Balance, bone density and falls

Balance, bone density and falls: a note for the not so old…

REBECCA DALZELL
Bec Dalzell is the Haemophilia Physiotherapist at the Royal Brisbane & Women’s Hospital

THE FACTS

No one wants to be called ‘old’! Most of us feel young at heart and hate to consider that our bodies are experiencing anything different! Unfortunately once we pass early adulthood we are all in a gradual state of decline. Even before we feel it, we are beginning to wear out. Our joints deteriorate, our muscles don’t work as well as they used to, our balance declines and our bones become less dense. These are unavoidable facts! For many, this decline slips by unnoticed for many years, until it suddenly starts to become apparent in later life. For others, including those with bleeding disorders, the starting point is often compromised, and the signs of this process can begin to present themselves earlier…Let me explain.

People with bleeding disorders have been shown to have poorer balance when compared to others of the same age, and this begins in childhood. Joint bleeds and joint damage can alter what is called proprioception (our awareness of where our body is in space) and this, among other factors, can contribute to decreased balance reactions. Many may not be aware of this deficit, or the need to address it – until it’s too late!

Bone density in those with severe bleeding disorders has also been shown to be decreased, beginning in childhood, when compared with controls. There are numerous possible contributing factors here including:

• Prolonged periods of immobilisation during childhood and adolescence (a lack of weight bearing activity in this time leads to a decreased peak bone mineral density or BMD)
• Significant arthropathy (bleed related joint damage)
• Lack of prophylaxis
• Exposure to hep C and HIV.

Decreased BMD may initially be asymptomatic, but ongoing decline can lead to osteoporosis and increased risk of fracture. These factors, along with haemophilia-related joint damage, pain, and decreased joint range of motion, mean that those with bleeding disorders are at increased risk of falls and fracture (even though they may not know it) – and this can have serious consequences.

Studies done in the general population show that 30% of those over 65, and 50% of those over 80 fall each year. 20-30% of those in the general population who fall suffer injuries that reduce mobility and independence and increase the risk of premature death. For those with bleeding disorders these statistics would most likely be higher due to the presence of additional falls risk factors.

THE GOOD NEWS

It’s not all bad news. Your Haemophilia Treatment Centre Physiotherapist can help! There are a huge range of activities you can do with your Physiotherapist to help improve balance, optimise BMD, prevent falls and enhance quality of life. Many of these problems can be averted.

Physical activity has been shown to have numerous benefits. Research shows that balance can be improved, and most falls prevented, through physical activity. Exercise programs that address strength, balance, flexibility and/or endurance (2-3 of these components) have been shown to significantly reduce the rate of falls, and the number of people falling.

BMD can also be positively influenced by exercise. For those who are younger – teens to early twenties – exercise can significantly help to build strong bones to optimise peak BMD (giving you a much better starting point for the rest of your life!). For those who are more mature, it has been shown that BMD can be maintained, if not slightly improved, and bone turnover decreased, through strength training and weight bearing exercise (3). Hip fractures have been found to be nearly half as frequent in adults who have been physically active in their daily life compared to less active people.

Physical activity also helps reduce pain, improve joint nutrition, strengthen muscles, improve joint stability, preserve and possibly improve joint range of movement, assist in weight control, improve posture, and prevent secondary musculoskeletal complications. These all help to maintain function and prevent many of the associated adverse health outcomes.

There are also many health and environmental factors that can both optimise BMD, and reduce falls risk, significantly reducing the risk of fracture. These will be explained further below.

ACTION PLAN:PREVENTION IS THE BEST MEDICINE

Participate in physical activity throughout life

• Best if started early and continued throughout life. Short term ‘boom and bust’ programs have little long term benefit
• Make it a lifestyle choice and find ways to incorporate ‘incidental’ activity into your day, eg pulling or pushing, using the stairs, or not using the remote for the TV (every little bit of movement helps!)
• Find activities you enjoy
• Set goals
• Exercise with a friend
• Include activities that challenge your balance, eg. the Strong Bloody Men program (Qld), or Tai Chi as seen on the Inspire DVD (available through HFA), or Pilates classes
• Include weight bearing and resistance activities for bone health
• Talk to your physiotherapist if you need help getting started, or you want some ideas of what might be best for you.

General health issues (talk to your GP)

• Regular vision checks – declining vision increases falls risk
• DEXA scans to assess BMD (as appropriate). Indicated routinely if you are over 70 years or have a previous fracture, or advised if there are significant other predisposing factors
• Calcium – important for good bone health. Ensure adequate dietary intake (at least 1,200 mg per day), and discuss supplements with your GP as appropriate
• Vitamin D – also important for bone health. Small amounts of daily sun exposure helps in maintaining healthy levels of vitamin D
• Discuss pharmacological interventions with your GP, eg bisphosphonates or calcitonin, as required
• Avoid tobacco smoking and excessive alcohol intake (negatively impacts on bone health…among other things!)

Environmental issues

• Ensure a safe home environment – remove trip hazards, install rails, de-clutter, etc
• Install good lighting for better visibility
• Use walking aids or assistive devices for safety when required
• Wear safe and supportive footwear.

FOR MORE INFORMATION

• Osteoporosis Australia
• Look up your local state’s falls guidelines, eg Stay on your feet (Qld), or Your home safety checklist (WA and Tas)
• Contact your Haemophilia Treatment Centre including the Haemophilia Physiotherapist
• Talk to your GP for general health issues and relevant investigations.

References

1. Barnes, C, Wong, P, Egan, B, et al. Reduced bone density among children with severe hemophilia. Pediatrics 2004 Aug;114(2):e177-81.

2. Forsyth, AL, Quin, DV, Konkle, BA. Role of exercise and physical activity on haemophilic arthropathy, fall prevention and osteoporosis. Haemophilia 2011 Sep;17(5):e870-6.

3. Kohrt WM, Bloomfield SA, Little KD, Nelson ME, Yingling VR; American College of Sports Medicine. American College of Sports Medicine Position Stand: physical activity and bone health. Medicine and Science in Sports and Exercise 2004 Nov;36(11):1985-96

4. Paschou, S, Anagnostis, P, Karras, S, et al. Bone mineral density in men and children with haemophilia A and B: a systematic review and meta-analysis. Osteoporosis International 2014 Oct;25(10):2399-407.

5. Sherrington, C, Whitney, JC, Lord, SR, et al. Effective exercise for the prevention of falls: a systematic review and meta-analysis. Journal of the American Geriatrics Society 2008 Dec;56(12):2234-43.