Traditional Chinese exercises deserve a distinct place in osteoporosis exercise prescriptions Re: Effect of exercise on bone health in middle aged and older adults: hierarchical network meta-analysis of randomised trials

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Dear Editor
Lu and colleagues’ hierarchical network meta-analysis is a timely and valuable contribution to exercise guidance for bone health.1 By synthesizing 124 randomized trials involving 18 429 participants and examining exercise modality, dose, bone mineral density (BMD) and incident fractures, the authors move beyond generic recommendations towards clinically relevant prescriptions. Traditional Chinese exercises (TCEs), particularly Tai chi, could further refine this framework by adding clinically actionable specificity.

The category of “mind-body exercise” is useful for network synthesis but broad for clinical prescription. Tai chi and yoga differ in movement patterns, weight transfer, balance demands and training progression. Category-level estimates cannot determine whether observed benefits arise from one practice or from a shared component.1 Where the evidence network permits, separate estimates for Tai chi and other practices, accompanied by clear descriptions of their training components, would better inform exercise selection.

Our umbrella review provides complementary, condition-specific evidence.2 Among 77 associations involving osteopenia or osteoporosis, selected Tai chi comparisons were rated as high certainty under GRADE. In postmenopausal women, mean BMD differences were 0.04 g/cm² at the lumbar spine (95% confidence interval 0.02 to 0.06) and 0.02 g/cm² at the femoral neck (0.00 to 0.04). These findings support closer examination of Tai chi in osteoporosis care. Direct comparison with Lu and colleagues’ network estimates is inappropriate because the populations, comparators and certainty-assessment frameworks differed. Overlapping trials also mean that the two reviews should not be interpreted as independent confirmations. Evidence for Tai chi should not be generalized automatically to all TCE modalities.

BMD alone does not capture the full clinical value of exercise. TCEs can combine weight-bearing activity with controlled movement and postural training. Our review also identified benefits for physical function in knee osteoarthritis and for muscle strength and physical performance in sarcopenia or frailty.2 Although these findings concern different populations, they are relevant when osteoporosis combined with pain or functional limitations. TCEs are adaptable and require little equipment, which may suit community programmes. Their effects on long-term adherence and fracture outcomes in osteoporosis remain to be established.

Exercise prescriptions should specify programme duration and sustained participation alongside weekly metabolic-equivalent (MET) volume. Our subgroup analyses suggested greater skeletal benefits with regular, sustained practice, but did not establish a causal dose–response relationship.2 Reporting session frequency, programme duration, progression and achieved adherence would improve reproducibility beyond a weekly MET target alone.

The fracture estimate for mind-body exercise in Lu and colleagues’ analysis is encouraging but remains low certainty and cannot be attributed specifically to Tai chi.1 Future trials should test defined TCE programmes with adjudicated fractures and falls, while measuring BMD, physical function, adherence and adverse events. Tai chi may be considered an adaptable component of comprehensive osteoporosis management, alongside appropriate resistance and weight-bearing exercise, nutritional support and indicated pharmacotherapy. Fracture prevention remains an outcome to establish.

References

1. Lu C, Li L, Zhang L, et al. Effect of exercise on bone health in middle aged and older adults: hierarchical network meta-analysis of randomised trials. Bmj 2026;394:e100561. doi: 10.1136/bmj-2026-100561 [published Online First: 20260909]
2. Chen WX, Li YZ, Kang LD, et al. Efficacy and evidence certainty of traditional Chinese exercises for musculoskeletal disorders: an umbrella review of meta-analyses. Br J Sports Med 2026 doi: 10.1136/bjsports-2026-111792 [published Online First: 20260817]

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Effect of exercise on bone health in middle aged and older adults: hierarchical network meta-analysis of randomised trials

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Traditional Chinese exercises deserve a distinct place in osteoporosis exercise prescriptions Re: Effect of exercise on bone health in middle aged and older adults: hierarchical network meta-analysis of randomised trials

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Effect of exercise on bone health in middle aged and older adults: hierarchical network meta-analysis of randomised trials

Check this box if you would like your letter to appear anonymously:: Last Name: Chen First name and middle initial: Wen-XiaoEmail:

chen_wenxiao0927@163.com

Address: No. 826, Southwest Road, Shahekou District, Dalian, Liaoning, People’s Republic of ChinaOccupation: PhD candidateOther Authors: Yi-Zi Li (Department of Epidemiology, School of Public Health, China Medical University, Shenyang, China.), Ming Lu* (Department of Trauma and Tissue Repair Surgery, Dalian Municipal Central Hospital, China.), Qi-Jun Wu* (Department of Epidemiology, School of Public Health, China Medical University, Shenyang, China.)Affiliation: 1. Department of Trauma and Tissue Repair Surgery, Dalian Municipal Central Hospital, China.BMJ: Additional Article Info: Rapid response