56 Comments

balance training so important. many exercises and tools out there- yoga, tai chi and less reliance on heavy cushioned shoes (like Hokas!) high risk for falls due to decreased foot Proprioception👣

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This is a great article and thank you. I am a physician who is 77 years old. I have severe neuropathy from vincristine treatment and related balance issues. I use a cane or a walker everywhere I go and I am certain that I would have fallen and been injured without one. Many people I treated did not want to use a cane. As you point out, frailty is a marker for fracture risk. Sarcopenia is a huge problem there. You can increase your strengh even at 90 with progressive resistance exercise.

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Nov 8, 2023·edited Nov 8, 2023

As a young woman I logged years of backpacking and back country skiiing with a back pack along with thousands of miles of weight bearing exercise. Yet at 64 my femur snapped during a slide on a hill while hiking. I declined the Fosamax recommendation. Some studies show micro-structure bone changes in CRPS which I developed after a minor bone fracture 30 years ago. It is the osteoporosis or CRPS weakening my bones? medicine did not have the answers. Now I only hike with poles, using a abundance of caution and techniques to avoid falls.

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This is where a referral to my fellow physical/physiotherapists is in order. We are trained to differentiate deficits that contribute to falls and then prescribe correct interventions which may be exercise. The Intl Osteoporosis Society has some content that does not align with this terrific post’s findings but does encourage exercise and lifestyle mod for patients with downloadable posters in many languages for your clinic or office. I have no affiliation with them but will link. https://www.osteoporosis.foundation/patients

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The gap between what we know and what we think/say we know is huge. But people want safety/certainty and providers want to provide services, so on and on we go. We should all be grateful to those with the ethics, wisdom and courage to speak the truth! 👏

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Another fantastic article on the nature and danger of “groupthink” and therapeutic fashion.

Maybe it’s “institutional capture” by vested (and conflicted) interests ….or whatever the avant- garde term for the concept might be these days. But it’s certainly a dereliction of duty among the various “societies”….and the guideline writers those societies help to legitimize.

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I have become skeptical of osteoporosis screening over the past couple years, enough to go through the main RCTs like the 1996 paper mentioned here, https://woojin.substack.com/p/reviewing-alendronate-vs-placebo

Great to know that there are prominent scientists who are doing a deep dive and calling out their concerns into this established practice.

At first I was surprised at how difficult it was to find a good RCT that shows any medication reduces risk of clinical fractures. Many studies looked at subclinical vertebral fractures as a primary endpoint instead for example.

DXA screening itself also seems to lack robust data supporting improvements in hard clinical endpoints like hospitalization and mortality.

What bothers me the most is that despite uncertainty any of these interventions improve clinical outcomes, there are incentives and a push for their use. It’s become a clinical quality measure. I believe insurance plans incentivize DXA until age 85 or so, every two years. USPSTF gives a B recommendation, with no age cut off. That can be major burden on an individual, and essentially guarantees that they’ll meet an indication for pharmacotherapy.

Most importantly, that debate of opposing viewpoints is discouraged and actively thwarted is no longer surprising. Rather it’s the standard, unfortunately.

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Another wonderful article. During the early years of my medical practice I smelled a rat when the subject of osteoporosis was thrust into the limelight about the time that a new biphosphonate drug was ready to hit the market. That smell became an overwhelming stench when I learned through contact with many colleagues throughout southern California that the pharmaceutical firm that produced the drug was supplying bone density scanners to every OB-GYN doctor at no cost. I suspect the company made a fairly nice return on their "investment".

I would add a note of caution to those who claim that exercise is an effective preventive measure. There are many factors that cause elderly people to fall and suffer fractures that have nothing to do with bone density. Visual problems, difficulties with balance, and countless other problems with neuromuscular function are often at fault. This segment of the elderly population is certainly going to be less physically active due to their overall medical condition and may give a false impression of correlation between exercise and bone health. It may not be a good idea to urge an elderly person to undertake physical activities that may indeed expose them to further risk.

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Teppo, thank you for your article. I appreciate the confirmation that exercise is important preventing fractures. I've been listening recently to podcasts on longevity, and Peter Attia, for one, has pointed out that muscle mass is an indicator of lifespan. Muscle allows you to exercise, and protects the bones by reducing the impact on them during a fall. And if exercise itself is necessary for proper immune system functioning, any fall that prevents an elderly person from exercising is tanking their immune system.

That said, I would love to know the effect of Vitamin D and Vitamin K2 on bone health. Does taking higher doses of these vitamins - specifically K2 - prevent fractures when there is a fall? Because if there *is* a way to make stronger bones (whether or not you know how to measure that) simply by eating fermented foods (which are high in K2), then we should be exploring that.

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This is a good one, thank you. I forwarded it to my healthy, athletic 79-year old mother. She's been caught up in the whole bone density scan = "you must take this osteoporosis medicine" thing for the last 10 years or so. Perhaps longer.

The people who run the clinic that administers the shot she has been prescribed are aggressive and unpleasant about making sure she stays on "schedule." Women do get bullied about this sort of thing--as though if you don't get your shot you are...committing suicide. Or something.

Anyway, this is at least a different perspective from what she has been hearing.

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..."And more importantly:

2. Why is pharmacotherapy the only ‘fix’ for those identified at ‘high fracture risk’ instead of exercise, as a more effective, safer and less costly an alternative?

Sadly, the osteoporosis community adopted the focus on fracture risk change with no need for solid evidence."...

For number 2 the answer is obvious. Income, revenue and profits. That's it!

Sadly, 95% of the entire medical system has been constructed without any solid evidence that would support its existence as being a benefit to mankind.

Nearing age 74, I have never experienced a bone break or fracture. I have no real clue as to why despite tripping, stumbling and falling on numerous occasions over the many decades.

The best I can figure one of the main factors has been avoiding all drugs as much as possible over the last 50 years.

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There are significant side effects to some of the bone-strenthening infusions. After my cancer treatments put me into menopause, my oncologist said it would be a standard to have infusions of a bone-strengthening drug--a drug that included risks such as pain, fatigue and necrosis of the jaw that would make me unable to get fairly typical dental interventions I may need as I age. I said no, but it was continually offered, even after a bone scan that was within healthy range. My question is, why do they push it given the risks/benefit ratio in a case like mine & given the research you've outlined?

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It feels a bit like a time warp. The last article is from 2016. Since then the "falls prevention" world has moved on considerably with guidelines and Cochrane analysis and a general acceptance that this is an important part of preventing fractures.

That physicians may still try to diagnosis and treat osteoporosis is another thing, but probably thanks to yours and your colleagues' efforts, the "falls prevention" community has really really grown.

These are from 2023

https://pubmed.ncbi.nlm.nih.gov/36178003/

https://pubmed.ncbi.nlm.nih.gov/36893804/

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Nov 7, 2023·edited Nov 7, 2023

I love guest posts that question orthodoxy; soon you will have covered all the ineffective interventions for every major disease! :) My mom demonstrates the accuracy of what you write; she was prescribed a bisphosphonate for many years which ironically caused osteonecrosis of the jaw so that her dentures no longer fit, but it did NOT prevent a hip fracture when she eventually fell. (She also became dangerously underweight due to difficulty with eating, as there wasn't much a dentist could do without a jaw bone). It's interesting that exercise is the prescription for preventing bone loss; its true effectiveness in preventing fracture is probably due to preventing falls. There needs to be more research in both physical AND cognitive (links below) interventions for fall prevention.

https://academic.oup.com/biomedgerontology/article/72/5/669/2630045

https://www.brainhq.com/news/nih-grant-made-to-test-brainhq-training-impact-on-falls/

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As a martial

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This is a great post and thank you. I am a physician with a high fall risk due to severe and persistent neuropathy from vincristine treatment. I always use a cane or walker when I am up because I have seen the disasters that can result from falls. I am also 77 years old and use progressive resistance exercise to maintain my strength and muscle mass to help with stair climbing etc. It is highly effective and many programs don't use enough resistance or progression for maximal effect.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4849483/pdf/nihms756840.pdf

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