WHAT You NM TO KNOW ABOUT BALANCE AND FAILS

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1 WHAT You NM TO KNOW ABOUT BALANCE AND FAILS A PHYSICAL THERAPIST'S PHISPECTIVE Falls among the elderly are prevalent, dangerous, and can diminish their ability to lead an active and independent life. About one in three seniors above age 65, and nearly one in two seniors over age 80, will fall at least once this year, many times with disastrous consequences.* Physical therapists can help prevent falls with evaluation and development of individualized treatment plans including exercises to improve strength, mobility, and balance. Risk factors associated with falls: Being older Difficulty with balance or walking Poor vision Leg or trunk weakness Pre-existing medical conditions, such as Parkinson disease, stroke, or diabetes Being on more than four medications simultaneously Use of an assistive walking device A past history of falls Maintaining Physical Activity The most critical action seniors can take to help prevent falls is to maintain physical activity. Physical therapists recommend activities of any fitness level, including gardening, line dancing, and yoga to help improve balance and movement. Test Your Balance Balance may be improved with exercises that strengthen the ankle, knee, and hip muscles and with exercises that improve the function of the vestibular (balance) system. A simple assessment of your current balance can be done at home. Do not attempt to do this test alone make sure that you have someone next to you to decrease the potential risk of falling. Perform this test standing with a counter surface in front of you: 1. Stand tall, wearing flat, closed shoes, with your arms folded across your chest. Keep your eyes open, focus on an object in front of you, raise one leg, bending the knee about 45 degrees, and start a stopwatch. 2. Remain on one leg, stopping the watch immediately if you uncross your arms, tilt sideways more than 45 degrees, move the leg you are standing on, or touch the raised leg to the floor. 3. Repeat this test with the other leg. 4. Repeat steps 1 3 above with your eyes closed. 5. Compare your performance with eyes closed to the norms for various ages: 20 to 49 years old (24 to 28 seconds); 50 to 59 years (21 seconds); 60 to 69 years (10 seconds); 70 to 79 years (4 seconds); 80 and older (most cannot do this test).

2 How a Physical Therapist Can Help Once a physical therapist has reviewed a complete medical history and thoroughly examined you, he or she will design an individualized program of exercises and activities with an emphasis on strength, flexibility, and proper gait. A personalized plan may include a walking regimen that includes balance components such as changes in surfaces/terrains, distance, and elevations; Tai Chi (which emphasizes balance, weight shifting, coordination, and postural training); and aquatics classes geared toward balance and coordination. The physical therapist also may teach specific strengthening and balance exercises that can be performed at home. If necessary, the physical therapist will refer you to other medical professionals, such as an ophthalmologist or neurologist. To find a physical therapist in your area, visit Physical therapists are health care professionals who diagnose and manage individuals of all ages who have medical problems or other health-related conditions that limit their abilities to move and perform functional activities in their daily lives. Physical therapists examine each individual and develop a plan of care using treatment techniques to promote the ability to move, reduce pain, restore function, and prevent disability. Physical therapists also work with individuals to prevent the loss of mobility by developing fitness-and wellness-oriented programs for healthier and more active lifestyles. The American Physical Therapy Association ( is a national organization representing physical therapists, physical therapist assistants, and students nationwide. Its goal is to foster advancements in physical therapist education, practice, and research. Consumers can access physical therapy news and information at *National Council on Aging WA APTA American Physical Therapy Association The Science of Healing. The Art of Caring North Fairfax Street Alexandria, VA

3 Preventing Falls and Related Fractures National Institutes of Health Osteoporosis and Related Bone Diseases National Resource Center 2 AMS Circle Bethesda, MD Tel: BONE or Fax: TTY: Internet: Ault govfbone NIAMSBonelnfo@ mail.nih.gov The NIH Osteoporosis and Related Bone Diseases National Resource Center is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases with contributions from the National Institute on Aging, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute of Dental and Craniofacial Research, the National Institute of Diabetes and Digestive and Kidney Diseases, the NIH Office of Research on Women's Health, and the HHS Office on Women's Health. The National Institutes of Health (NIH) is a component of the U.S. Department of Health and Human Services (HHS). Falls are serious at any age, and breaking a bone after a fall becomes more likely as a person ages. Many of us know someone who has fallen and broken a bone. While healing, the fracture limits the person's activities and sometimes requires surgery. Often, the person wears a heavy cast to support the broken bone and needs physical therapy to resume normal activities. People are often unaware of the frequent link between a broken bone and osteoporosis. It is known as a silent disease because it progresses without symptoms, osteoporosis involves the gradual loss of bone tissue or bone density and results in bones so fragile they break under the slightest strain. Consequently, falls are especially dangerous for people who are unaware that they have low bone density. If the patient and the doctor fail to connect the broken bone to osteoporosis, the chance to make a diagnosis with a bone density test and begin a prevention or treatment program is lost. Bone loss continues, and other bones may break. Even though bones do not break after every fall, the person who has fallen and broken a bone nearly always becomes fearful of falling again. As a result, she or he may limit activities for the sake of "safety." Among Americans age 65 and older, fall-related injuries are the leading cause of accidental death. This publication explores the components of the Fracture Triangle and offers tips for reducing the chances of fallrelated fractures that result from low bone mass and osteoporosis. If one of the following three factors is modified, the chances of breaking a bone are greatly reduced:

4 Fall Force Fragility The Fall Itself The Force and Direction of the Fall The Fragility of the Bone(s) That Take the Impact Did You Know? More than 90 percent of hip fractures are associated with osteoporosis. Nine out of 10 hip fractures in older Americans are the result of a fall. Elderly individuals who have a hip fracture are 5 to 20 percent more likely to die in the first year following that injury than others in this age group. For those living independently before a hip fracture, 15 to 25 percent will still be in long-term care institutions a year after their fracture. Most falls happen to women in their homes in the afternoon. The Fall Itself Several factors can lead to a fall. Loss of footing or traction is a common cause of falls. Loss of footing occurs when there is less than total contact between one's foot and the ground or floor. Loss of traction occurs when one's feet slip on wet or slippery ground or floor. Other examples of loss of traction include tripping, especially over uneven surfaces such as sidewalks, curbs, or floor elevations that result from carpeting, risers, or scatter rugs. Loss of footing also happens from using household items intended for other purposes for example, climbing on kitchen chairs or balancing on boxes or books to increase height. A fall may occur because a person's reflexes have changed. As people age, reflexes slow down. Reflexes are automatic responses to stimuli in the environment. Examples of reflexes include quickly slamming on the car brakes when a child runs into the street or quickly moving out of the way when something accidentally falls. Aging slows a person's reaction time and makes it harder to regain one's balance following a sudden movement or shift of body weight. 2

5 Improving Balance Do muscle-strengthening exercises. Obtain maximum vision correction. Practice using bifocal or trifocal glasses. Practice balance exercises daily. Changes in muscle mass and body fat also can play a role in falls. As people get older, they lose muscle mass because they have become less active over time. Loss of muscle mass, especially in the legs, reduces one's strength to the point where she or he is often unable to get up from a chair without assistance. In addition, as people age, they lose body fat that has cushioned and protected bony areas, such as the hips. This loss of cushioning also affects the soles of the feet, which upsets the person's ability to balance. The gradual loss of muscle strength, which is common in older people but not inevitable, also plays a role in falling. Musclestrengthening exercises can help people regain their balance, level of activity, and alertness no matter what their age. Changes in vision also increase the risk of falling. Diminished vision can be corrected with glasses. However, often these glasses are bifocal or trifocal so that when the person looks down through the lower half of her or his glasses, depth perception is altered. This makes it easy to lose one's balance and fall. To prevent this from happening, people who wear bifocals or trifocals must practice looking straight ahead and lowering their head. For many other older people, vision changes cannot be corrected completely, making even the home environment hazardous. Medications That May Increase the Risk of Falling Blood pressure pills Heart medicines Diuretics or water pills Muscle relaxants or tranquilizers As people get older, they also are more likely to suffer from a variety of chronic medical conditions that often require taking several medications. People with chronic illnesses that affect their circulation, sensation, mobility, or mental alertness as well as those taking some types of medications (see above table) are more likely to fall as a result of drug-related side effects such as dizziness, confusion, disorientation, or slowed reflexes. Drinking alcoholic beverages also increases the risk of falling. Alcohol slows reflexes and response time; causes dizziness, sleepiness, or lightheadedness; alters balance; and encourages risky behaviors that can lead to falls. 3

6 The Force and Direction of a Fall The force of a fall (how hard a person lands) plays a major role in determining whether or not a person will break a bone. For example, the greater the distance of the hip bone to the floor, the greater the risk of fracturing a hip, so tall people appear to have an increased risk of fracture when they fall. The angle at which a person falls also is important. For example, falling sideways or straight down is more risky than falling backward. Did You Know? Being tall appears to increase your risk of a hip fracture. How you land increases your fracture risk. Catching yourself so you land on your hands or grabbing onto an object as you fall can prevent a hip fracture. Protective responses, such as reflexes and changes in posture that break the fall, can reduce the risk of fracturing a bone. Individuals who land on their hands or grab an object on their descent are less likely to fracture their hip, but they may fracture their wrist or arm. Although these fractures are painful and interfere with daily activities, they do not carry the high risks that a hip fracture does. The type of surface on which one lands also can affect whether or not a bone breaks. Landing on a soft surface is less likely to cause a fracture than landing on a hard surface. Preliminary research suggests that by wearing trochanteric (hip) padding, people can decrease the chances of fracturing a hip after a fall. The energy created by the fall is distributed throughout the pad, lessening the impact to the hip. Further research is needed to fully evaluate the role of these devices in decreasing the risk of a hip fracture following a fall. Bone Fragility Although most serious falls happen when people are older, steps to prevent and treat bone loss and falls can never begin too early. Many people begin adulthood with less than optimal bone mass, so the fact that bone mass or density is lost slowly over time puts them at increased risk for fractures. Bones that once were strong become so fragile and thin that they break easily. Activities that once were done without a second thought are now avoided for fear that they will lead to another fracture. 4

7 Steps to Prevent Fragile Bones Consume adequate amounts of calcium and vitamin D (see "Recommendations for Calcium and Vitamin D Intake" chart). Exercise several times a week. Ask your doctor about a bone mineral density test. Ask about medications to slow bone loss and reduce fracture risk. Prevention of Falls and Fractures Safety first to prevent falls: At any age, people can change their environments to reduce their risk of falling and breaking a bone. Outdoor safety tips: In nasty weather, use a walker or cane for added stability. Wear warm boots with rubber soles for added traction. Look carefully at floor surfaces in public buildings. Many floors are made of highly polished marble or tile that can be very slippery. If floors have plastic or carpet runners in place, stay on them whenever possible. Identify community services that can provide assistance, such as 24-hour pharmacies and grocery stores that take orders over the phone and deliver. It is especially important to use these services in bad weather. Use a shoulder bag, fanny pack, or backpack to leave hands free. Stop at curbs and check their height before stepping up or down. Be cautious at curbs that have been cut away to allow access for bikes or wheelchairs. The incline up or down may lead to a fall. Indoor safety tips: Keep all rooms free from clutter, especially the floors. Keep floor surfaces smooth but not slippery. When entering rooms, be aware of differences in floor levels and thresholds. Wear supportive, low-heeled shoes, even at home. Avoid walking around in socks, stockings, or floppy, backless slippers. Check that all carpets and area rugs have skid-proof backing or are tacked to the floor, including carpeting on stairs. Keep electrical and telephone cords and wires out of walkways. Be sure that all stairwells are adequately lit and that stairs have handrails on both sides. Consider placing fluorescent tape on the edges of the top and bottom steps. For optimal safety, install grab bars on bathroom walls beside tubs, showers, and toilets. If you are unstable on your feet, consider using a plastic chair with a back and nonskid leg tips in the shower. Use a rubber bath mat in the shower or tub. 5

8 Keep a flashlight with fresh batteries beside your bed. Add ceiling fixtures to rooms lit by lamps only, or install lamps that can be turned on by a switch near the entry point into the room. Another option is to install voice- or sound-activated lamps. Use bright light bulbs in your home. If you must use a step-stool for hard-to-reach areas, use a sturdy one with a handrail and wide steps. A better option is to reorganize work and storage areas to minimize the need for stooping or excessive reaching. Consider purchasing a portable phone that you can take with you from room to room. It provides security because you can answer the phone without rushing for it and you can call for help should an accident occur. Don't let prescriptions run low. Always keep at least 1 week's worth of medications on hand at home. Check prescriptions with your doctor and pharmacist to see if they may be increasing your risk of falling. If you take multiple medications, check with your doctor and pharmacist about possible interactions between the different medications. Arrange with a family member or friend for daily contact. Try to have at least one person who knows where you are. If you live alone, you may wish to contract with a monitoring company that will respond to your call 24 hours a day. Watch yourself in a mirror. Does your body lean or sway back and forth or side to side? People with decreased ability to balance often have a high degree of body sway and are more likely to fall. Practice Balance Exercises Every Day While holding the back of a chair, sink, or countertop, practice standing on one leg at a time for a minute. Gradually increase the time. Try balancing with your eyes closed. Try balancing without holding on. While holding the back of a chair, sink, or countertop, practice standing on your toes, then rock back to balance on your heels. Hold each position for a count of 10. While holding the back of chair, sink, or countertop with both hands, make a big circle to the left with hips, then repeat to the right. Do not move your shoulders or feet. Repeat five times. Reducing the Force of a Fall Take steps to lessen your chances of breaking a bone in the event that you do fall: Remember that falling sideways or straight down is more likely to result in a hip fracture than falling in other directions. If possible, try to fall forward or to land on your buttocks. If possible, land on your hands or use objects around you to break a fall. Walk carefully, especially on hard surfaces. 6

9 When possible, wear protective clothing for padding. Talk to your doctor about whether you may be a candidate for hip padding. Decreasing Bone Fragility Individuals can protect bone health by following osteoporosis prevention and treatment strategies: Consume a calcium-rich diet that provides between 1,000 and 1,200 mg (milligrams) of calcium from a combination of foods and supplements. Obtain between 200 and 600 IU (International Units) of vitamin D each day, depending on age. Participate in weight-bearing and resistance-training exercises most days, preferably daily. Talk with your doctor about having a bone mineral density (BMD) test. The most widely recognized BMD test is called a dual-energy x-ray absorptiometry, or DXA test. It is painless, a bit like having an x ray, but with much less exposure to radiation. It can measure bone density at your hip and spine. Talk with your doctor about possibly beginning a medication approved by the Food and Drug Administration for osteoporosis to stop bone loss, improve bone density, and reduce fracture risk. People need to know whether they are at risk for developing osteoporosis or whether they have lost so much bone that they already have osteoporosis. Although risk factors can alert a person to the possibility of low bone density, only a BMD test can measure current bone density, diagnose osteoporosis, and determine fracture risk. Many different techniques measure bone mineral density painlessly and safely. Most of them involve machines that use extremely low levels of radiation to complete their readings. Sometimes, ultrasound machines, which rely on sound waves, are used instead. Individuals may wish to have a BMD test to determine current bone health. Today, Medicare and many private insurance carriers cover bone density tests to detect osteoporosis for individuals who meet certain criteria. Talk with your doctor about whether or not this test would be appropriate for you. Falls are serious, but simple, inexpensive steps can be taken to reduce your risk of falling and of breaking a bone if you do fall. 7

10 Recommendations for Calcium and Vitamin D Intake Age (years) Calcium (mg) Vitamin D (IU) 19 to 30 1, to 50 1, to 70 1, and older 1, Upper limit 2,500 2,000 Source: National Academy of Sciences, Resources For more information on osteoporosis, visit the National Institutes of Health Osteoporosis and Related Bone Diseases National Resource Center Web site at or call For more information on fall prevention, visit the National Institute on Aging Web site at or call The National Institutes of Health Osteoporosis and Related Bone Diseases National Resource Center acknowledges the assistance of the National Osteoporosis Foundation in the preparation of this publication. Reviewed January

11 Once Is Enough: A Guide to Preventing Future Fractures National Institutes of Health Osteoporosis and Related Bone Diseases- National Resource Center 2 AMS Circle Bethesda, MD Tel: BONE or Fax: 'ITV: Internet: NIAMSBoneInfo@ mail.nih.gov The NIH Osteoporosis and Related Bone Diseases - National Resource Center is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases with contributions from the National Institute on Aging, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute of Dental and Craniofacial Research, the National Institute of Diabetes and Digestive and Kidney Diseases, the NIH Office of Research on Women's Health, and the HHS Office on Women's Health. The National Institutes of Health (NIH) is a component of the U.S. Department of Health and Human Services (HHS). 47: P-J SERVICES. So, you've broken a bone. Only those who have experienced a fracture can truly understand how painful and debilitating it can be. Recovering should be your first priority. However, you and your doctor also will want to determine whether this fracture is a symptom of osteoporosis. If you have this underlying disorder, it puts you at greater risk for future fractures. If you are age 50 or older, there is a very good chance your fracture is related to osteoporosis. This fact sheet will help you better understand the relationship between fracture and osteoporosis, so you can take action now to strengthen and protect your bones. Many people are unaware of the link between a broken bone and osteoporosis. Osteoporosis, or "porous bone," is a disease characterized by low bone mass. It makes bones fragile and more prone to fractures, especially the bones of the hip, spine, and wrist. Osteoporosis is called a "silent disease" because bone loss occurs without symptoms. People typically do not know that they have osteoporosis until their bones become so weak that a sudden strain, twist, or fall results in a fracture. Osteoporosis is a major public health threat for an estimated 44 million Americans, 68 percent of whom are women. In the United States today, approximately 10 million people already have the disease and nearly 34 million more are believed to have low bone mass, which leaves them at increased risk for osteoporosis. Of the 10 million Americans estimated to already have osteoporosis, 8 million are women and 2 million are men. 4'44 ei I'd 3

12 One in two women and one in four men will have an osteoporosis-related fracture in their lifetime. At least 90 percent of all hip and spine fractures among older white women can be attributed to underlying bone fragility. Moreover, women near or past menopause who have sustained a fracture in the past are twice as likely to experience another fracture. Yet, unfortunately, only 5 percent of patients with osteoporotic fractures are referred for an osteoporosis evaluation and medical treatment. The Osteoporosis Evaluation I've already had a fracture. Is it too late to talk to my doctor about osteoporosis? It is never too late. Ideally, you should talk to your doctor during your recovery about whether you might be a candidate for an osteoporosis evaluation. But even if your fracture has healed, you can be evaluated and begin taking steps to protect your bones now. What kind of doctor should I see about getting an osteoporosis evaluation? Many different kinds of doctors can evaluate and treat osteoporosis. Start with your primary care doctor or the doctor treating your fracture. He or she probably can conduct the evaluation and may then refer you to a specialist, such as an endocrinologist or rheumatologist, if you require treatment. What does an osteoporosis evaluation involve? One thing your doctor will do is ask about your medical history and lifestyle to determine whether you have risk factors for osteoporosis. Some of the factors that increase the risk of developing osteoporosis include personal or family history of fractures; low levels of the hormone estrogen or testosterone; and the use of certain medications, such as glucocorticoids or anti-seizure medications, that may contribute to bone fragility. Your doctor also may want to test your blood or urine and may suggest that you have a bone mineral density test. What is a bone mineral density test? Is it painful? A bone mineral density (BMD) test is the best way to determine your bone health. This test can identify osteoporosis, determine your risk for fractures (broken bones), and measure your response to osteoporosis treatment. The most widely recognized BMD test is called a dual-energy x-ray absorptiometry, or DXA test. The test is safe and painless, a bit like having an x ray, but with much less exposure to radiation. It can measure bone density at your hip and spine and takes only 15 minutes to complete. For a DXA test, you will be asked to lie on a table while a machine above you measures your bone density. 2

13 Some private insurance plans will cover BMD tests ordered by your doctor. Medicare also may pay for a BMD test under certain circumstances for women and men age 65 or older. Your doctor and his or her office staff can help you determine if Medicare will cover a BMD test for you. Strategies to Reduce Your Risk of Fractures If I am diagnosed with osteoporosis, what should I do next? You may feel concerned or even frightened after being diagnosed with osteoporosis. However, the good news is that, armed with information and the support of your doctor, you can significantly improve your bone health and reduce your risk of future fractures with a combination of medication, diet, exercise, and lifestyle modifications. Some of my friends take medication for osteoporosis. Should I consider this? Yes. Several medications are available to prevent and treat osteoporosis. These products have been proven effective at minimizing additional bone loss and reducing fracture risk. Your doctor can help you understand the benefits and risks of each of the following medications and select one that is right for you: bisphosphonate drugs: alendronate (Fosamax), 1 risedronate (Actonel), ibandronate (Boniva), and zoledronic acid (Reclast) calcitonin (Miacalcin and Fortical) raloxifene (Evista), a selective estrogen receptor modulator (SERM) teriparatide (Forteo), a form of the parathyroid hormone (PTH), which is secreted by the parathyroid glands estrogen therapy (also called hormone therapy when estrogen and another hormone, progestin, are combined). In men, reduced levels of testosterone may be linked to the development of osteoporosis. Men with abnormally low levels of testosterone may be prescribed testosterone replacement therapy to help prevent or slow bone loss. What else can I do to protect my bones? In addition to taking your medication, some of the most important things you can do are to follow a diet rich in calcium and vitamin D, maintain an adequate daily intake of protein, monitor your sodium intake, and get plenty of exercise. Brand names included in this publication are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory. 3

14 Calcium is needed to maintain healthy, strong bones throughout your life. Unfortunately, most Americans do not get enough calcium from their diets. Dairy products such as milk, cheese, and yogurt are excellent sources of calcium, and some nondairy foods such as broccoli, almonds, and sardines can provide smaller amounts. In addition, many foods that you may already enjoy juices, breads, and cereals can now be found fortified with calcium. Calcium supplements can ensure that you get enough calcium each day, especially in people with a proven milk allergy. The Institute of Medicine recommends a daily calcium intake of 1,000 mg (milligrams) for men and women, increasing to 1,200 mg for adults age 50 and older. Calcium supplements are available without a prescription in a wide range of preparations and strengths. Many people ask which calcium supplement they should take. The "best" supplement is the one that meets your needs based on tolerance, convenience, cost, and availability. In general, you should choose calcium supplements that are known brand names with proven reliability. Also, you will absorb calcium better if you take it several times a day in smaller amounts of 500 mg or less each time. Vitamin D plays a significant role in helping your body absorb calcium. The relationship between calcium and vitamin D is similar to that of a locked door and a key. Vitamin D is the key that unlocks the door, allowing calcium to enter your bloodstream. As we age, our bodies become less able to absorb calcium, which makes getting enough vitamin D even more important. The recommended daily intake for vitamin D is 400 to 600 IU (International Units). Many people get this amount through natural exposure to sunlight, which our bodies use to make vitamin D, and by consuming vitamin D-fortified foods such as milk. In addition, many calcium supplements are fortified with vitamin D. Sodium, a main component of table salt, affects our need for calcium by increasing the amount of it we excrete in urine. As a result, people with diets high in sodium, or table salt, appear to need more calcium than people with low-sodium diets to ensure that, on balance, they retain enough calcium for their bones. Protein in excess amounts also increases the amount of calcium we excrete in urine, but it provides benefits for bone health as well. For example, protein is needed for fracture healing. In addition, studies have shown that elderly people with a hip fracture who do not have enough protein in their diets are more likely to experience loss of independence, institutionalization, and even death after their fracture. The recommended daily intake for protein is 56 grams for men and 46 grams for women. 4

15 I've always been active, but I don't want to risk breaking another bone. Maybe I need to spend more time "on the sidelines" from now on. It is perfectly understandable that you want to avoid another fracture. No one who has broken a bone wants to revisit that pain and loss of independence. However, living your life "on the sidelines" is not an effective way to protect your bones. Remaining physically active reduces your risk of heart disease, colon cancer, and type 2 diabetes. It may also protect you against prostate and breast cancer, high blood pressure, obesity, and mood disorders such as depression and anxiety. If that isn't enough to convince you to stay active, consider this: exercise is one of the best ways to preserve your bone density and prevent falls as you age. What type of exercise is best to reduce my risk of another fracture? Exercise can reduce your risk of fracturing in two ways by helping you build and maintain bone density and by enhancing your balance, flexibility, and strength, all of which reduce your chance of falling. Building and maintaining bone density: Bone is a living tissue that responds to exercise by becoming stronger. Just as a muscle gets stronger and bigger with use, a bone becomes stronger and denser when it is called upon to bear weight. Two types of exercise are important for building and maintaining bone density: weight-bearing and resistance. Weight-bearing exercises are those in which your bones and muscles work against gravity. Examples include walking, climbing stairs, dancing, and playing tennis. Resistance exercises are those that use muscular strength to improve muscle mass and strengthen bone. The best example of a resistance exercise is weight training, with either free weights or weight machines. Reducing the risk of falling: You can significantly reduce your risk of falling by engaging in activities that enhance your balance, flexibility, and strength. Balance is the ability to maintain your body's stability while moving or standing still. You can improve your balance with activities such as tai chi and yoga. Flexibility refers to the range of motion of a muscle or group of muscles. You can improve your flexibility through tai chi, swimming, yoga, and gentle stretching exercises. Strength refers to your body's ability to develop and maintain strong muscles. Lifting weights will increase your strength. 5

16 Smart Moves Walking Hiking Strength training Bicycling Dancing Swimming Tai chi Gardening Stair climbing How can I exercise safely if I have osteoporosis? If you have osteoporosis, it is important for you to get plenty of exercise. However, you will need to choose your activities carefully. Be sure to avoid activities with a high risk of falling, such as skiing or skating; those that have too much impact, such as jogging and jumping rope; and those that cause you to twist or bend, such as golf. Unfortunately, some people become so afraid of breaking another bone that they become more sedentary, which leads to further loss of bone and muscle. Rest assured, however, that by practicing proper posture and learning the correct way to move, you can protect your bones while remaining physically active. Every activity can be adapted to meet your age, ability, lifestyle, and strength. Your doctor or a physical therapist can help you design a safe and effective exercise program. In the meantime, here are some general guidelines for safe movement: Don't: wear shoes with slippery soles slouch when standing, walking, or sitting at a desk move too quickly engage in sports or activities that require twisting the spine or bending forward from the waist, such as conventional sit-ups, toe touches, or swinging a golf club. Do: pay attention to proper posture. This includes lifting your breastbone, keeping your head erect and eyes forward, keeping your shoulders back, lightly "pinching" your shoulder blades, and tightening your abdominal muscles and buttocks. make sure to use a handrail when climbing stairs bend from the hips and knees and never from the waist, especially when lifting. 6

17 Before embarking on any exercise program, be sure to consult your doctor. My fracture happened after I tripped on a rug in my own home. How can I prevent another fall? Falls are a major source of fractures. The likelihood that you will fall depends on both personal and enviroknental factors. Personal factors: A fall may occur because your reflexes have slowed over time, making them less able to react quickly to a sudden shift in body position. Loss of muscle mass may occur as you age, which can diminish your strength. Changes in vision and hearing can also affect your balance, as can the use of alcohol and certain medications. People with chronic illnesses that affect their circulation, sensation, mobility, or mental alertness are more likely to fall. To reduce your risk of falling, keep this personal safety checklist in mind: Personal safety checklist Stay active to maintain muscle strength, balance, and flexibility. Have your vision and hearing checked regularly and corrected as needed. Discuss your medications with your doctor to see if one of them (or their combination) might lead to falls. Environmental factors: At any age, people can make changes in their environment to reduce their risk of falling and breaking a bone. The following safety checklists provide a few tips that should help: Indoor safety checklist Use nightlights throughout your home. Keep all rooms free from clutter, especially the floors. Keep floor surfaces smooth but not slippery. When entering rooms, be aware of differences in floor levels and thresholds. Wear supportive, low-heeled shoes even at home. Avoid walking around in socks, stockings, or floppy slippers. Check that all carpets and area rugs have skid-proof backing or are tacked to the floor, including carpeting on stairs. Keep electrical cords and telephone lines out of walkways. Be sure that all stairways are well lit and that stairs have handrails on both sides. Consider placing fluorescent tape on the edges of top and bottom steps. 7

18 Install grab bars on bathroom walls beside tubs, showers, and toilets. If you are unstable on your feet, consider using a plastic chair with a back and nonskid leg tips in the shower. Use a rubber bathmat in the shower or tub. Keep a flashlight with extra batteries beside your bed. Add ceiling fixtures to rooms lit only by lamps, or install lamps that can be turned on by a switch near the entrance to the room. Use at least 100-watt light bulbs in your home. Outdoor safety checklist In bad weather, consider using a cane or walker for extra stability. In winter, wear warm boots with rubber soles for added traction. Look carefully at floor surfaces in public buildings. Many floors are made of highly polished marble or tile that can be very slippery. When floors have plastic or carpet runners in place, try to stay on them whenever possible. Use a shoulder bag, fanny pack, or backpack to leave hands free. Stop at curbs to check height before stepping up or down. Be cautious at curbs that have been cut away to allow access for bikes or wheelchairs. The incline may lead to a fall. What is hip padding? Should I consider it? Research has shown that hip protectors can decrease the risk of hip fracture among people who are at high risk for falls. Most hip protectors are washable undergarments that fit over the hips. On each side of the garment is a thin layer of lightweight foam plastic. Hip protectors are typically worn by people who have an unstable stride or posture and by people who tend to fall down (with the main impact near the hip) rather than the more typical fall forward (with the main impact on the hands or knees). However, studies have found that up to one-third of people refused to wear hip protectors or wore them for only limited periods. Is there anything else I can do? If you are a smoker, now would be a good time to quit. Tobacco is toxic to your bones, putting you at higher risk for low bone mass and osteoporosis. Excessive alcohol intake also may be damaging to your bones, and people who drink heavily tend to have more bone loss and fractures due to poor nutrition and an increased risk of falling. 8

19 Where can I go for more information? NIH Osteoporosis and Related Bone Diseases National Resource Center 2 AMS Circle, Bethesda, MD Tel: BONE (2663) or TTY: Fax: Internet: NIAMSBonelnfo@mail.nih.gov National Institute on Aging Information Center P.O. Box 8057, Gaithersburg, MD Tel: TTY: niainfo@nia.nih.gov Internet: American Academy of Orthopaedic Surgeons 6300 North River Road, Rosemont, IL Tel: BONE (2663) Fax: permr@aaos.org Internet: National Osteoporosis Foundation nd Street NW, Washington, DC Tel: or patientinfo@noforg Internet: Reviewed January

20 For Your Information This publication contains information about medications used to treat the health condition discussed here. When this fact sheet was printed, we included the most up-to-date (accurate) information available. Occasionally, new information on medication is released. For updates and for any questions about any medications you are taking, please contact the Food and Drug Administration at 888 INFO FDA ( , a toll-free call) or visit its Web site at For updates and questions about statistics, please contact the Centers for Disease Control and Prevention's National Center for Health Statistics toll free at or visit its Web site at Recognizing the National Bone and Joint Decade: