Multi‐component exercise programs are recommended to reduce fracture risk, however their effectiveness in real world community settings remain uncertain. This 18‐month randomized controlled trial investigated the effects of a 12‐month, community‐based, supervised multi‐component exercise program followed by a 6‐month ‘research‐to‐practice’ transition, on areal BMD, trabecular bone microarchitecture, functional performance and falls in older adults at increased fracture risk. One‐hundred and sixty‐two adults aged ≥60 years with osteopenia or at increased falls risk were randomized to the Osteo‐cise: Strong Bones for Life multi‐component exercise program (n=81) or a control group (n=81). Exercise consisted of progressive resistance, weight‐bearing impact and balance training (3‐days/week) performed at community leisure centres. Overall 148 (91%) participants completed the trial, and mean exercise adherence was 59% after 12‐months, and 45% during the final 6‐months. After 12 months, there were significant net beneficial effects of exercise on lumbar spine and femoral neck BMD (1.0‐1.1%, P<0.05), muscle strength (10‐13%, P<0.05) and physical function (timed stair climb 5%; four‐square step test 6%; sit‐to‐stand 16%, P ranging <0.05 to <0.001), which persisted following the 6‐month transition. There were no significant effects of the 18‐month intervention on distal femur or proximal tibia trabecular bone microarchitecture or falls incidence, but per protocol analysis (≥66% exercise adherence) revealed there was a significant net benefit of exercise [mean (95% confidence interval): 2.8% (0.2, 5,4)] on proximal tibia trabecular bone volume fraction [Osteo‐cise 1.5% (‐1.2, 4.2); controls ‐1.3% (‐2.6, 0.1)] after 18‐months, due to changes in trabecular number [Osteo‐cise 1.7% (‐0.9, 4.3); controls ‐1.1% (‐2.4, 0.2)] and not trabecular thickness [Osteo‐cise ‐0.2% (‐0.5, 0.2); controls ‐0.2% (‐0.4, 0.0)]. In conclusion, this study supports the effectiveness of the Osteo‐cise: Strong Bones for Life program as a real‐world, pragmatic, evidence‐based community exercise program to improve multiple musculoskeletal health outcomes in older adults at increased fracture risk.

A robust multi-tissue biomaterial is fabricated for regeneration of hard-to-soft musculoskeletal tissue interfaces.