Vini Simas,1 Wayne Hing,1 Rodney Pope,1 Mike Climstein1,2 1Water-Based Research Unit, Faculty of Health Sciences and Medicine, Bond Institute of Health and Sport, Bond University, Gold Coast, QLD, 2Exercise, Health and Performance Research Group, Faculty of Health Sciences, The University of Sydney, Sydney, NSW, Australia Background: Age-related bone loss is a major health concern. Only exercises associated with high-impact and mechanical loading have been linked to a positive effect on bone turnover; however, these types of exercises may not always be appropriate for middle-aged and older adults due to physical decline or chronic disorders such as osteoarthritis. Water-based exercise (WBE) has been shown to affect different components of physical fitness, has lower risks of traumatic fracture, and applies less stress to joints. However, the effects of WBE on bone health are unclear.Objective: This study aimed to explore whether WBE is effective in preventing age-related bone deterioration in middle-aged and older adults.Methods: A search of relevant databases and the references of identified studies was performed. Critical narrative synthesis and meta-analyses were conducted.Results: Eleven studies, involving 629 participants, met all inclusion criteria. All participants were postmenopausal women. Eight studies compared WBE to a sedentary control group, and four studies had land-based exercise (LBE) participants as a comparison group. Meta-analyses revealed significant differences between WBE and control group in favor of WBE for changes in bone mineral density (BMD) at the lumbar spine (mean difference [MD] 0.03g/cm2; 95% confidence interval [CI]: 0.01 to 0.05) and femoral neck (MD 0.04g/cm2; 95% CI: 0.02 to 0.07). Significant differences were also revealed between WBE and LBE in favor of LBE for changes in lumbar spine BMD (MD −0.04g/cm2; 95% CI: −0.06 to −0.02). However, there was no significant difference between WBE and LBE for changes in femoral neck BMD (MD −0.03g/cm2; 95% CI: −0.08 to 0.01).Conclusion: WBE may have benefits with respect to maintaining or improving bone health in postmenopausal women but less benefit when compared to LBE. Further research is required on this topic. Keywords: aquatic exercise, bone mineral density, osteoporosis, preventive medicine, sports medicine