RDs were randomly assigned to a high-intensity resistance exercise training (HIT-RT) exercise group (EG; n = 21) or a control group (CG; n = 22). After 12 months of exercise, the results of the intervention showed that lumbar spine BMD was maintained in the EG, and it decreased significantly in the CG. While the researchers considered other factors like nutrition intake, they nevertheless showed evidence of RT positively impacting BMD, as it was mentioned in the study that: “HIT-RT/protein/vitamin D/calcium intervention was feasible, safe, and effective for tackling sarcopenia and osteopenia/osteoporosis in older men with osteosarcopenia.” [p. 1641; 19].

RT is frequently prescribed because it is consistently proven to be a safe method that improves mass muscle size and strengthens the bones among middle-aged and older adults. Using potentially the same sample as [19, 25] expanded on the first study by examining the effect of RT in combination with whey protein. It was argued that RT in combination with whey protein should be utilized for older adults. In their study, a total of 43 men aged 72 years and older were contacted. This study aimed to assess the effect of high intensity dynamic resistance exercise (HIT-DRT) and whey protein on BMD. The participants were divided into two groups; the first group was supervised HIT-RT (twice/week) for 18 months, and the second group was the control group where participants were not in RT bouts and just maintained their habitual lifestyle. Individual supplementation with protein powder was based on a four-day diet with at least two training sessions consisting of RT completed by all participants. BMD declined significantly in the control group and was maintained in the HIT-RT. The results showed a positive impact on BMD, and the authors stated that: “applying careful conditioning, consistent supervision, and working only to RM, HIT-DRT on devices combined with moderate protein supplementation is a safe, attractive, and highly effective and efficient approach for addressing osteosarcopenia in older men with sarcopenia and osteoporosis” [p. 15; 19].

The authors noted that supplements in combination with RT had a positive impact on BMD for adults with RDs. However, three out of four articles discussed the positive effect of RT in combination with supplements on BMD and one reported no significant change. Pinto et al. [12] concluded in their intervention that creatine was unable to cause changes in BMD, but it did affect the lean mass for the participants. As such, it appears that based on the evidence presented above, whey protein, vitamin D, and omega-3, in combination with RT, helps improve BMD for adults with RDs.

What are the effects of RT with a combination of other exercises on BMD?

Out of the 17 studies, five studies explicitly looked at effects of RT with a combination of different exercise modalities on BMD (see Table A2). Those interventions were: RT with power training interventions, aerobic interventions, and agility interventions.

A study by Liu-Ambrose et al. [22] examined RT combined with agility. They tracked 43 participants over 18 months with the aim of comparing the effects of high-intensity RT and agility training on BMD. The researchers reported that the RT group significantly increased bone density (1.4 ± 0.6%) at the radial shaft compared with a 0.4 ± 0.5% loss in the agility training group. It was concluded that resistance and agility training programs performed in groups are safe and efficient to increase bone density of the upper cingulate osteoporotic skeleton, particularly for those with relatively lower bone mass.

Furthermore, Kemmler et al. [20] examined the effect of multipurpose exercise program on the body composition and functional ability of elderly women. The study consisted of 246 participants aged 65–80 years over an 18-month period as well. The participants were divided into two groups: an exercise (n = 123) and control (n = 123) group. The individuals of the exercise program engaged in intense and diverse physical exercises. Conversely, those in the control group were involved in a low frequency program. The results of the study showed significant effects in favor of the multipurpose exercise program for overall body composition.

In the study by Armamento-Villareal et al. [14], RT was combined with aerobic exercises. This intervention included 160 participants over 26 weeks. The primary purpose of the study was to assess the relative efficacy of several exercise modes in improving physical function and retreating weakness in older adults with obesity. It was found that a combination of exercises helped protect against bone loss: “both resistance and combined aerobic and resistance exercise can be recommended to protect against bone loss during weight loss therapy of older adults with obesity” [p. 430; 14]. The findings demonstrated that compared to aerobic exercise alone, RT and a combination of aerobic and RT were more effective in preventing bone loss caused by weight gain at the total hip and femoral neck.

Finally, Genest et al. [17] also assessed the effect of RT through different training interventions on overall BMD. In their study, 47 men aged 65–90 years were tracked across six months. The exercise interventions included supervised RT, Whole Body Vibration Exercise (WBV) as externally stimulated muscle activation, Qi Gong (QG) classes which are considered a low impact training modality, and lastly, wearing a Spinal Orthosis (SO) as an effortless, almost passive modality. Results indicated that the low impact training concepts (QG) are particularly suitable for older pre-sarcopenic subjects with limited mobility and elevated fracture risk. Subjects achieved significant improvements in lumbar flexion strength.

Based on the evidence presented above, there appears to be a positive impact of exercise in combination with RT interventions on BMD for adults with RDs. All the aforementioned articles described positive effects through their interventions.

Does RT improve balance and risk of falling outcomes for older adults?

Of the 17 articles included in this review, three articles explicitly discussed RT intervention in combination with either supplements or other exercises and its positive impact on participants’ improved balance (see Table A2).

In a study by Swanenburg et al. [23], it was discussed that supplements intake played a notable role in strength training. This study aimed to compare vitamin D supplements with exercise on the risk of falling and postural balance in elderly females with RDs. A total of 24 independently living females participated in the study, and the intervention program lasted three months. The risk of falling was assessed through a balance test (Berg Balance Test) and postural balance (force plate). The experimental group (supplements + RT) showed substantial reductions in the risk of falling and an improvement in muscular strength and activity level compared to the control group. The intervention showed a substantial decline in the risk of falling as a consequence of the three-month program.

In addition, Gianoudis et al. [18] examined the effects of multimodal exercise programs on falls and fracture risk factors in 162 participants over 12 months. The aim of the study was to examine the effect of weight bearing training and/or balance training on risk factors for falls and fractures. The intervention showed an increase in the lumbar spine BMD compared to the control group. The authors suggested that practical performance measures should be enhanced in older adults with risk factors for falls and/or low BMD.

Lastly, the study by Aquino et al. [9] focused on the participant’s seven-point improvement in Dynamic Gait Index along with BMD for both the lumbar spine and femoral neck. This was a case study of a participant who was 70 years old. The purpose of this study was to evaluate the degree to which a 12-month power-based RT program improved BMD and fall risk. The yearlong intervention resulted in a 24% increase in the patient’s lumbar spine and 29% increase in their BMD for the femoral neck. It was found that power training with RT had a significant impact on decreasing the prospect of falls for this individual: “power training might therefore represent a viable form of training for reducing fracture risk for postmenopausal women with osteoporosis by reducing the likelihood of falls and the repercussions associated with falls if/when they do occur” [p. 48; 9].

In summary, although individuals may engage in RT, it appears that interventions that combine therapy to achieve the desired effect are most robust. A repetition of RT through an exercise protocol is an effective intervention that positively affects osteosarcopenia along with many other RDs.

Discussion

The purpose of this systematic review was to determine and elucidate how RT interventions are effective in maintaining or increasing BMD in older adults with RDs. While not a primary focus, this review also considered how RT might influence quality of life in older adults by synthesizing evidence on its role in improving BMD, which could lead to better health outcomes and reduced fall risk. It appears that most of the research completed does not contemplate RT interventions without supplement intake or other means of exercises, which confounds the decision-making process. The systematic review identified key themes that helped understand the effect of RT. Those themes covered the overall effect of RT on BMD, the effect of RT with combination of supplements (e.g., vitamins, proteins), RT in combination with different exercises, and the significance of RT on improving balance and risk of falling outcomes for older adults.

Of the 17 articles reviewed, 14 demonstrated positive effects of RT on bone health and BMD, while three reported no change (see Table A2). The positive effects included reduced bone loss, decreased fracture risk, and improved balance. However, most studies showing increased BMD combined RT with supplements (e.g., whey protein, omega-3, creatine intake) or other exercise types (e.g., power, aerobic, agility training), rather than examining RT in isolation. The specific benefits may vary depending on the type of RD, disease history, and patient characteristics.

RT appears to have an overarching benefit on BMD. Research has shown that RT may increase BMD in several areas of the body, such as in the lumbar spine, and in the femoral neck, hips, and legs. These are important findings particularly for older adults who are diagnosed with RDs and/or bone fractures. As suggested by Kemmler [19], “HIT-DRT supported by vitamin D/calcium/protein supplementation applied in older men with osteosarcopenia generates favorable effects on bone, lean body mass, and muscle force compared with a control group, also supplemented with vitamin D, calcium, and whey protein” [p. 1641]. Nevertheless, while Beavers and colleagues [15] acknowledged that exercise impacts BMD, they suggested that exercise did not diminish reduction in BMD; “although the exercise intervention did not attenuate weight loss-associated reductions in BMD, clinical classification of osteoporosis and osteopenia in the population remained unchanged” [p. 731]. As such, while research on RT programming has provided valued insights on the proper techniques of implementing effective RT programs, an important aspect of RT programming remains determining the optimal training variables such as intensity, volume, frequency, and exercise selection.

Mohebbi et al.’s [6] systematic review and meta-analysis on the relationship between exercise training and BMD in postmenopausal women reinforces the positive impact of exercise on BMD, although exercise was not limited to RT interventions and BMD changes were also assessed at the femoral neck and total hip (in addition to the lumbar spine) in their review. They also reported no significant differences based on osteopenia/osteoporosis status, menopausal stage, or supervision of exercise, indicating that exercise may benefit BMD across various subgroups. Notably, their inclusion criteria were more stringent compared to this systematic review, which included only controlled exercise trials with interventions lasting at least six months. Nevertheless, the findings of this systematic review may have important clinical implications for managing bone health in older adults with RDs. Given the apparent positive effects of RT on BMD, clinicians should consider incorporating RT into routine care plans to reduce the risk of fractures and bone loss in this vulnerable population. This is especially relevant for patients with conditions like osteoporosis, osteosarcopenia, and rheumatoid arthritis, where maintaining or improving BMD is critical for long-term health outcomes. Although RT has been shown to enhance bone health, it may also contribute to improved balance and physical function, indirectly reducing fall risk and promoting independence in older adults. Furthermore, while the review did not primarily focus on quality of life, improving BMD and physical function through RT may lead to enhanced overall well-being, mobility, and functional capacity. This suggests that RT may have broader benefits beyond skeletal health, potentially helping patients maintain a higher quality of life as they age. Therefore, integrating RT into patient care, alongside careful consideration of intensity, duration, and supplementation, could offer a multi-faceted approach to improving both physical and quality-of-life outcomes in older adults with RDs.

This systematic review included high-quality studies, but some limitations were noted, such as changes in equipment [24], absence of control groups [12], small sample sizes [9], and subjects’ familiarity with training modalities [17]. While most of the studies included in the review were RCTs, one case report [9] and one non-RCT [11] study was also included. These study designs may have limitations in terms of internal validity, particularly when compared to RCTs. Nevertheless, they met the review’s inclusion criteria, which was designed to comprehensively assess the availability of literature on the topic and capture a broader range of evidence, particularly given the relatively limited number of RCTs in this specific population. In addition, while two studies [17, 20] did not explicitly state that BMD outcomes were measured, we feel that they still fit within the scope of our review given the valuable insights into how exercise interventions impact factors closely related to bone health [17] and the close association between body composition and BMD [20]. Our focus on publications after December 31, 1999 and concentrating on the lumbar spine may have also limited the generalizability of results. Finally, the initial literature search was challenging due to the broad nature of RDs and the need to search for multiple specific conditions.

As such, questions remain about the impact of sole RT interventions on adults with RDs. Future research should employ sound methodology to address limitations like self-reported data and volunteer response bias, thereby enhancing our understanding of effective strategies for patient care. More specifically, we recommend that future studies should prioritize high-quality RCTs and include weight-bearing exercises while implementing longer interventions (ideally 12 + months). These approaches would provide more comprehensive insights into RT’s effects on BMD in RD patients. Future research should also investigate optimal RT protocols, including exercise intensity, duration, and frequency, as the ideal intervention for this population remains to be determined.

Conclusions

This systematic review developed a more complete picture and identified RT to be a safe, non-invasive method to improve BMD in older individuals with RDs. Most of the articles included in this review had comparable results. For example, when combined with supplements, such as vitamin D, whey protein, and creatine, RT interventions appear to be well tolerated and generally have a positive impact on bone health. While ongoing corroboration regarding the effect of RT on BMD is needed, the authors ask for more longitudinal RT interventions to establish optimal protocols for managing bone health in older individuals with RDs and to better understand the isolated effects of RT on BMD in this population.

Electronic supplementary material

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Abbreviations

BMD

Bone mineral density

CG

Control group

EG

Exercise group

HIT-DRT

High intensity dynamic resistance exercise

HIT-RT

High-intensity resistance exercise training

HiRIT

High-intensity resistance and impact training

1 RM

One-rep max

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

QG

Qi Gong

RCTs

Randomized controlled trials

RT

Resistance training

RDs

Rheumatic diseases

SO

Spinal Orthosis

WBV

Whole Body Vibration Exercise

Author contributions

M.C., M.K., E.J., and S.L. made substantial contributions to the conception of the work and the interpretation of data. M.C. and S.L. performed the systematic search and synthesis. M.C., M.K., E.J., and S.L. have approved the submitted version and have agreed to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

Funding

None.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable. The manuscript does not contain clinical studies or patient data.

Consent for publication

Not applicable. We confirm that this manuscript has not been published elsewhere and is also not under consideration by another journal.

Competing interests

The authors declare no competing interests.