HARRI SIEVÄNEN Bone exercise and fall prevention
IOF/WWC Helsinki Jun 2, 2013 Bone Exercise and Fall Prevention Harri Sievänen, ScD Research Director, The UKK Institute President, Finnish Osteoporosis Association Email: harri.sievanen@uta.fi 2
Bones, muscles, tendons, joints, ligaments and motor nerves (+CNS) = An apparatus for locomotion 3 For appropriate function, bones are light and stiff - not massive!
Locomotion involves hazards Accidents happen no matter what you do, but risk can be reduced To fracture or not to fracture? Bone strength Balance and fall mechanics Photo, 16.1.2007, Timo Marttila Falls are common:1/3 of 65+ and ½ of 80+ population fall annually 1/5 1/3 of those who fall suffer moderate to severe injuries (of these injuries 1/4 requires hospitalization) > 90 % of hip fractures are caused by a fall (Parkkari et al CTI 1999)! 4
Reduced loading 11 months Clearly reduced loading leads to great and rapid bone loss Recovery is possible provided that functional ability recovers Long-term disuse is the worst that can happen to bone! pqct images adapted from Natri et al. Am J Sport Med 1999 5
Increased loading - Several years* - Growth spurt! - Recovery! Loading makes the bone stronger, but the process is slow* Adaptive potential is basically large (irrespective of genetics) pqct images adapted from Heinonen et al. Bone 2001 6
Specifications for osteogenic loading Dynamic forces Great forces delivered at high rate (~high acceleration) Unusual loading environment (differing from habitual loading) Small number ( 50) of high loads (-> saturation) Great number (>> 1000) of low-to-moderate loads Resting periods between loading bouts (-> for recovery from saturation) Regularity Simply, various jumping exercises are most effective Adapted thoughts by Drs HM Frost, LE Lanyon, and CH Turner, and our own long experience 7
Bone mass/ strength Timing of Bone Exercise Adoslencents Adults Aging people Osteoporotic patients Children Age (yrs) Muscle force and balance Bone strengthening 8
Balance Maintenance of dynamic balance (ie, to stay on your feet while moving) is a challenging and complex task Where am I? Central nervous system What should I do? Senses Vision Proprioception Vestibular system Musculoskeletal System Muscles (mass, force, power) Joints (flexibility) Pain 9
Muscle performance and bone strength over the life span Falls Fractures Age 10
Physical functioning over the life span Finnish population 18-79 years of age Physical functioning index (range 0 100) 100 80 Fit, healthy 60 40 Unfit, healthy independent 20 0 Unfit, frail, unhealthy dependent 18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 + 80 Aalto A-M et al 1999 11
Vicious circle of falling among older adults 10 70 % 30 90 % Fear of falling 50 60 % Falling Reduced physical activity Increased risk of falling Reduced Physical functioning 12
Fall-induced deaths among 50+ year old Finns during 1971-2009 Korhonen et al Injury 2013 13
Hip fractures among 50+ year old Finns during 1970-2010 Korhonen et al, Osteoporos Int 2013 14
Proportion of the aged people is increasing Men Finland 2010 Finland 2020 Women Men Women Population (thousands) Population (thousands) Source: www.nationmaster.com 15
How can we prevent falling? Strength and balance training (eg OTAGO-training) Class-based, home-based and tailored exercises -> depending on the group the risk reduces 15% - 50% Dietary supplementation of vitamin D and calcium Reduction of psychotropic drugs In high risk populations, home hazard assessment and management Cataract surgery Cardiac pacing Antislip devices under slippery conditions Kannus et al, Lancet 2005 16
Physical activity and the risk of hip fracture 12 year follow-up of 61200 women 35 year follow-up of 2505 men 1,2 1,2 1 0,8 0,6 0,4 0,2 0 < 3 METh/wk 3-8.9 MET-h/wk * 9-14.9 MET-h/wk * 15-23.9 MET-h/wk * > 24 METh/wk 1 0,8 0,6 0,4 0,2 0 * * Low PA Medium PA High PA Feskanich et al JAMA 2002 Michaelsson et al PLoS Med 2007 Physical activity is associated with decreased risk of hip fx Apparently this influence operates through (somewhat) stronger bone and better control of movement and balance Moayyeri Ann Epidemiol 2008: Meta analysis, Risk reduction 38% in women and 45% in men 1 17 7
Hip fractures and costs Finland ~7000 hip fractures/year Costs ~140 million /year ~ 0.4 million /day!!! e.g. UK ~ 89000 hip fractures/year Costs ~ 2.3 billion/year ~ 6 million/day!!! What if 1/3 of these hip fractures could be prevented by physical activity? 18
Take home messages Falls of older adults are common and costly because of subsequent injuries and fractures Falls can be prevented (cost-effectively and simply) Maintenance of physical functioning is the key element Regular physical activity in addition to targeted and tailored exercises (including Wii games and WBV) are the means (NB, 3 to 4 hours/week (~½ hr/day!) of brisk PA is not much besides its several other health benefits (CVD, DM2, obesity)) Patient societies and NGOs in general can be most valuable players in this life-long game. For the older people, health care system is in the key position and it should provide efficient preventive actions in their services (eg, Falls clinics) 19 19
Bone Exercise Recommendations for children and adolescents Jump and hop, run and play! Keep on moving as fast and as frequently you can. Adapted from Bone Exercise Recommendations UKK Institute and Finnish Osteoporosis Association 2006 20
Bone Exercise Recommendations for adults Keep on moving on regular basis, maintain speed and power! Don t stop jumping and leaping. Listen to your body. Adapted from Bone Exercise Recommendations UKK Institute and Finnish Osteoporosis Association 2006 21
Bone Exercise Recommendations for elderly people Do regular exercises for muscle performance and balance. Keep on walking briskly and frequently. Listen to your body. Adapted from Bone Exercise Recommendations UKK Institute and Finnish Osteoporosis Association 2006 22
Bone Exercise Recommendations for osteoporotic patients Strenghten muscles for good posture. Keep on standing, walk frequently. Listen to your body, and remember safety. Consult professionals whenever needed. Adapted from Bone Exercise Recommendations UKK Institute and Finnish Osteoporosis Association 2006 23
(No pain, no gain!) Listen to your body! Use it, or loose it! Break the fall, not the bone! Capture the fracture! 24